COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64069907 RK301 .P34 The diseases of chil RECAP ... H .J JL^ i \ N^S T K:N 'J. EATMENT. ? Kl T O r\ XT ID TP T> PEDLEY, .■!iCi!mi:e^wiim:*^'^'-'-^Z(Ut:;»i»iSsm Columbia ^nibersiitp in tfjc €it^ of i^eto gorli ^cfjool of Bental anti (I^ral burger? i^eferetice Eitiratp THE DISEASES OF CHILDREN'S TEETH, THEIR PREVENTION AND TREATMENT. THE DISEASES OF CHILDREN'S TEETH THEIR PREVENTION AND TREATMENT. A MANUAL FOR MEDICAL PRACTITIONERS AND STUDENTS, R. DENISON PEDLEY, M.R.C.S., L.D.S. Eng. F.R.O.S. Edin. Dental Sitrgeon to the Evelina Hospital for Sick Children^. Soitthwark, London. Wi\i\) numerous Illttsitmtiong. Published in London by J. P. SEGO & CO., 289 & 291, EEGENT STREET, AA\ In America by the S. S. WHITE DENTAL xVIFG. CO., CHESTNUT STREET, PHILADELPHIA, PA., U.S.A. All Riijhts Reserved. frao I AS A TEIBUTE OF ESTEEM AND AFFECTIONATE EEGARD, I DEDICATE THIS BOOK TO MY FATHEE, GEORGE PEDLEY, FEOM WHOSE EIPE EXPEEIENCE I HAVE LEAENED MOEE THAN I CAN TELL. Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/diseasesofchildrOOpedl CONTENTS. COJVTEJVTS. INTRODUCTION STEUCTUEE ERUPTION CARIES PAGE 1 CHAPTER I. CHAPTER II. CHAPTER III. CHAPTER IV. INFLAMMATION OF THE PULP. PULPITIS CHAPTER V. INFLAMMATION OF THE PERIODONTAL MEMBRANK, PERIODONTITIS, ALVEOLAR ABSCRSS, NECRO- SIS, AND OTHER SEQUEL.E CHAPTER VI. IRREGULARITIES OF THE TEETH a. Irregularities of Sfriicture in Temporary and Peruia nent Teetli b. Irregularities of Form in Temporary and Permanent Teeth c. Irregularities of Number in Temporary and Perma- nent Teeth d. In'sgularities of Position in Temporary and Perma- nent Teeth ... e. Overcrowding of the Teeth and Its Treatment 15 33 45 51 67 68 77 7'J 84 lie CONTENTS. PAGE CHAPTER VII. THE HYGIENE OF THE MOUTH— In the Home 133 In the School 143 In the Hospital. The Relationship between Dental and other Diseases ... ... ... ... ... ... 150 CHAPTER VIII. TREATMENT— a. Examination of the Patient 184 b. The Instruments Required 185, 234 c. Toothache in Temporary and Permanent Teeth 186, 194 d. Stopping or Filling of 205 214 (i) Temporary Teeth (ii) Permanent Teeth e. Extraction of Temporary and Permanent Teeth f. Injuries of the Teeth (J. Tartar and Its Removal 235 254 259 PREFACE. ix. PREFACE. QO numerous are the subjects to which the attention of the Student of Medicine is necessarily directed while passing through a Hospital training, that, in most instances, the Dental Department is neglected. It is when settling down in the country, where the area of practice is wide, and the opportunities of obtaining skilled dental assistance are few, that the Practitioner of Medicine finds much reason to regret the absence of a knowledge of Diseases of the Teeth, and the means by which they may be prevented. As children form so large a proportion of the patients he is called upon to treat, I am not without hope that the Greneral Practitioner X. PREFACE. may find in the following pages some facts worthy of his consideration. If I may venture — from a Dental Practi- tioner's point of view — to offer a word of advice to the Student of Medicine, it is that he should supplement his reading by a brief course of practical work in the Dental Department of his own hospital, where he may possibly learn how teeth are saved as well as lost. In the chapter on Treatment much will be found that is as applicable to adults as to children, for Caries of the Teeth is essentially the same in both. Although writing particularly for the Student and Practitioner of Medicine, I have en- deavoured to embody in these pages informa- tion which, I hope, may prove of service to the Student and Practitioner of Dentistry . In the preparation of this Manual, I am deeply indebted to Mr. Sidnky Spokes, Dental Surgeon to University College Hospital, for material assistance. PREFACE. To Dr. Arthur Nkwsholme, Medical Officer of Health for Brighton, I am also indebted for his kindness in correcting and approving the chapter on " The Hygiene of the Mouth." The Illustrations from Models and Photo- graphs have been drawn by Mr. Alfred Beauchamp. My thanks are tendered to Messrs. Aish & Sons, of Broad Street, Golden Square, W., for placing at my disposal most of the illustrations of instruments. Richard Denison Pedley. London, October, 1895, INTRODUCTION. IN order to claim attention for a consideration of the connection between Disease in child- ren and abnormal dental conditions, it is only necessary to refer to the large proportion of cases occurring during Infancy and Childhood, in which the digestive tract is at fault. And if it be true, as some have taught, that failure of the digestive tract is increasing, it also appears true that dental caries is accompanying it with equal step. Indeed it may rather be suggested that the prevalence of dental disease has been preparing the way for the manifesta- tion of other departures from a normal perform- ance of the function of nutrition. Although from time to time the matter has been referred to by physicians writing upon such subjects, it is scarcely too much to say that only within recent years has the importance of the teeth in CHILDREN'S TEETH. connection with the maintenance of good health, received anything like proper considera- tion at the hands of medical practitioners, and that even now there is need for further recog- nition. The departure from a normal standard becomes, perhaps, of still greater importance in those pathological conditions in which the organs of digestion are essentially at fault. Situated as the teeth are, at the very entrance of the alimentary tract, and concerned, as they are, in the function of nutrition, it becomes a matter of vital importance that their preserva- tion in a state of functional integrity should be the first care of those who are consulted upon, or find themselves charged with, the manage- ment of cases in which there is faulty assimila- tion. Recent investigations in bacteriology have not only explained the way in which the teeth themselves are destroyed, thus influencing more or less directly the general condition of health, but they have also been the means of suggesting a. hitherto unrecognised factor in the causation of various diseases, the origin of which has frequently been looked for elsewhere outside the body. It is now evident that the mouth, besides containing normally some six or INTRODUCTION. eight kinds of micro-organisms, forms an excellent incubator for the cultivation of many other forms of bacteria, and when in addition to its natural advantages, unhealthy teeth are present, themselves the foci of decomposition and microphytes, it becomes manifest that it may be necessary to look in the mouth for a possible source of infection in such instances as when pneumonia or actinomycosis attack a patient without appreciable cause. These points are considered later on, but are alluded to as show- ing the necessity of recognising that a diseased condition of the teeth may be an indirect cause of constitutional complaints of an infective nature, and also help to directly induce and maintain an abnormal condition in the function of nutrition. It is proposed to present, in the following pages, a short account of the most important of those points of dental pathology and treatment occurring in children, which the fully trained medical practitioner should be cognisant of. In the first place it may be well to remind the reader, briefly, of the origin and structure of the tooth tissues, as these have an impor- tant bearing upon what follows, both from a CHILDREN'S TEETH. prophylactic and restorative point of view. In order to emphasize the importance and value of preventive treatment, the Hygiene of the Mouth in the Home, in the School, and in the Hospital ward has been fully considered, ^n attempt has also been made to prove the relationship which exists between dental and other diseases. STRUCTURE. CHAPTEE I. STRUCTURE. FOR the purposes of description each tooth consists of a " crown," the part exposed in the mouth, and which is separated from one or more " roots " (implanted in the jaw) by the constricted portion called the '*neck." The surface of a crown nearest to an imaginary median line at the front of the mouth is called the '* mesial," that farthest away the " distal ; '' whilst the aspect opposite the lips and cheeks has been named " labial " or " buccal " accord- ing to whether the tooth is at the front or at the side of the mouth; and the terms " palatal '' or " lingual '' suffice to describe the inner sur- faces. Although the hard parts of a tooth remind one of bone it is to be remembered that the teeth do not belong to the skeleton. The dentine and cementum more closely resem- ble bone in formation, whilst the other tissue, enamel, is of epiblastic origin. CHILDREN'S TEETH. Bonfc of socket. Periodontal Membrane. Cementum with lacunte andcanaliculi, devel- oped from submucous tissue. Organic 33 per cent.jinorganic 66 per cent. Dentine; developed from submucous tissue ; Or- ganic 18 per cent., Inorganic, 72 per cent. — Pulp ; Blood - vessels. Nerves, Connective tissue, developed from sub mucous tissue. Enamel; developed from Epithelium ; Organic 3 percent.. Inorganic 97 per cent. Fig. 1.