intijeCitpofiBtetoliovfe to College of ^fjp^iciang anb ^urgcong d^tttxmtt llihxavv Presented By DR. WILLIAM J. GIES to enrich the lihr&ry resources available to holders il'i' of the GIES FELLOWSHIP in Biologic&l Chemistry Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/atlasofdentalextOOwall AN ATLAS OF DENTAL EXTRACTIONS WITH NOTES ON THE CAUSES AND RELIEF OF DENTAL PAIN DESIGNED FOB THE USJE OF MEDICAL STUDENTS AND PRACTITIONERS. C, EDWARD WALLIS, M.R.C.S., L.R.C.P., L.D.S. DENTAL SURGEON AND LECTURER ON DENTAL SURGERY KING's COLLEGE HOSPITAL; ASSISTANT MEDICAL OFFICER (PUBLIC HEALTH DEPT.) LONDON COUNTY COUNCIL ; LATE DENTAL SURGEON VICTORIA HOSPITAL FOR CHILDREN, CHELSEA, ETC. SECOND EDITION WITH ELEVEN PLATES. PHILADELPHIA BLAKISTON'S SON AND CO. 1012 WALNUT STEEET 1919 Printed %n Great Britain. PREFACE. This " atlas " and notes have been designed for the use of medical students and practitioners with the object of assisting them to perform such emergency dental operations as may be expected to occur in a country practice or on board ship where the services of a dental surgeon cannot be obtained. A minimum number of dental appliances has been recommended and various means of improvising a dental ch^ir have been shown. I have to express my great indebtedness to Professor Underwood, Dr. Harold Austen, Mr. Norman Bennett, and Mr. Gr. K. Aubrey for many valuable suggestions, and also to Messrs. Allen & Hanburys for the loan of the blocks. C. EDWARD WALLIS. June, 1909. PREFACE TO SECOND EDITION. A SECOND edition having been called for a complete revision has taken place, which the author hopes may increase its usefulness to the medical practitioner unable to obtain the services of a dental surgeon. C. EDWARD WALLIS. 13, QxjEEN Anne Stbeet, London, W. 1. THE CAUSES AND RELIEF OF DENTAL PAIN. In considering the causes of toothache one must bear in mind the various structures of which a tooth is com- posed, and the surrounding tissues with which it is in close relation. A tooth may be regarded as a hard, unyielding box, enclosing a highly sensitive and vascular pulp or " nerve " as it is commonly called. The portion of tooth which is implanted in the jaw is more or less conical in shape and closely surrounded by its bony socket, which is therefore a hollow cone. Between the root and the socket is a fibrous mem- brane known as the " periodontal membrane," in which a capillary network ramifies for the nutrition of the socket and the external surface of the root; and through this membrane pass the blood-vessels that enter the pulp. Irritation applied to any vascular tissue produces hyperemia, which may be but transitory, or pass into the condition of inflammation if the irritant be not speedily removed. It is important, therefore, to distinguish hvo dif event sources of the pain of toothache according as the pulp or periodontal membrane is the part primarily affected, for on the correctness of diagnosis will depend the chance of successful treatment. Inflammation of the pulp.— The hypersemia of the pulp occurring in this condition leads to swelling that causes a darting, shooting, or throbbing pain in the 2 CAUSES AND RELIEF OF DENTAL PAIN. tooth, owing to the resistance offered by the unyielding wall of the pulp cavity to the expansion of the pulp tissue. Heat or a lowered position of the head intensifies the throbbing, since either will still further increase the congestion. As the periodontal membrane is not involved, pain is not usually felt on the tooth being pressed or bitten into its socket. Infl,ammation of the periodontal membrane. — This membrane, on becoming inflamed, is thickened, and therefore raises the tooth in its socket ; hence it appears lengthened and is bitten upon before its neighbours when the jaws are closed, pain being produced from the mem- brane being squeezed between the two unyielding surfaces of tooth and socket. The pain is of a dull, heavy, not throbbing character, not worse at night, and often relieved by heat and gene- rally in early stages by pressure. The tooth is tender to the slightest touch, and the gum surrounding it is swollen and feels velvety to the finger. Irritation of the dental pnlp. — If the irritation be long continued and slight, an increased formation of dentine may take place from stimulation of the odontoblasts. Irritation of the dental pulp may arise from : (1) Caries with or without the presence of cavities. (2) Heat aLnd cold, contact of sweet, sour, or acid substances. (3) Conduction of heat and cold through a metal filling. (4) Exposure of dentine from any cause producing loss of the enamel, such as friction from bands or dental plates, wearing down of teeth from excessive use or loss of the enamel due to overuse of a hard toothbrush or abrasive tooth-clj^aning pastes or powders. CAUSES AND RELIEF OF DENTAL PAIN. 3 Symptoms. — The symptoms depend upon the amount of hypergemia; thus slight discomfort may follow on taking hot or cold fluids, the contact of cold air, etc. The pain, however, is usually of a shooting or darting character and occurring at irregular intervals, sometimes brought on by heat or cold, especially cold, or by the contact of sweet, salt, or sour substances. The tooth may also be tender to the slightest touch owing to an extension of the hypersemia to the dental periosteum. Treatment. — When the pain is due to the presence of a cavity in the tooth it should be thoroughly syringed with warm water, and into the cavity must be inserted a small pellet of cotton-wool that has been dipped in one of the following local aneesthetic substances (it is essen- tial to squeeze the excess from the pellet, as it is undesir- able for the medicament to overflow into the mouth) : Oil of cloves. Eugenol. Creosote. Oil of cinnamon. Strong liquefied carbolic acid. Warm saturated solution of carbonate of soda. Oil of peppermint. Cocaine crystals, especially the crystals dissolved in glycerine 1 in 3. Carbolised resin is a most convenient preparation for the purpose, as in addition to relieving pain it serves as a temporary stopping for two or three days until a dentist can be seen. Formula for Carbolised Resin: Eesin • 4 parts Carbolic acid crystals . . ... 4 parts Chloroform . . . . . . 3 parts 4 CAUSES AND RELIEF OF DENTAL PAIN. In cases in whicli owing to the loss of the enamel the dentine has become exposed and highly sensitive to heat and cold, relief can be obtained almost immediately by the application of solid nitrate of silver to the sensitive area; the most convenient plan is to fuse a little of the powdered salt on the end of a probe or hair-pin so as to form a bead, which can be readily applied to any part of the mouth. When there is no visible cavity it is well to treat the pain on general constitutional principles with anti- neuralgic remedies, such as aspirin, phenacetin, chloral hydrate, antipyrin, gelsemium, and so forth. The application of iodine and aconite paint to the gums in the vicinity of the painful tooth frequently affords great relief by the counter-irritation and anodyne effect produced. Iodine and Aconite Paint, ^ Liquor iodi fortis) T • •,• r equal parts. Lm. aconiti > ^ ^ To be applied to the gums on a small swab of cotton- wool not more than twice daily. In severe and urgent cases it may be necessary to administer morphine hypodermically. In all cases, however, in which no cavity can be seen, the patient should be advised to consult a dentist, who may be able to find a dental cause not discoverable without the use of special dental appliances. Acute inflammation of the pulp is usually the result of its exposure or infection by the advance of caries; it may, however, be produced by the fracture of a tooth due to a blow, the application of arsenious acid for destroying the pulp, or as an extension of inflammation from the peri- odontal membrane. If a section be made through a tooth the pulp of which is in a state of acute inflammation, the pulp tissue will be CAUSES AND RELIEF OF DENTAL PAIN. 5 seen to be bright red, whereas a healthy dental pulp is of a very pale pink colour. Symptoms. — Pain, usually of a shooting character, brought on by food pressing against the exposed surface or by the application of heat or cold, and in its early stages characteristically intermittent. The pain is ivorse at night, when the patient lies down and becomes warm in bed, increased congestion being thus produced; the pulp is squeezed against the hard, unyielding walls of the pulp cavity. The pain may or may not be referred by the patient to the tooth really affected, a lower tooth being fre- quently indicated by the patient as the one in fault when the real source of pain is an upper one. Referred dental pain, however, never crosses the median line. Examples of referred pain. — Earache is frequently due to a carious molar tooth. Pain in the bicuspid or canine region may also be due to a carious wisdom tooth on the same side of the mouth. Course. — If the acute inflammation of the pulp be allowed to run its course untreated, the pulp usually becomes strangulated at the apical foramen and its death results ; death of the pulp, however, may not occur until a second or third attack. Treatment.- — -The first indication is the relief of pain, and this may be accomplished by the same means as for the pain due to irritation of the pulp, namely, the insertion of a pellet of cotton-wool dipped in one of the following : Oil of cloves, eugenol, creosote, oil of cinnamon, pure carbolic acid, oil of peppermint, a warm saturated solu- tion of carbonate of soda, or crystals of cocaine ; carbo- lised resin^ is also useful for this purpose, and has the 1 See " Formula for Carbolised Eesin " on p. 3. 6 CAUSES AND RELIEF OF DENTAL PAIN. additional advantage of serving as a temporary stopping for three or four days. Treatment. — If pain of a severe throbbing character has lasted for some time destruction of the dental pulp is usually advisable ; this is effected by the application of some preparation containing not more than gr. yg arsenious acid to the exposed pulp, the preparation being carefully retained in position by gutta-percha or wool soaked in sandarac or mastic varnish. Arsenic should not as a general rule be applied to temporary teeth. The process of "killing the pulp " should be in most cases a painless one ; in the cases in which much pain ensues the cause is usually the application of too tight a dressing, which does not allow of the expansion of the pulp due to the congestion produced by the arsenic. The application of