— DIAGEAM OF A VEETICAL SECTION OF A TOOTH AND ITS ATTACHMENT. One side only of the socket is represented and part only of the Dentine. STRUCTURE. Enamel, — In enamel we have the hardest tissue in the human body ; it covers the whole of the crown or exposed part of a tooth, being thicker where there are cusps and terminating at the neck by a thin edge which is slightly overlapped by cementum. It is composed of prisms, closely joined together and placed at right angles to the surfaces of the crown, and, according to the generally accepted theory, it represents in a calcified condition the original soft columnar epithelial cells of the embryonic tooth germ. Where well-developed and intact, enamel presents a pearly lustre and protects the tissue beneath, for the very small percent- age of organic matter present does not afford sufficient pabulum for microbes. On the other hand, the surfaces of the crown of a tooth are not plane and the elevations of enamel necessi- tate the existence of corresponding depressions, or pits and fissures, in which retained particles of food undergo fermentation with the forma- tion of acid. Although enamel is hard enough to turn the edge of dental instruments, it occa- sionally becomes chipped tlirough the improper use of a tooth. In cases of faulty development, where possibly a deficiency of lime-salts has CHILDREN'S TEETH. prevented a complete calcification, the enamel will present a chalky aspect, and this can also be noticed where, the tissue having been per- haps originally good, the process of decalcifica- tion has commenced. In other cases in which the proportion of organic matter present is still larger, the enamel may be observed to be brownish in colour. In the deciduous dentition the colour is generally lighter although the density is supposed to be less. Dentine. This tissue, which makes up the large mass of tooth substance, consists of a hard matrix penetrated throughout by a system of minute tubules running spirally from the centre towards the periphery, and each containing a dentinal fibril — a fine process from the cells upon the surface of the pulp. The tubules divide and give off branches, and, in the root portion of the tooth, terminate beneath the cementum in what is termed " the granular layer " of dentine, a system of uncalcified loculi by means of which the protoplasmic elements of the two tissues are brought into relationship. With regard to the matrix, recent observations show a much closer analogy to bone than has hitherto been supposed. According to the STRUCTURE. latest views* the matrix consists " of a reticu- lum of fine fibres of connective tissue modified by calcification, and where that process is com- plete, entirely hidden by the densely deposited lime-salts." It is proposed to call these '' odonto-genic fibres, " not that they are regarded, any more than the osteogenic fibres of bone, as the actual material of which the tissue is composed, but merely as the scaffold- ing upon which it may be built up. There are also reasons for supposing that there exists a lamination of the matrix concentric with the pulp. It may be detected in newly-formed dentine but is hidden when the calcification is perfect. Although the dentinal fibril has generally been entrusted with the function of sensation in dentine, the matter cannot be said to have been satisfactorily explained, as a demonstration of the ultimate ending of the nerve fibres of the pulp is yet wanting. The dentme is formed upon the surface of the pulp by a process of calcification and, where this is incomplete, loculiwith rounded contom^s * Some points in the Structitre and Develo2',')nent of Dentine by J. Howard Mummery, M.K.C.S., L.D.S., (Philosoph. Trans. 1891.) lo CHILDREN'S TEETH. are to be found in the substance of the tissue. These are known as "interglobular areas" and they form an element of weakness should the tooth be attacked by caries. Cementum. In the human tooth, cementum is confined to the surface of the root, or im- planted portion of the tooth, slightly over- lapping the enamel at the neck by a very thin margin. It closely resembles bone in its com- position as well as in structure, but it is not thick enough to contain Haversian systems and blood-vessels. Lacunae and canaliculi, how- ever, are present, the former arranged in the longitudinal layers of cementum which are applied to the surface of the dentine. Sharpey's fibres are also to be found running transversely to the lamellse. The lacunae contain ''bone- cells " and, from these, fine processes are prolonged into the canaliculi communicating with one another, whilst some of those in the innermost layer penetrate the "granular layer " of the dentine. The two structures are there- fore, closely connected. The outer surface of the cementum is covered by the periodontal, or alveolo-dental, membrane, from which the hard tissue itself is developed by a process of calcifi- STRUCTURE. ii cation, and there is reason to believe that the thickness of the deposit of cementum increases during the life-time of the tooth. The Pulp Chamber and its Contents. The centre of a tooth is occupied by a soft mass, surrounded everywhere by dentine and com- posed of connective-tissue, cells, blood-vessels, and nerves. This is called the pulp, or more popularly and insufficiently the "nerve" of the tooth. The shape of the central chamber, and its contained pulp, corresponds with the external aspect of the crown of the tooth, cornua of the pulp being present beneath the cusps, whilst below there are prolongations into the root-canals. The pulp is the remaining soft portion of the original formative organ, a large part of which is represented by the dentine in the more or less completed tooth. There is reason, however, to believe that the form- ation of dentine goes on slowly during the rest of the life-time of the tooth, the chamber gradually becoming smaller until at last, in some instances, it may be obliterated and the pulp, as such, is no longer present. It appears also as if the pulp may be stimulated into a quickened formative activity by the approach CHILDREN'S TEETH. of caries, and a protective layer, or barrier, of dentine is then formed beneath the increas- ing cavity of decay. The row of cells upon the surface of the pulp are larger and other- wise differentiated during the active formation of dentine. They are termed " odontoblasts," and from the distal margin one or more pro- cesses (dentinal fibrils) pass into the dentinal tubes. The blood-vessels and nerves enter at the apex of the root and breaking up into branches form plexuses beneath the odonto- blasts. No lymphatics have hitherto been demonstrated. The Alveola- dental, or periodontal, membrane. This important structure intervenes between the bone of the socket and the root of the tooth, and serves to maintain an intimate and living relationship between the two. Connective tissue fibres run from one to the other in a slightly oblique direction thus allowing a limited mobility of the tooth. The fibres at the neck blend with the fibrous structure of the periosteum of the jaw and of the gum, and both in this situation and at the apex of the root the membrane is somewhat thicker, whilst some of the fibres can be traced into the bone STRUCTURE. 