arsenic for this purpose should not be undertaken by anyone without special training, as it is frequently a matter of considerable difficulty, and may cause sloughing of the gums and necrosis of the alveolus if carelessly performed. Gh,ronic siipiJiirative inflammation of the pulp usually arises from infection of the dental pulp that has been exposed by caries. Symptoms. — Pain coming on at irregular intervals of a wandering neuralgic character, which the patient may not refer to a tooth at all; the presence of throbbing is not in- frequent, and may assist in locating the som^ce of the pain. A paroxysm is often brought on by the sudden appli- cation of heat or cold, sweet or salt substances. The characteristic symptom of suppurative inflammation of the pulp is the production of great increase of pain on the application of heat. The tooth is not tender unless the periodontal membrane is involved and the gum is not swollen. CAUSES AND RELIEF OF DENTAL PAIN. 7 Treatment. — The application of local anaesthetics and sedatives on cotton-wool as for irritation of dental pulp ; opening the pulp chamber usually gives immediate relief, but is a procedure that can only be carried out with special dental instruments. General constitutional treatment must therefore be used to supplement local palliative ap- plications until skilled dental treatment can be obtained. Polypus of the p?^^^:*.— Sprouting granulation of the exposed surface of a chronically inflamed pulp may take place, the granulations growing till the carious cavity is completely filled by them, constituting what is known as polypus of the pulp ; a polypus of this kind is not usually very sensitive. Treatment. — The polypus must be cut away and the pulp destroyed by arsenious acid. Periodontitis {dental 'periostitis, pericementitis). — In- flammation of the fibrous and vascular membrane which lines the socket of a tooth and covers and nourishes the cementum is called variously " dental periostitis," " peri- odontitis," and " pericementitis." It may be general, involving the periodontal membrane of all the teeth, or local, being in that case confined to the socket of one tooth only; like inflammation elsewhere, it may be acute or chronic. General inflammation of the periodontal membrane is dependent on some constitutional condition, such as rheumatism, gout, tuberculosis, syphilis, or may be asso- ciated with one of the exanthem^tous fevers, the inhala- tion of the fames of phosphorus as in match -makers, the administration of mercury. Localised periodontitis may be acute, frequently running on to alveolar abscess, or chronic, in which suppuration either does not occur at all or is restricted to the periodontal membrane near the mar gin of the. socket. 8 CAUSES AND RELIEF OF DENTAL PAIN. Acute localised periodontitis. — Causes: (1) Inflammation spreading from a living inflamed pulp, through the apical foramen to the periodontal membrane immediately surrounding it. (2) Direct absorption by the periodontal membrane of septic m'aterial from a putrefying pulp. (3) Stopping an imperfectly sterilised tooth from which septic material is unable to escape, except through the apical foramen. (4) Injury caused by a blow upon the tooth, injuring and perhaps leading to infection of the periodontal membrane. (5) The escape of arsenic from a dressing applied for the destruction of a dental pulp. (6) Exposure and infection of the periodontal membrane supervening in the condition known as pyorrhoea alveolaris (Riggs' disease). Symptoms. — In the early stages the tooth or teeth may be merely tender and uncomfortable ; later, however, owing to the swelling of the periodontal membrane, the affected teeth become raised, as well as loose and tender to the slightest touch. The gums also become involved, since the periodontal membrane is reflected outwards at the margin of the alveolus, and become swollen and deeply congested, presenting a velvety feeling when touched by the finger. Sudden changes of temperature or weather will often bring on or accentuate an attack of periodontitis in those subject to this affection. When periodontitis is produced by mercury or phos- phorus, there is tenderness and loosening of the teeth, extreme congestion of the gums, which become spongy and readily bleed, together with great oral foetor. Ulceration with sloughing of the gums and necrosis of the jaw may ensue. CAUSES AND RELIEF OF DENTAL PAIN. 9 Ptyalism is especially marked in mercurial poisoning. General treatment. — Constitutional : Remove the cause if possible, as in the case of mercury and phosphorus poisoning. Treat general condition if gouty, rheumatic, tuber- culous, or syphilitic. Local. — Render the mouth as aseptic as possible by the use of mouth washes, of which sanitas combined with chlorate of potash lotion (gr. x to the ounce) is one of the best. In cases in which one or more teeth are involved, counter-irritation applied by first drying a large area of the gums near the affected teeth and then painting it with iodine and aconite joaint gives great relief. Formula'. R> Liquor iodi fortis ) , ^ ^ . . \ equal parts. Liu. aconiti j This should not be applied more than twice or three times daily, as it tends to make the mucous membrane so sore that further applications become impossible. The application of a capsicum plaster, which is a sort of diminutive mustard leaf, to the previously dried gum also gives great relief ; it should be held over the root of the affected tooth with the finger until it adheres, and then allowed to remain until it falls off. Chronic localised, 'periodontitis. — This condition must be treated in the same way as the above, by general consti- tutional treatment and by the application of the iodine and aconite paint night and morning, or if more con- venient by the application of capsicum plasters. Chronic suppurative period.ontitis — p)ijorrh(]ea alveolaris {Biggs' disease). — The pathology of this condition is very obscure ; it is apparently due to a pyogenic infection. 