13 on the one side, and the cementum on tlie other to persist as Sharpey's fibres. In the meshes next the cementum are seen the osteo- blasts concerned in the calcification of that tissue whilst blood-vessels and nerves ramify in the membrane, some of them being derived from trunks which also supply the pulp This common origin of some of the vessels and nerves of the pulp and the periodontal membrane may have a certain significance in the diseased conditions aff'ecting either structure. Lym- phatics and some elastic fibres have also been described, (Black). By some this membrane has been regarded as a ligament, but apart from its serving as an attachment for the tooth, its function is important not only as a forma- tive organ for the production of cementum, but also as a means of keeping up a living connec- tion for a " dead '' tooth, when the sensitive and vascular pulp has been destroyed by operation or disease. For, in consequence of the communication existing between the termination of the dentinal fibrils and the contents of the canaliculi of the cementum, either by means of direct contact, or by way of the granular layer, the dentine may be 14 CHILDREN'S TEETH. supposed to be brought into connection to some extent, with the periodontal membrane. At all events so long as this latter is intact, the pulpless tooth is not regarded by the rest of the organism as altogether a foreign body but frequently, with proper care, does duty for many years. In this manner we are con- fronted with an apparent paradox of a " dead '^ tooth still alive ! THE ERUPTION OF TEETH. 15 CHAPTER II. THE ERUPTIOJY OF TEETH. AS is common amongst Mammalia, Man is provided with two sets of teeth, the first to serve from infancy through a part of child- hood, wliilst the second set, which is nearly complete at puberty, is intended to last the rest of the life- time There are many points of anatomical interest connected with the eruption of these two sets of teeth and the change from one to the other, but the physiological aspects are of more prac- tical importance in consideration of the neces- sity which exists, at this body-building period of life, for the proper action of all the organs concerned in nutrition. The temporary or milk teeth are twenty in number, ten in each jaw, five on each side, right and left, viz., two incisors, a "central" and " lateral," one canine, and two molars, " 1st and 2nd temporary molars.'' In those i6 CHILDREN'S TEETH. cases where parents are anxious for, or capable of, instruction on such matters it may be useful for the practitioner to remind them of the analogy, in numbers, of the temporary teeth with the fingers and toes, the digits of the right and left hands being compared with the teeth on each side of the upper jaw, those of the feet Central Incisors. Lateral Incisors. Canine. 1st Molar. 2nd Molar, Fig. 2 and 3.-M0DELS OF UPPER AND LOWER JAWS. Showing Temporary Teeth complete. From a child aged 3 years. with the teeth in the lower jaw. Intelligent watching and counting will often prevent a permanent tooth being mistaken for a tempo- rary one by those who are unable to recognise the individual anatomical peculiarities. THE ERUPTION OF TEETH. T7 Central Incisors. Lateral Incisors. Canine 1st Bicuspid. 2nd Bicuspid. K % "1st permanent (6 years) Molar. 2nd permanent (12 years) Molar. Figs. 4 and 5.— MODELS OF UPPER AND LOWEE JAW. Showing Permanent Teeth complete. From a child aged 13 years. X These lines indicate the former ^wsition of the 2nd temporary molars now replaced by the 2nd bicuspid teeth. C CHILDREN'S TEETH. As is well known, the temporary teeth make their appearance above the gums at different ages, the central incisors about 'the sixth or seventh month after birth, the laterals from the ninth to tenth^ the first molars about twelve months, the canine about eighteen months, and the second molar about two years. Whilst these dates are variable, it is generally stated that the teeth in the lower jaw make their appearance slightly in advance of the corres- ponding ones in the upper. During the development of these teeth they are contained in crypts in the bone, and when eruption occurs the crowns of the teeth are alone complete ; the roots are only gradually added, and the individual tooth is not finished until some time after the crown has taken its place. So that although we may expect to see the crowns of all the temporary teeth on inspecting the mouth at the end of the second year, the temporary dentition is probably not perfect until the fourth or fifth year, or perhaps even later. As the implantation of the teeth at their eruption is not complete their arrangement in proper line is more easily determined by the THE ERUPTION OF TEETH. 19 action of the lips and clieeks upon the outer surfaces, and the pressure of the tongue upon the inner side. In the front of the mouth the cutting edges of the upper teeth overlap those of the lower, whilst at the sides the outer cusps of the upper molars close outside those of the lower. There are two stages in the erujotion of the temporary teeth ; first, the absorption of the crypt, and secondly the absorption of the gum. The bony crypt is from the first widely open at the top, but not sufficiently so to allow the crown to pass through without removal of some of the osseous tissue. The whole process is, normally, a physiological one, and should be accomplished without the manifestation of any constitutional disturbance. If any reflex irritation may be expected to occur during absorption and the escape of the tooth, it is reduced to a minimum from the fact that the teeth are cut in groups with intervals of rest in between, instead of all coming through about the same time. This arrangement is decidedly in favour of the child, but it is also beneficial from the point of view of the development of the jaw. If the back teeth were erupted at the CHILDREN'S TEETH. same time as the front, such is the form of the jaw at six months, that the back teeth in each jaw alone would come into contact, leaving an '' open bite" in front. But the incisors by being first erupted separate the jaws in front, and the interval of six months which follows, before the appearance of the first molars, allows the development of the jaw to progress in the normal directions, and, by an elongation of the ramus, to provide room for the full eruption and regular apposition of the back teeth. But whatever the cause may be, whether due to heredity or some evolutionary process working in a new direction, it is well known that in some cases it not unfrequently happens that the period of " teething" is accompanied by a train of symptoms which marks the pas- sage of a physiological process into a patholo- gical condition. In addition to the increased secretion which is associated with the com- mencement of functional activity in the sali- vary glands, there may be noticed, as abnormal conditions, the usual indications of irritation in the rest of the digestive tract, viz. : — colic, diarrhoea and vomiting, and if the nervous system (at this age in an unstable condition, THE ERUPTION OF TEETH. and liable to respond readily to morbid stimuli) becomes involved, convulsions may also ensue. It is often an open question how far such symptoms may be caused by irritation due to teething. The fact that they occur at other moments of infantile life, in consequence of improper feeding or exposure to cold, may account sometimes for their presence, accident- ally so to speak, during the eruption of a tooth . Still, when we find that these symptoms coincide with a turgid, swollen gum, a hot mouth, and that the speechless child directs attention to the spot by trying to overcome tension by pressure, we may reasonably con- clude that the fans et origo is the tooth, more especially as when the latter escapes all the symptoms, both direct and reflex, quickly dis- appear. In connection with this condition arises the question as to the use of the gum lancet. Although still condemned by some, its employment, in suitable cases, appears reason- able. Most practitioners have at some time been called to a child cutting a tooth who, after