10 CAUSES AND RELIEF OF DENTAL PAIN. though in many cases the pneumococcus and Micrococcus catarrhalis may be found. Symptoms. — Those of suppuration of the periodontal membrane, phis inflammation of the gums (gingivitis), accompanied by the formation of deep pockets, from which pus exudes round the necks of the teeth, leading to destruction of the periodontal membrane, absorption of the alveolus, and loosening of the teeth. Treatment. — The treatment of this condition is exceed- ingly unsatisfactory ; at the same time efforts must be made to minimise the suppuration by the use of antiseptic mouth- washes, such as chlorate of potash in combination with sanitas, permanganate of potash, etc. In cases of suppurative gingivitis due to dental neglect, which is often mistaken for pyorrhoea alveolaris, much benefit is to be derived from a vigorous massaging of the gums with ordinary sodium chloride applied on a pledget of lint twice daily for a Aveek at least; arrangements should also be made for a thorough scaling of the teeth by a dental surgeon at the earliest opportunity. In cases of genuine pyorrhoea alveolaris zinc ionisation accompanied with the use of an autogenous vaccine is sometimes of great benefit, though, as before, a thorough scaling of the teeth is an essential preliminary. Alveolar abscess. — An abscess arising from a tooth is known as an alveolar abscess or " gum-boil"; it is usually situated at the end of the root of a tooth. Causes. — Extension of septic infection from the pulp or periosteum of a tooth. Symptoms. — Those of periodontitis much intensified, e. g. the tooth is raised and tender; the gums are swollen, deeply congested; pus frequently wells up at side of tooth. Sulcus between cheek and tooth instead of being hollow is filled up by a globular or diffuse swelling. CAUSES AND RELIEF OF DENTAL PAIN. 11 Sometimes diffuse cellulitis of the face occurs, the whole cheek becoming swollen, tense, shining, very painful, and the eye closed if the abscess is connected with an upper tooth. The pus from an upper tooth may burrow into the antrum in the case of upper bicuspids (or molars), or be directed towards the palate (upper lateral incisor) either between the periosteum and the bone, when there will be great pain, or between the periosteum and the mucous membrane, when there will be but little pain, since the tissue in that situation is somewhat lax and therefore yields readily. When an abscess it situated at the root of a lower molar, particularly a lower wisdom tooth, trismus may occur from : - (1) Spasm of the masseter, which symptom will dis- appear under an ana3Sthetic. (2) Inflammatory infiltration of the masseter, in which case the administration of an anaesthetic will simply enable the operator to apply the necessary force to open the jaw with a screw wedge or Mason's gag. An abscess from a lower wisdom tooth sometimes points beneath the angle of the jaw, and an abscess connected with any lower tooth may burst either through the cheek or beneath the margin of the mandible. The subinaxillary lymphatic glands may become infected, in which case they will be swollen and tender. The submaxillary lymphatic glands in children are SGipetimes infected with tubercle, probably conveyed to the glands by carious teeth with exposed pulps. . Treatment of alveolar abscess. — When an alveolar abscess has already formed, great relief will usually be obtained by incising the abscess in the mouth. In cases in • which the abscess is very large and is threatening to burst, outside the cheek, it is wise to apply 12 CAUSES AND RELIEF OF DENTAL PAIN. a piece of gauze with flexible collodion over the thinned area of skin, and thus to minimise the danger of or prevent the occurrence of an external opening ; at the same time efforts must be made to make the abscess point in the mouth, and this is best done by the applica- tion of a roasted dried fig or a dried fig squeezed dry from boiling water and held in the mouth over the abscess ; it is often necessary to apply a succession of these fig poultices. Poppy-head fomentation, made by boiling two ounces of bruised poppy-heads for ten minutes in a pint of water and held in the mouth, often gives great relief and may shorten the course of the affection. In severe cases of alveolar abscess extraction of the tooth is the only course open to the medical practitioner, and the sooner it is done the better for the patient ; the old idea that it is necessary to wait till the inflammation has subsided is often disastrous, as it