keeping the household awake for several nights, has, perhaps, been seized with convul- sions. The crown of a tooth has been easily CHILDREN'S TEETH. recognised beneath a swollen, more or less tense gum, and a simple incision in the case of an incisor or canine, or, as is more frequently demanded, a crucial incision over a molar, has resulted in cessation of all symptoms, and a good night's rest for all concerned. Such treat- ment in such a recognised pathological condi- tion is infinitely better practice than the administration of so-called '' teething powders" which, when they contain preparations of mercury, as is too often the case, can only be alluded to here for the purpose of condemna- tion. The possible occurrence of undue haemorr- hage and septic infection may with proper care be ignored, whilst the formation of a cicatrix, which is said to retard the advance of the tooth, can only take place where the incision has been prematurely made, and even in such a case the more lowly organised tissue may be expected to give way without trouble. As a possible explanation of \hQ conduction and radiation of nervous stimulation from an erupting tooth we may refer again to the incomplete condition of the tooth itself. At tliis period the edge of the open, forming root will be in intimate relation with the pulp THE ERUPTION OF TEETH. 23 tissue, and if there is pressure by resisting gum (vis a fronte) the irritation may give rise to relatively the same degree of stimulus received in the case of a large exposure of pulp in an adult tooth affected with caries. It has been stated that the crowns of the twenty temporary teeth are normally present in the mouth by the end of the second year. Each of these on being shed will be replaced by a tooth of the permanent series, and in addition there will be twelve molars which come up behind, three on each side, above and below. In the table on the following page the dates must be understood as being merely approxi- mate. As is the case with those of the temporary set, the permanent teeth are incomplete when the crowns appear through the gum, and thus any obstruction caused by retained temporary teeth, or their roots will easily direct the per- manent tooth into a wrong position and as the bone of the alveolar process is built up round the neck of the erupting tooth in whatever situ- ation it may assume, the completion of the root will perpetuate the irregularity unless an opportunity is afforded for rectification. 24 CHILDREN'S TEETH. ^ c3 r. ^ ^ ^ r. ^ *. OJ " " •^ •* " '^ " P^. ^ ^ ^1—; G^l ^r-{ ^ f-] 10 ■^ i-H -i-i (M t> 00 a 1 T-H IX) CM l-H 1 ^j 1 — 1 t- li t-H £ ;^ o C5 l-l t— 1 cq ,a ;; s :; ;; ^ 0) O l-H ' - - r PM 02 03 „ J :; 03 : : fi^] a CD P^ C5 1 I— ( 1 CM 1—1 CO CI o CO t- '0 ~ " w " " " " += PQ O c-i CD ft -, S - ^ CD PI i CD = :; &H «1 0) PL, Ti O OD rH CO P-i § ^ • 03 CO ^ 03 '0 '0 ;-i 03 1— 1 d '0 S CD « CD "3 Is s CD IS -a CD "S CD 1 ^ OJ c:S oe (D h:? s CO fe THE ERUPTION OF TEETH. The actual shedding of the temporary teeth sets in somewhere about the seventh year, the incisors being lost first, but the process which thus physiologically brings to a close the life of a temporary tooth will have commenced some time before the tooth actually disappears. The cementum covering the root is first gradu- ally absorbed, and then the dentine, until finally perhaps nothing remains but a cap of enamel resting upon the gum. Caries may, of course, cause the destruction of temporary teeth, or by the production of pain lead to their removal by extraction. One of the principal signs which indicate the approaching loss of the temporary teeth may readily be noticed without subjecting the little patient to a searching examination of the mouth. Whilst the temporary teeth have been fulfilling their function the permanent teeth have been developing behind them in the jaws, and these latter have also been increasing in size. The result is that the temporary teeth instead of remaining shoulder to shoulder now become separated , and are, so to speak, spread around the margin of the jaws. The spaces between the teeth are characteristic of the 26 CHILDREN'S TEETH. approaching change. On the loss by absorp- tion of a temporary tooth, the respective per- manent tooth is generally found ready to take its place, but in those cases where the tempo- rary molars have been removed for pain caused by caries, it may be some time before the corresponding successor is erupted, and thus a prolonged reduction of the surfaces for masti- cation results. It is well also to remember that the first of the permanent teeth to make their appearance are the first molars, which should be erupted behind, and next to, the second temporary molars about the sixth year, and before the temporary incisors disappear, This arrangement provides masticating surfaces at the back of the mouth, whilst the temporary molars are being replaced by the bicuspids . and in those cases where the temporary molars are prematurely lost by neglect, the first per- manent molars, if not themselves neglected, are the only teeth to be relied upon to provide some surface for mastication, and to prevent the wearing out of the incisors by attrition, which would otherwise result. Occasionally the temporary teeth are not lost at the proper time, and instances are THE ERUPTION OF TEETH. 27 recorded of a retention* of temporary molars at tlie ages of 63* and ^b yearst- Whilst it is generally best that such teeth should not be retained long after puberty, it must be remembered that the corresponding bicuspid may be absent through non-development, and that at a more advanced age the gap caused by the extraction will not so readily be filled up by the approach of the adjoining teeth towards each other. The temporary canine tooth should be the last of the milk dentition to disappear. It serves the useful purpose of preserving the necessary room for the permanent canine to take its place between the lateral and the first bicuspid. The crypts in which the two latter teeth are developed, are placed side by side, whilst that of the canine is more deeply placed in the jaw, so that the premature loss of the tem- porary canine allows the permanent tooth on each side to approach the other with the result that the aftercoming permanent canine assumes a position outside the dental arch. This, how- ever, as will be shown later on, is not the only J. Ackery, Trans. Odontological Society, 1891. Salter, Dental Pathology and Surgery, p. 196. 28 CHILDREN'S TEETH. cause which produces "outstanding canines." The anterior permanent teeth, at all events in the u]3per jaw, are inclined somewhat obliquely forwards instead of taking a vertical position as did the temporary ones. This spreading arrangement allows the larger crowns of tlie permanent teeth to adapt themselves round a segment of a larger circle at the front of the jaws, the canine also sharing, normally, in the regularity of position, side by side with the neighbouring teeth. It is often a matter of importance for the practitioner to be able to recognise the mem- bers of the temporary and permanent dentitions, and when a systematic watching and record has not been observed by those in charge of the child, it is, occasionally, not an easy matter for one without special experience to determine what teeth are present in the mouth and to differentiate between, say, a temporary and a permanent canine ; or perhaps, a carious con- dition of the crown of a temporary molar, still firmly implanted and unduly retained, might possibly prevent the due recognition of an un- erupted, or perhaps, misplaced, bicuspid. Any individual front tooth of the temporary THE ERUPTION OF TEETH. 29 series is smaller than its representative of the permanent dentition. As regards the temporary molars, they are larger teeth than the bicuspids, but the characteristic shape of the crowns of the latter when intact, especially those of the upper jaw, enable them to be easily recognised. The crowns of the temporary teeth are usually lighter in colour, and instead of the enamel being bevelled to a thin edge at the neck, as occurs in a permanent tooth, the temporary teeth have a thickened rounded rim marking the boundary of the crown. Internally, the pulp and its prolongations into the roots are perhaps relatively larger than in a completed permanent tooth, but this will depend to some extent upon the age of the tooth, and, although of importance in other directions, does not offer assistance in distinguishing a temporary from a permanent tooth whilst in the mouth. Parents, however, occasionally appeal to the general practitioner with regard to an extracted molar, and an inspection of the roots alone, will enable a decision to be easily made. In the case of a temporary tooth there will generally be some, frequently to a large extent, signs of absorption ; but the roots, or the remains of 36 CHILDREN'S TEETH them are always widely separated to allow for the reception of the crypts beneath, in which the permanent teeth (bicuspids) are developing. A point ill connection with this relationship is alluded to under " Extraction of Teeth." The first upper temporary molar has three cusps, two external, and one internal ; the first lower has four cusps, two external and two internal; whilst the second temporary molars present a similar appearance on the crown to that of the permanent molars behind them. The two cusps of the lower bicuspids are not so marked as in the case of the upper ones and the depression between them is bridged over by a ridge of enamel. Indeed the inner cusp of a first lower bicuspid is often but feebly marked, and as the outer, or labial, surface of the crown is rounded vertically, the tooth may approach the shape presented by the tooth in front ofj and next to it, namely the lower canine. The inner cusp of the second lower bicuspid is much more pro- nounced, and assists in forming a squarish surface. The practical importance of distinguishing temporary from permanent teeth is evidenced. THE ERUPTION OF TEETH. 31 if in no other way, by the necessity which arises for determining whether some particular tooth should be saved by treatment, or whether it may be extracted ; in the case of the former the appropriate filling must be decided upon, as the methods and composition employed are somewhat different for temporary and perma- nent teeth. On the other hand, the fact that a temporary tooth has, normally, a distinctly limited lifetime, renders, in certain cases, a waste of time and labour in filling- unnecessary, and an extraction advisable or justifiable. This question will be alluded to later on in connection with the extraction of temporary teeth, but it may be well to refer here to the great danger which exists in connection with the first permanent molars. The general arrangement of the crown is similar to that of the second temporary molar, and from the fact that it is erupted before any of the temporary teeth are lost, and that it has no predecessor, the first permanent molar is commonly regard- ed as being itself a temporary tooth, the loss of which is to be expected before long From its position at the back of the mouth it does not get its proper share of inspection and atten- 32 CHILDREN'S TEETH. tion, even if its presence is recognised, and the result is that its decay and loss are too fre- quently ignored to the great injury of a com- plete dentition. It should ever be borne in mind that, instead of being the last teeth of the temporary set, the six-year-old molars are the first of the permanent set, and most impor- tant teeth, not only for size and masticating function, but also on account of the position they hold in the jaws and in the series of teeth making up a full set. After their eruption the temporary teeth are gradually replaced by the corresponding members of the permanent dentition, and at twelve years, and not until then, the second permanent molars may be expected. It is, therefore, most important that at all events up to that age or period, the six-year, or first permanent, molars should be preserved as presenting the only constant masticating surfaces during the change which is taking place between the temporary and permanent teeth. CARIES, 12, CHAPTER III. CARIES. THE condition which is undoubtedly account- able for, by far, the largest proportion of dental diseases consists in the destruction of the hard tissues of a tooth, and although it has received the name of Caries, it must be borne in mind that it is not a similar process to that which takes place in bone. It invariably commences on the external aspect, and is due to external agents, and although the process is more or less gradual, and the destruction what may be termed molecular, yet it must always be remembered that the tissues concerned are non-vascular. In order to understand the causation of caries, as it affects the teeth, it may be desir- able to remind the reader that the teeth owe their density of structure to lime salts which are deposited in the process of development. Weak acids are capable of dissolving out the 34 - CHILDREN'S TEETH. lime salts, leaving behind a gelatinous matrix in the case of the dentine. Such acids are constantly found in the mouth. The secretion from the mucous membrane of the gums is sometimes said to be acid, but in conditions of health this acid secretion is neutralised at once l)y the constant flow of saliva from the salivary glands. Where the mouth is in an unhealthy condition, it is not at all uncommon io find the saliva acid, and then we have an important factor in the production of caries. The principal source from which acids are formed in the mouth is found in particles of food remaining in the neighbourhood of the gums and teeth, or, in brief, on those surfaces which the tongue does not sweep. In such positions the food undergoes fermentative changes. It is a well established fact that to micro- scopic organisms we owe such processes as fermentation. In order that these may be carried out successfully, material is necessary, and also a chamber kept constantly moist, at a sufficiently high temperature, with free access to the air. The mouth is such an ideal chamber with all the conditions favourable for CARIES. 35 the action and propagation of micro-organisms, and the particles of food left upon, or in the neighbourhood of the teeth, are the material essential for cultivation. It is now well recog- nised that the production of caries in teeth depends entirely upon the presence of micro- organisms in the mouth ; thirty species of these were isolated and cultivated by Miller of Berlin, twelve of them being characterised by the formation of lactic acid. There are two stages in the process which results in the loss of a tooth by decay or caries. In the first the protective covering of enamel is affected to such an extent that the dentine beneath becomes accessible. In the second, sufficient destruction of the dentine takes place to subject the pulp to irritation and subsequent inflammation. The amount of tissue removed, and the rate at which the process progresses vary in individual cases, whilst the age of the tooth and the consequent size and condition of the pulp also influence the course of the dis- ease. The activity of the agents concerned is modified by the changes in their environment, or life-relations, brought about by local hygienic conditions, and also by the extent to 36 CHILDREN'S TEETH. which the tissues involved are well, or badly, developed. The action of germs upon particles of food (carbo-hydrates)* retained in the fissures and interstices of the teeth results in fermeuta- tion, and the production of acid, and when this remains sufficiently long- in contact with the enamel, and has been frequently enough re- newed, the lime salts in the tissue are dissolved and a nidus is formed in which the bacteria and. sugar are even better protected, and in which the fermentative process can proceed still more rapidly. It is said that the lactic acid produced combines with the lime-salts set free, and that thus the organisms remain unaffected. So soon as the process of decalcification has brought the dentine within range, the bacteria are able to travel along the dentinal tubules, and to extend the destructive action into the surrounding matrix. Whether this destruction depends upon a continuance of the decalcifica- tion merely, or whether the albuminous dental cartilage is dissolved by certain germs which have the power of peptonising it, the result is readily apparent, and owing to the exposed * Converted into some form of sugar by ptyalin, the active principle of saliva. CARIES. 