may lead to the formation of an external opening in the cheek and perma- nent scarring of the face. An abscess arising from a lower wisdom tooth usually necessitates its extraction ; this is often a matter of great difficulty, and can only be accomplished by using the elevator ; it sometimes happens that it is impossible to reach the wisdom tooth, in which case it may be necessary to remove the second lower molar before dealing with the offending wisdom tooth. Local ansesthesia in the extraction of teeth. — The hypo- dermic injection of certain anaesthetic solutions is in a considerable proportion of cases successful in enabling the extraction of teeth to be performed painlessly. At the same time it is essential for the operator to know exactly what he is injecting and the exact amount and purity of the active ingredient contained in his injection. CAUSES AND EELIEF OF DENTAL PAIN. 13 jSTothing can be more dangerous than the injection of the much advertised proprietary local anaesthetics, many of which contain an indefinite amount of cocaine, and which within the writer's knowledge have over and over again produced serious results. The most widely used preparation for dental local anaesthesia is probably novocaine combined with adren- alin ; special dental tablets are made for this purpose, and when boiled in a test-tube with 1 c.c. of normal saline provide an admirable local anaesthetic for dental use. A very satisfactory syringe is that designed by Dr. Dawson, of Dublin, as it is readily sterilisable, and more- FlG. 1. over, by reason of its " finger-rings," affords a perfect command over the barrel and piston. The special " washerless " syringe sold by the Dental Mfg. Co. of London is specially suitable for dental local anaesthesia. Procedure. — (1) The patient's mouth should be thoroughly rinsed with sanitas and water or a perman- ganate of potash mouth- wash. (2) The syringe and needle are next sterilised with 1 in 20 carbolic lotion. (3) If novocaine is used the syringe should then be filled with 17 minims (1 c.c.) of the solution, and then an injection made of about 12 minims on the external and 4 minims on the internal side of the alveolus, the 2 14 CAUSES AND RELIEF OF DENTAL PAIN. aim of the operator being to surround the tooth with a zone of ansesthesia, and for this purpose at least two punctures are necessary. The point of the syringe should be inserted about 3 mm. from the free edge of the gum adjacent to the tooth to be removed ; the needle should be inserted quickly and the injection made very slowly, the syringe being held in position for some seconds after the requisite quantity has been injected. When the gum becomes blanched, and not till then, the ansesthesia may be regarded as complete. Hypodermic injections into the gums should not be made — (1 ) In inflammatory or suppurative conditions of the mouth. (2) In cases of alveolar abscess. In such cases the application of cotton- wool soaked in 10 per cent, novo- <3aine for some five minutes will much alleviate the pain ■of a dental extraction. The local anaesthesia that can be produced by freezing the gums with a spray of ethyl chloride is frequently very useful in the case of temporary teeth and readily acces- sible single-rooted permanent teeth, but it must be borne in mind that it has a great tendency to cause the teeth to l)ecome brittle owing apparently to the freezing of their " organic " matter, with the result that they may be very readily broken during the attempt at extraction ^nd thus lead to much difficulty. GENERAL NOTES ON EXTRACTION OF TEETH. 15 GENERAL NOTES ON EXTRACTION OF TEETH. The minimiini number of forceps that can be expected to deal with any ordinary case of extraction is five, and tliis number combined with a " fish-tail " elevator will be sufiicient for practically every tooth. In Figs. 2 and 3 the patterns suggested are shown together with a pair of "conveying forceps" such as are very useful for apply- ing medicaments on cotton-wool for the relief of pain, and also a dental probe for ascertaining the exact position and extent of carious cavities. The use of so-called "straight" forceps for lower molar and bicuspid teeth is not recommended, as they are exceedingly difficult to use and do not provide nearly as much leverage as those of the so-called "hawksbill" pattern as shown here. The blades of all dental forceps must be bevelled so that they grasp the teeth on a flat and not a sharp edge, as is frequently the case with ill- clesigned forceps, which simply break the teeth instead of grasping them. The " straight " elevator is not recommended, as not only is it difficult to* use but is an exceedingly dangerous instrument in the hands of one nnaccustomed to its use. It is of the utmost importance that all instruments used for extracting teeth should be efficiently sterilised, ■either by boiling or else by prolonged soaking in a solu- tion of carbolic acid (1 in 20) or lysol; it is also essential that the forceps should be clean in the ordinary sense of the word before being placed in the antiseptic lotion. Inasmuch as few medical practitioners possess the luxury of a dental operating chair, a convenient substitute 16 GENERAL NOTES ON EXTRACTION OF TEETH. 6 I— I GENERAL NOTES ON EXTRACTION OF TEETH. 17 ■CO 6 18 GENERAL NOTES ON EXTRACTION OF TEE'J^H. can be readily devised as shown in Fig. 4 by placing two strong cLairs back to back against a wall in such a way as to prevent the chair in front being tilted backwards by the flinching of the patient or the efforts of the operator. This plan, combined with such other positions as ar& Fig. 4. A. Cnsliion on back of chairs. B. Chair resting firmly against a wall. shown in dealing with particular teeth, is sufficient for every case. Special care must be taken when extracting a tooth that stands alone ; it frequently happens that the gum is firmly adherent to a tooth of this kind and may there- fore be seriously torn during the process of extraction ; in such a case it may be necessary to cut away the tag^ of gum with a lancet or scissors. THE EXTRACTION OF TEMPORARY TEETH. 19 THE EXTRACTION OF TEMPORARY TEETH. All the temporary teeth except the molars have one root. There are no bicuspids in the temporary dentition. The position of the temporary molars is occupied by the bicuspids in the permanent dentition. The hiciispids erupt between the roots of the "tem- porary molars," and therefore occupy their position when they are lost. In extracting the temf ovarii teeth the paiient should he Fig. 5. The temporary teeth. placed in the sayne position as for the corresponding per- manent teeth. General principles. — Grasp the crown of the tooth firmly in the forceps. In the case of a temporary molar it is important tO' avoid pressing the forceps upwards or downwards to any appreciable extent for fear of removing the crown of an on-coming bicuspid which Ties between its roots ready to take its place. For tipper incisors or canines use " straight " or bayonet root forceps. For upper molars use right or left upper molar forceps or bayonet root forceps in cases where the crown is much broken down. 20 THE EXTRACTION OF TEMPORARY TEETH. For lo'wer incisors and canines use lower hawksbill root forceps ; the same forceps can be used on either side of the mouth. For lower temjyorari/ molars use lower hawksbill molar forceps or lower hawksbill root forceps. Broken-down temporary teeth and roots can either be extracted with root forceps or prised out with the " fish tail " elevator, making use of an adjacent tooth as a fulcrum. It is quite 'unnecessary to have special forceps for temporary teeth. It is important to avoid extracting prematurely a second temporaru molar ; loss of this tooth ma}^ lead to a moving forward of the adjacent first permanent molar and consequent crowding and irregularity of the bicuspid teeth. The temporary canines should also be retained until their permanent successors show signs of erupting ; premature extraction of the temporary canines allows the bicuspid teeth to move forward and thus may lead to the deformity of projecting canine teeth. Undue retention of the temporary teeth may, on the other hand, lead to irregularity of the permanent ■successors ; in cases of doubt it may be well to postpone extraction until the advice of a dental surgeon can be obtained. Dentition Table. The following table shows the order in which the milk teeth and permanent teeth appear, and the average age at their eruption. There are wide variations as to time, and great irregularity in the order of their appearance. Milk teeth. — The first dentition bea^ins at the sixth or HAEMORRHAGE AFTER EXTRACTION. 21 seventh month, and is completed by about the second year. (1) lower, 6th month; (2) upper, 7th month. (1) upper, 9th month; (2) lower, 10th month. 12th month. 18th month. 2nd year (often later). The full primary dentition is 20 teeth ; 10 in each jaw. Central incisors Lateral incisors First molars Canines Second molars Permanent teeth : First molars . Lower central incisors Upper central incisors Lateral incisors First bicuspid Second bicuspid Canines . Second molars Third molars (wisdom) 6^ years 7 „ 9 10 11 12 13 „ 17 to 25 years, or at any later period. The full permanent dentition is 32 teeth; 1 6 in each jaw. HEMORRHAGE AFTER EXTRACTION: TREATMENT. Local. — In slight cases it is sufficient for the patient to sit quiet with cold or iced water in his mouth ; where ice cannot be obtained holding vevj/ hot water in the same way is often successful, especially if alum be dissolved therein. It is not infrequent, however, that blood will continue to well up from the socket from which the tooth has 22 HEMORRHAGE AFTER EXTRACTION. been removed ; in such a case it is necessary to syringe the socket with ice-cold or very hot water or boric lotion, and then to apply pressure to the bleeding point by firmly plugging the socket with cotton-wool or lint soaked in fresh adrenalin or other supra-renal gland preparation ; the application of tannin, either as glycerin of tannin or on wool soaked in hazeline and powdered with tannin, answers in many cases. Perchloride of iron is a most unsatisfactory remedy, and should only be used as a last resource when nothing else is obtainable. Gonstitutiunal. — It is not uncommon for an operator to be warned by the patient that excessive bleeding has pre- viously followed the infliction of a cut or the extraction of a tooth. It has been shown that a large proportion of these cases are due to insufficient coagulability of the blood owing to an insufficiency of calcium salts ; it is therefore wise in such cases to administer one of the drugs which are known to rapidly increase the coagulability of the blood. Calcium lactate, calcium chloride, and magnesium carbonate have all been shown to produce this effect in a marked degree within the space of an hour or so ; the salt selected should be administered in a single dose of 3J the night before the proposed operation. The best and most pleasant to take is calcium lactate, which may be administered in compressed tablets or in a draught such as the following : P) Calcii lactatis . . . . . . . 