37 conditions of the teeth the physical gigns of caries, or decay, are easily observed. The first change is seen in the enamel, which loses its semi-translucent appearance at one spot, and is discoloured and rough, the colour varying from white to a darkish brown. The tissue is porous and can easily be perforated by a steel point, or cut into with a fine chisel. When sufficient enamel is removed, the dentine immediately beneath is found softened and dis- coloured, this condition extending on all sides beneath the still sound enamel which forms the margin of the cavity. The carious dentine varies both in colour and consistence. The colour may be a light yellow, or a dark brown, ilearl}^ black, the former generally presenting in cases where the progress of caries has been rapid, the latter where the course has been slow and chronic. These two forms are sometimes distinguished by the terms " soft " and •' hard " caries ; for the dentine may be of a cheesy con- sistence, or, in some cases, a pasty mass with a putrid odour, whilst in others where the tissue is very dark, it would almost seem as if the advance of the destructive process had been checked. 38 CHILDREN'S TEETH The direction of the decay may he super- ficial or deep, as the extent of caries varies not only in different teeth but in the different tissues of an individual tooth. The structure of the enamel and dentine differs very much in density, and this fact largely accounts for the slowness, or rapidity of caries ; the tissue with the greatest amount of organic material is more rapidly disorganised, so that it is not uncommon to find, in preparing a cavity for filling, that a comparatively small hole in the enamel leads down to a large unexpected, or at all events previously unknown, excavation in the dentine. In some cases the decay is so rapid that the first intimation is the collapse of a large portion of the crown, when the dentine below may be found to be a caseous mass. In others, caries has spread superficially over the whole surface, the enamel is gone and the dentine is of brownish colour reduced in quantity and burnished. j^s the enamel and dentine are entirely devoid of blood-vessels there is no such thing as "vital 'or inflammatory action present in caries of these structures. Experiments have shown conclusively that a precisely similar CARIES. 39 condition can be produced in teeth long removed from the mouth, and where natural teeth and ivory blocks have been worn as artificial substitutes, caries has been found just as active in them as in living teeth in the same mouth. It is, jDcrhaps, scarcely necessar}^ to remind the reader that artificial teeth are now made of porcelain and that ivory is no longer used. Not only has it been demonstrated that, by imitating the usual surroundings, artificial caries can be produced in an extracted toothy which cannot be distinguished from natural caries, even by the microscope, but it has also been proved that without the presence of micro-organisms caries cannot occur. Having thus considered the actual, or excit- ing causes of dental caries, it may be well to allude briefly to those conditions which pre- dispose the tooth tissues to this disease. They may be readily mentioned under two headings : a. Abnormal conditions of the tooth itself. h. Abnormal conditions of its environment. Defective tooth structure is an important factor of caries. It has already been mentioned that teeth vary in density, and 40 CHILDREN'S TEETH. every dental surgeon is familiar with this fact owing to the cutting operations necessary to remove carious tissue. The difference is due to imperfect calcification, and microscopic sections show this both in enamel and dentine. In the latter it is more apparent in what have been described as '' Interglobular areas." Imperfect enamel, such as one finds of con- stant occurrence in what are called '' honey- combed" teeth, is also due to a deficiency of lime-salts. The tissue is pitted all over the crown, and is sometimes absent in certain spots, or else is deeply furrowed. This latter condition, especially, is found in the permanent incisors. In addition to the intrinsic defects there may be external faults. Wherever there is an irregularity on the crown of a tooth, or any departure from the smooth and beautifully polished surface of the enamel, food is apt to collect, and caries is the result. It is not at all uncommon to find chinks or crevices in the crowns of molars and bicuspids just where the folds of enamel meet, leading down to dentine which is also defective. In such cases acid secretions prepare the way, and softening takes place assisting the inroads of true caries. CARIES. 41 Another cause depending upon the teeth themselves is due to an irregular position being assumed. From what lias already been stated it will be apparent that any arrangement tend- ing to favour the retention of food particles in the neighbourhood of the teeth will conduce to caries. So, when a tooth does not range properly side by side with its fellows in the alveolar arch, angles are necessarily formed which the tongue finds it difficult to sweep, and the debris collected in the recesses jeopard- ises not only the misplaced tooth but its inno- cent neighbours In this latter case we see a predisposing cause depending upon surrounding circum- stances, and it may be said, generally, that a crowded condition of the teeth, and any simi- lar impediment to the maintenance of a hygienic state of the mouth, will constitute such a cause, There seems to be reason to believe that caries affects the modern tooth to a much greater extent than obtained in bye- gone times, and the absence of this destruction which is apparent upon inspection of ancient skulls, and also the immunity enjoyed by many existing savage races, would point in the 42 CHILDREN'S TEETH. directioa that amongst the concomitant effects of civilization must be enumerated a liability to caries of teeth. The extent to which cook- ing and other preparation of food is practised and possibly the nature of the food itself, may have a great deal to do with this. There are also indications that some members of the dental series are undergoing suppression, the individual teeth showing the greatest tendency to non-appearance being the lateral incisors and third molars. In conjunction with this gradual withdrawal, on the part of Nature, of organs which are no longer necessary, we may con- sider the interference with the ordinary rules governing natural selection which is taking place in the human race fari passu, and in proportion to, the progress of what is recognized as civilization ; and we thus perceive how the standard of the actual tooth structure may become lowered in consequence of outside influences. The effect too, of certain drugs seems likely to be overlooked , the administration of mer- cury in congenital syphilis, or in the form of " teething powders," has a prejudicial effect upon the formation of the teeth undergoing de- CARIES. 43 velopment and appears to modify the process of calcification. One result of the lessened use of a tooth is observed when, the principal opposing tooth being lost, the surface is no longer kept clean by mastication, but remains subject to accumu- lation of food with subsequent caries. And although the tartar which tends to collect upon the sides of such a tooth may not itself produce caries, it may lead to irritation of the gum and unhealthy secretion, thus imitating another predisposing condition to which attention must be drawn. We allude to the sordes which form around the teeth during the exanthemata and other constitutional febrile attacks, which in this respect are quite as noxious, although frequently overlooked, as the equally common results associated with such local affections as the different forms of stomatitis. The retention of the diseased temporary teeth, or the existence of a cavity in the next tooth will also predispose a well-formed tooth to attack by caries. By taking a comprehensive view it will be be seen that these two classes of predisposing causes can re-act one upon the other, for bad 44 CHILDREN'S TEETH. structure may lead to loss of teeth, imperfect nutrition and, as a more remote effect, debased offspring ; whilst on the other liand it becomes FIG. 6.