5j- Syrup q.s. Aq. ad 3J. Fiat haustus. — To be taken as a draught the night before the dental extraction takes place. The effect of these salts appears to last about three to four days, so that in the event of dental extractions being performed on successive days a second dose is not called for. PMN AFTER EXTRACTION. 23 PAIN AFTER EXTRACTION. Pain after the extraction of a tooth may be due to the lateral displacement of the alveolus which is brought about by the application of the forceps ; this can be minimised by applying firmly a finger and thumb after the tooth has been removed and so restoring the alveolus to its former position. Besides this, owing to the socket becoming septic either from the operator making use of unsterilised instruments or else operating in a mouth that is very foul, pain may continue in a tooth socket for a consider- able time. To avoid this every mouth, before operation, should be made as clean as possible by the use of tooth powder and sanitas and permanganate of potassium mouth-washes,^ and after the extraction has taken place every effort must be made to keep the socket free from the remains of food and other decomposable matter. If, two or three days after the extraction, the patient complains of pain in the socket, the treatment is to keep it syringed out with sanitas and water or weak permanganate lotion. A pledget of cotton-wool soaked in liquor potassae and pure carbolic acid, equal parts, usually affords immediate relief from pain after the socket has been syringed out in this way. INDEX. Aconite and iodine paint, 4 Acute inflammation of pulp, 4 Alveolar abscess, 10 AnEesthesia, local, 12 Anodyne applications, 3 Arsenic for dental pulp, 6 Bicuspids, extraction of riglit and left upper, plate 3 of i-ight lower, plate 4 of left lower, plate 5 Biniodide of mercury, 15 Calcium chloride, 22 — lactate, 22 Canines, extraction of upper, plate 1 of lower, plate 2 — temporary, premature extraction of, 20 Carbolic acid, 3, 5 Carbolised resin, 3 Carbonate of magnesium, 22 Chair, operating, 18 Chloride of ethyl, 14 Chronic periodontitis, 7 — suppiirative inflammation of pulp, 6 Collodion, flexible, 12 Dentition table, 20 Destruction of dental arsenic, 6 pulp by Earache, 5 Elevator, use of, plates 10, 11, and page 15 Ei-uption of teeth, order of, 21 Ethyl chloride, 14 Extraction, haemorrhage after, 21 — pain after, 23 — of temporary teeth, 19, 20 — of permanent teeth (see under names of teeth). Fig-poultice, 12 " Fish-tail " elevator, plate 10 Fomentations, poppy-head, 12 Forceps, 16, 17 Gag, Mason's, 11 Gingivitis, 10 — naistaken for pyorrhoea alveolaris,. 10 Glands, infection of, 11 Gum-boil, 10 Haemophilia, 21 Haemorrhage after extraction, 21 Hawksbill forceps, 15 Improvised oj)erating chair, 18 Incisors, extraction of upper, pla.te 1 — — of lower, plate 2 Inflammation of the pulp, 1, 4 "26 INDEX. Inflammation of periodontal mem- brane, 2 Instrviments, sterilisation of, 15 Iodine and aconite paint, 4 Lactate of calcium in lisemopliilia, 22 Local ansestliesia, 12 Mason's gag, 11 Masseter, spasm of, 11 Mercurial poisoning, 7 Mercury, biniodide of, 15 Molars, extraction of right upper, plate 6 of left aipper, plate 7 — — of riglit lower, plate 8 — — of left lower, plate 9 — pi-emature extraction of tempo- rary, 20 Novocaine, 13 Operating cliair, 18 Pain after extraction, 23 — referred, 5 Percbloride of iron, 22 Periodontitis, 7 Phosphorus poisoning, 7 Polypus of pulp, 7 Poppy-head fomentations, 12 Potassium chlorate, 9 Ptyalism, 9 Pulp, inflammation of, 4 Pyorrhoea alveolaris, 8 Referred pain, 5 Resin, carbolised, 3 Riggs' disease, 8 Roots, extraction of, plates 10, 11 Scarring of face, 12 "Straight" forceps, 15 and platfe 1 Stumps, extraction of, plates 10, 11 Suppurative inflammation of dental pulp, 6 Syringe, Dawson's, 13 Tannin in haemorrhage, 22 Teeth, order of eruption of, 21 ■ — permanent, plates 1-11 — temporary, 19 Temporary teeth, extraction of, 19 ■ — — premature extraction of, 20 shapes, 19 Trismus, 11 Yaccines in pyorrhcea, 10 Wisdom teeth, extraction of lower, plate 10 of upper, plates 6, 7 Zinc ionisation in pyorrhoea, 10 LIST OF PLATES. 1. Extraction of Upper Incisors and Canines. 2. Extraction of Lower Incisors, Lower Canines, and Incisor AND Canine Roots. 3. Extraction of Right and Left Upper Bicuspids. 4. Extraction of Right Lower Bicuspids and Lower Roots ON THE Right Side op the Mouth. 5. Extraction op Left Lower Incisors, Bicuspids, and all Roots on Left Side op Mouth. 6. Extraction of Right Upper Molars. 7. Extraction of Left Upper Molars. 8. Extraction op Right Lower Molars. 9. Extraction of Left Lower Molars. 10. Extraction of Upper and Lower Roots and Lower Wisdom Teeth. 11. The Use of the Elevator for Extracting Lower Stumps AND Lower Wisdom Teeth. PLATE 1. Extraction of Upper Incisors and Canines. fe < Q Q ^ <1 CO 03 • c 1 — 1 m o H !z; H 1— 1 <1 M ^ ^ fM CM CM U^ o b - Ph 03 in ■A o % ce cq "^ -(-:> _g a 'r-] .2 a> -p ri2 ft bJD bD rH m 4^ '^ rjl Pi 'id cS d ^ s s be ^ fcl)g cC c3 ce 2 — -^^ rH -fJ ■^ c3 fl -S .1=; «ti § 2 ^ ^ .^ -(-) ti: 3i ri~- 2 =3 2 .2^ ni a3 9 "3 ^ S.1 O fli . O r^ o 2 tooth anter t teetl :of t at tl ent. 's^ s di ^ d si H ^r; -+-i rS - photos. ards between i er to loosen, ai b from its attac -U tl-l hen withdraw alveolus toge 11 the case of S ^'p-^ -^^ CO -r-i .3 ^ !-, 02 -t^ d 9 M c3 a o U. o Apply blades ; Press forcibly Rock gently ii order to f When quite lo r extraction pres; specially import s ,2 -2.2 '+3 C3 ^S y a a < PLATE 2. Extraction of Lower Canjnes, all Lower Incisors, AND Incisor and Canine Roots. w. EH O O P^ H !?; S o m ^ -p 1— 1 0) ■4J Q ;?; u ol i •N Tj: CQ •S P5 'O! o if^'rt ^• ££=^ 2 s rt g §3^ r' ^ c3 - -. o ^ ^ D. V ^ o >^ w . . n:3 S -e o Appl Pres Eock Whe r extrac c o a> -ij '■^Z ^j CS <^ o a a < - PLATE 4. EXTEAGTION OF RiGHT LoWER, BlOUSPIDS AND LoWER Roots on the Right Side of the Mouth. 53 Q m m (N3dO) 3ZIS Tin J ^ o M b o P^ ^ ^ e: K H <1 -1 1 — 1 H^ Cj Pi ^ -< p o O !3 0/ 2^3 Ph *■ I— I s o C; c p^ '!^ «s ^ ^ o _1 o b < ^ >< H •S ,£3 h3 .3 +3 S S I § ^ 3 O ^ gr^ 01 -*^ r^ rQ '^ ^ 4^ -2 £ 3 2 K o cc -*-^ O r. r- bi X ai .. M O O t/j W ^ '7^ £ « fi p; IZ! _ o o o e, s C a a < o PLATE 5. ExTEAOTioN OF Left Lower Inoisoes, Bicusfids, and ALL Roots on Left Side op Mouth. H ■ Q c o o (N3d0) 3ZIS Tin J u OS o 13 1— 1 OJ m o ^4 rn ^ I—* '&D o .S f» 'S o bD :< _fl 1— 1 'S o P5 CO rH 1—1 o ^ CO o o PI vA ?H « H ^ pu o H ^ rA 1 m fcn O )^ J2; o h- 1 H o <:: D^ &H M f^ a) O CO 4^ F r^^ Pi 0) PI o ^ Ph ctf O fl O cti cS q-i O ■r-t hr '^ 5c Pm ^75 S eg 3 ^ fcj:t^ s be o .3 Ti ^ a rt c^ S M P rc! H ?^ b c« S ^ ^^ !=^ u o U. c _o 03 a < $ M ci o . ^, ?> fe "^ O) ^ ^.^ §? f^r— I CP O -rrt +^ o. O '-' " rH ^^ ^_s _^- 02 S '-+2 Oi 5P 2 S ^ PLATE 6. Extraction of Right Uppepi, Molaph. -iJ rf, O P^ P^ cS tj +-' -P rrt J- -w ^^ .2 H .Si :j5 •ep-Biq a8:;no a. o P H ^ H o <^ P^ 1— 1 Pm o 12; o H o <; ci ;l-i XI H ■epiJi^q .13^X10 13 03 2 ° o .^^ •" H m o5 M OJD+e d f^ 2 <^ 03 o o a p te '^^ ar for has t viccal 3 two _i3 ■O OJ '^ r^ -jd "^ ^ S S'ii- L. 03 '" 03 1 pL,^-^ 03 ^ §^1^1 ia pi s » rrL^ > -tJ ScOocpl w .S S ra fe fl 03 a i-r< rt S CO S •73 03 o -p -e ^ J.4--. 03 S-5 03 ?3 ncj o3 o; ^ 03 ^ ^ r^ g S >< 03 -p S q-i 03 -rH O O <5 ^ 4^ 4!j rH 3 O '* O O ^ 'P, ^ f^ g » & , OJ "" -s ^ s « "" eg rCl ^ CO .pH ^ ^ O P-, bo 8. a o o • S o3 'ci Pa be ■73 OJ I) Ti o p «; f t &-S o 42 si_s o '::t5 •r-l r-( 'T'. _, a u o a a < 3 S !3 CO CB ^ -^^ o S § g O ^_0 ^ ^ r^ - p-l o .If <^ PLATE 7. Extraction of Left Upper Molars. \^ o p-( o o <1 EH •ap-exq Ja^iiQ * -rt 'o <» i i-H o .gq-i s S^ o "o Ji "" S-:: 2 2 J; gn ^ ar-43 >^ t^'l ^ ;^ =^ ^ a. O ^ ts a; -^ o3 ^ "*^ OJ «<-i '3 be .. i a to < C5 r-H 02 'c3 f> - 5 < pq u o 3 ^ op OS O ^ 5-* ri >~,+^ ^^Ti o eg g o S ^^ c^ O m 0) r-l S CD .1^ ^ pi ,^3 ^5 be o -^ o ^ <= a; =^=^ CD O ^ fH -t^ 5£ oi pi — I m "o >.^ -& S P o3 2 -' fii '~' <-] o ce g ^ O 1-3 ^'^ X -1^ M 25 ^^ CD =2 o ^ f^ H fi cri O M CD 2 o P •S -?fi;^i e ;-^ ce :; ■^ ,—1 S "^ 13 ' ' i-H &£i— I rj ce " XI I— I 0^ m ^^ a >i ce O) OJ > V. ce ^ O^ o PLATE 10. Extraction op Upper and Lower Roots and Lower Wisdom Teeth. EH c <1 o o p^ o Q o ><1 0) o o o o ^ -2 c3 -^ .— 1 s § bo s ;^ o 1=1 o Ph p o ■4^ o X o ° 'S ■4J rP Ph CD O O ■75 CD i^H ?H © CS (T) ^3 i; o Ph o o o o 4^ o o CO c3 •^ ^^ ^ -^^ <^ rH ^ .s o I — I -u O Ph Q 03 .p ^ q-H o 03 03 .2 ;h o P. -1-2 o 03 •I — 5 O ;h Ph Ph CD 03 O ^ 03 >> ^ CD -1-3 © U o fl «+H O) m Ph c3 O rH o o -M -1-3 o • r-H '~^ n o © o ^ S g © o ^ ^ o © i^ ^"^ =+H © -^ r^ ^ P tS 02 -l-i © O .,. o © -1-= o S «3 3 0^ 2 ^ o -3 © © O! © 03 •l-H © 03 © -1-3 «+H O © -1-3 ^4-1 O © © Ph © =+H © , ^ Ph bJD o3 n © 03 £ "+3 © o o Ph -1-3 © © -^3 ,(J S © © O -1-3 © -1-3 O o o «4-i o © o -1-3 O §^ i^.^ © s © ^ " r1 ^ >ll Oj Ph i-h'' Ph ^3 O Ph 02 © -^3 O © «+H o rH 03 •PI •■-' Ph -^3 ^ s o3 P rP ^ © P Ph © © o o © o C3 Ph -1-3 P © © o .52 ^ tS © P ce § o o ^ r^ © 02 -^^ r^ -^ -^3 ^ 03 HH O -t-3 © -4-3 O •^ Ph -zs © _^;) P O! s § 02 p ^ P oT ° Ph 03 P •'^ O -M ^ -rH ^ 02 S^ o © o R 02 -^3 ■4^ O P c3 -i-j o c3 >^ © t4-H © o Ph biD P •rH o 4J © >-. P o -^3 o3 Ph -^3 © Ph O «4-H © -4-3 o o rP n5 P P rH c^ ce rH -4J © rP ^ r^ -4-3 © bp -4J ■fll '^ t>^ OS >^ .P t> Ph ^ © P © P Ph Ph be P O • rH 02 O © © -4-3 © -^3 p" «-H o 5+-I O 03 © r-i -4-3 O O Ph =+H 03 Ph © P CO TS n3 P © rP I- o ■40 03 © be -4^ P !> © rP © © ^ p ^ 7^. K^ -(-3 © r^ 03 o 03 © O* © n3 rP -4^ s ^ - © P © -4J O o Ph «4-H o P o p rP P O 02 C3 02 Ph O -^3 © c3 © © n:3 © Ph P O CM ^ ce ^ "o 'Ph 3 a i-H o £ s ^ & ^ o .^ =4-1 c» O i-H c3 !> O a -J UJ r OJ C« o O ^M O CD ^ q3 O IS 03 CD r^ o CD 'qjo o CD o =4-i CD O O E H UJ UJ O Q c/5 O bij o p o ?H CD > S ^ "^ .S .3 -^2 o p. f-j ;-i CD -1-2 CD o f— 1 o rO o (-1 O ^ H ?-4 r-H -(-2 O -1-2 O ^ ^ o o CO fl ^ -1-2 ■? o a ' 'o g p r^ o s m o •^ ^ ts o 02 ^ O CD CO "? -1-2 s CD o CD c5 -1-2 ,^3 -1-2 O rH -2 c3 m o rH t> r^ -tJ O 0) "^ -1-2 o -Ul ^ O CD s o O 1— 1 ^ ;h «+H