— MODEL OF UPPER JAW. Showing caries in temporary molars by which the permanent molars have been affected. From a child aged 9 years. manifest that an artificial interference with the survival of the fi.ttest may result in depraved structure of the teeth in succeeding generations. PULPITIS. 45 CHAPTER IV. IJYFLAMMATIOJY OF THE FULF. PULPITIS. i^OMPARATIVELY few in number are the VJ individuals, whether children or adults, who do not know that dentine when exposed by decay is sensitive, and that the sensation is the reverse of pleasant ; and although at present no satisfactory explanation is forthcoming, even as some sort of solatium, of the actual method by which the external stimuli are conveyed to the dental pulp, yet the presence in the den- tinal tubes of processes from its cells and the close relationship which the soft tissue bears to the hard, together with the existence of numer- ous nerves in the former, make it sufficiently easy to understand how an impression is con- veyed to the sensorium that a new and un- favourable set of conditions is affecting the 46 CHILDREN'S TEETH. vasculo-nervous mass in the pulp chamber, and threatening to abolish its vitality. A post-mortem examination of a tooth shows, in some instances, that an attempt to resist the approach of caries is manifested by an in- creased activity of the dentine-forming function of the pulp, a barrier of calcified tissue being constructed at that portion of the pulp chamber which is nearest to the carious cavity. But when once a direct communication is made (exposure of the pulp) the outside influences come more powerfully into play, including the admission of micro-organisms; the pain is increased, and the other usual pathological states accompanying inflammation are followed by suppuration. Another varia- tion of this ordinary sequence of events in what is called acute pulpitis, and which not uncommonly happens, is exemplified when the pulp is acutely inflamed (by transmission of irritation ?) before an exposure actually occurs, and then, owing to the confined space in which it is situated, severe pain is experienced, probably followed by gangrene of the pulp. Besides that due to caries the pulp is liable to inflammation caused in other ways. Fracture PULPITIS. 47 of a tooth (afterwards alluded to) may either absolutely expose the pulp, or lay bare the dentine so close to it as to subject it to irrita- tion, whilst other forms of violence may so interfere with the vascular and nerve supply entering the apical foramen as to cause inflam- mation or gangrene. Sometimes, however, exposure does not result in a more or less immediate destruction of the whole pulp, and the inflammatory action pursues a more chronic course, so that occa- sionally a secreting, or ulcerating, surface is to be found ; or perhaps, if the case is seen at a still later stage, the granulations have given place to a fibrous polypoid growth and, in rare cases, calcification has been noted. During the physiological absorption which takes place in temporary teeth, and principally in their roots, although the pulp and its pro- longations seem frequently protected by special formation of dentine, yet the root canals lead- ing to the pulp chamber do become opened and the soft mass may be destroyed. But this is not necessarily the case, and there would seem to be some process by which a line of demarca- tion is kept between the advancing area of CHILDREN'S TEETH. absorption and the still living remnant of the pulp. Another condition affecting the pulp is'not essentially concomitant with an exposure, or even with caries. Many cases have been Fig. 7— LONGITUDINAL SECTION OF EOOT OF BICUSPID. Stained with Carmine, and prepared by the Weil method. From Mr. Spokes' Collection, f inch Objective. A.— Pulp. B.— Dentine. C— Cementum. D.— "Pulp Stones~ recorded where in consequence of pain a tooth has been extracted and on examination of the pulp rounded or oval masses of calcified tissue have been discovered embedded in its substance. PULPITIS. 49 When these are large, or numerous enough it is easy to see how irritation of the nerves is- produced by pressure. (Fig. 7.) On the other hand, the pulp in some old teeth undergoes such an extended solidification that scarcely any soft tissue is to be found ; in still others none at all, and this without a history of pain. Perhaps in these cases there has been a concurrent degeneration of the nerve elements, and both together may be regarded, physiologically, as a senile condition of the tooth. Fig. 8.— UPPER MOLAR TOOTH (Split into two pieces.) Showing complete calcification of the Palp. If, as indeed happens in some cases, the pulp always succumbed without the occurrence of sequelae due to septic infection of adjacent tissues, a pulpless tooth might be regarded, in a certain sense, with relief, even if impaired for mastication. But the experience of dental surgeons forbids such an expectation, for whilst E 50 CHILDREN'S TEETH. a tooth in such a condition may not be atsolutely a foreign body (being, as already elsewhere pointed out, kept in some sort of relationship with the rest of the organism by means of the periodontal membrane) yet the putrid remains of the pulp exposed to the atmosphere through the mouth, will not only render this cavity unpleasant and unwholesome, and possibly affect neighbouring teeth, but also will constitute a source of danger to the tissues at the bottom of the socket, especially if the external outlet in the crown of the tooth become blocked by food or other substances. It is for these reasons that '' dead " teeth, if allowed to remain in the mouth, should first be treated secundum artem by the dentist. PE RIOD ON Til IS. 5 1 CHAPTER V. LJVFLAMMATIOJY OF THE PERIODOJYTAL MEMBRAJVE, PERIODOJYTITIS, ALVEOLAR ABSCESS, JVECROSIS, AJYD OTHER SEQELJE. When one considers how intimately the periosteum of a tooth (the periodontal mem- brane) is connected with the blood vessels and ner\^es of the pulp, it is scarcely a matter of surprise that inflammation of this fibro-vascular membrane arises for the most part as a contin- uation of pathological changes which have already affected the crown. In its simplest form such inflammation may commence as follows : — A cavity of decay in some surface of a tooth has laid bare the dentine. The access of salt or sugar, and of hot and cold water, sends a thrill of pain through the tooth. This 52 CHILDREN'S TEETH. may pass away within a few minutes, to be succeeded a few hours later by symptoms of inflammation in the periodontal membrane. There is an uneasy sensation, the tooth is tender to bite upon, seems raised above its fellows, and is somewhat loose in its socket. In a day or two the symptoms may subside, and the tooth is as firm and as useful as ever. Such transient irritation may happen to the soundest of teeth, and one is justified in con- cluding that it is due to direct communication of nervous irritation from the pulp to the periodontal membrane. Far more frequently, however, acute inflammation of a septic cha- racter occurs as a direct consequence of inoculation from the pulp chamber. It has been mentioned {vide Pulpitis) that exposure of a pulp is often followed by gangrene. The acute pain which usually accompanies this condition has subsided, and mastication pro- ceeds as usual. The necrotic condition of the pulp very soon extends through the whole length of the fangs. So long as the open cavity in the crown of the tooth remains patent the products of decomposition will escape into the mouth ; but as soon as this is closed, by the PERIOD ONTITIS. 53 accumulation of food, it is squeezed down by mastication into the tooth, septic material is forced through the open ends of the fangs (apical foramen) into the surrounding tissue, and acute inflammation is usually the result. A throbbing, aching, pain is referred to the tooth and gum around it. The gum is acutely inflamed, and the tissues beneath become Fig. 9. Model of lower jaw of a child aged 7 years, "showing alveolar abscess on the left side, caused by a second temporary molar tooth. infiltrated and swollen with inflammatory pro- ducts. The tooth is raised above its fellows and though at first relief is found by biting, it very soon becomes so acutely sensitive that any pressure is impossible, and the mouth cannot be closed. If at this stage the ofl'ender is ,54 CHILDREN'S TEETH. extracted, the periosteum which clotlies the fangs will be found thickened and quite red in colour. Later, this membrane will be stripped from the ends of the fangs, and pus is poured out between it and the tooth, expanding and dissolving the porous bony and fibrous tissue, making its way to the surface either round the neck of the tooth (Fig. 9) or through the alveolar plate and gum. Occasionally tlie pus finds its way through the inner (lingual or palatal) wall of the alveolus, but more fre- quently it opens through the buccal wall. In either case it may be expected to finally burrow through the mucous membrane which covers the alveolus. At the same time the constitu- tional symptoms are marked by an elevation of temperature, with headache, a coated tongue, and general malaise. With the exit of pus all the acute symptoms subside, and the tooth gradually sinks down again into its socket, leaving a small sinus on the gum through which pus is more or less continually discharged. This swelling and discharge is often spoken of as an alveolar abscess, or, more popularly, is called a gum-boil. PERIODONTITIS. 55 The consequences of such inflammation are somewhat different in temporary and perma- nent teeth. It has been pointed out in a previous chapter that the fangs of a temporary tooth are no sooner formed, than a jDi'Ocess is commenced by which they are eaten away, in order to make room for the erupting permanent tooth. The little mound of tissue crowded with the so-called ostecoclasts (large multi-nucleated cells) lies immediately beneath the open end of the fangs. This is essentially a vital process, and should the fangs remain healthy not only will they be removed, but the whole of the inside of the crown will be eaten out, so that the tooth may be tilted off the gum with the finger nail. An examination of such teeth shows little pits and cavities all over the inside of what is left. If caries has attacked any portion of the tooth, the dentine will be eaten out all the way round it, leaving the carious portion standing alone. When the exposure of a pulp occurs, fol- lowed by death and the forcing of septic matter through the fangs, the absorption papillse are entirely destroyed. The periodontal mem- 56 CHILDREN'S TEETH. brane is separated from the roots at the apex, and as p^as accumulates this separation may — and for the most part does — extend right up to "the neck. The alveolar wall is gradually •dissolved away, leaving the fangs of a dusty Thrown or greyish colour protruding through ihe outer wall and perforating the adjoining <;heek or lips. (Fig. 10.) The normal method Fig. 10. Model, showing necrotic root of an upper temporary central incisor tooth. ■of removal of the tooth to make way for its successor has ceased and it becomes a veritable foreign body. In cases where the periosteal covering has been removed from the lower por- tion of the fangs only, the tooth may remain firm in its socket, dark in colour with a small sinus through the alveolus discharging pus, showing that the apex of the fangs are necrotic. Septic inflammation of the periodontal membrane often ■extends to the crypts of the permanent teeth. This is more likely to occur in the region of the temporary molars. PERIOD ONTITIS. 5 7 Lying immediately beneath or above tliem (according as one speaks of the lower or upper jaw) are the permanent bicuspids, the crowns of which are the only part of them at all fully formed ; and it is no unusual occurrence when removing a temporary molar, the fangs of which are bathed in pus, to find the crown of the bicuspid lying loose below it dark in colour, in a necrotic condition and the formative tissue of the fangs entirely destroyed. The fangs of the permanent teeth are larger than those of their predecessors and more deepl}^ implanted in the jaw. The alveolar process is of denser structure so that when septic perio- dontitis affects them the symptoms are more acute owing to the greater difficulty in the escape of pus. When, however, pus has escaped and the tooth becomes firm in its socket once more, the vitality of the periodontal membrane is for the most part retained and the tooth will still receive some nourishment through the cementum. At the apex of the fang (or fangs) it will be destroyed, the termination of the fang will be necrosed and a fistulous tract established between it and the point of exit. The pathology of acute periodontitis followed 58 CHILDREN'S TEETH. by alveolar abscess is similar to that occurring in other bony tissues. The membrane sur- rounding the tooth becomes swollen and con- gested — hence the tooth is raised from the socket. Proliferation of cells from the fibrous tissue and the capillaries, with exudation of inflammatory lymph follows. Thrombosis of the blood vessels and a rapid liquefaction of inflammatory products into pus is a consequence of the poison introduced to the tissues, viz., micro-organisms and their chemical products, As pus accumulates, the inner layer of the perio- dontal membrane is more or less stripped from the cementum of the tooth. In chronic cases it is not unusual to find this layer expanded and thickened so that when the tooth is removed a small sac is found at the extremity of a fang. This stripping of the membrane from the tooth would take place more fre- quently were it not for the fact that pus readily finds a way into the cancellous bone of the jaw. Expansion and erosion take place simultan- eously. The throbbing, aching pain which occurs while these changes are taking place, at once ceases when pus has escaped through the bone into the fibro-cellular tissues. PERIODONTITIS. 59 In acute alveolar abscess the inflammatory oedema is considerable. It is especially notice- able in the upper jaw. Children often present themselves with their faces puffed and eyelids so swollen as to be almost closed. Just as if they had received a severe blow or injury to the face without breach of tissue. In weak or unhealthy children pus is likely to burrow deeply into the tissues of the jaw, destroying other teeth it may come in contact with, or making its way out on the face or beneath the jaw. This may occur in con- nection with either temporary or permanent teeth, though it is fiequently associated with the first permanent or six-year molar. A. F. A girl, a3t. five years, of pallid complexion, complains of a sore on her face. Had toothache some months ago ; three weeks since the face suddenly swelled up causing much pain. It was well poulticed by the mother. The child had an unhealthy looking sore on the left cheek opposite the molar region of the lower jaw. It was small in size, circumscribed, and on its summit there was a small papilla from which pus was oozing. Careful probing showed a direct connection Avith the roots of a lower temporary molar which was found deeply carious, but firm in its socket. This was removed, and in one week the scar alone remained. As in this instance, advice is often sought when the mischief is done. It also illustrates a method of treatment frequently adopted by 6o CHILDREN'S TEETH. the ignorantj viz., that of poulticing swellings upon the face, which, if nothing else happens, may leave a life-long scar. (Fig. 11.) Fig. 11— DEAWN FEOM A PHOTOGRAPH. Showing papilla ou the face from which pus was oozing. Caused by a neglected six-year molar. The swelling had been incised several times from the outside, Another case : — • Annie Knight, aged 13, five or six months ago had toothache on the right side. Seven weeks ago face began to swell, and hot fomentations were applied. It was then lanced, and has been poulticed since. On the right side, beneath the lower jaw was a small papilla, around it the skin was puckered and adherent to the bone. A carious permanent molar was found quite firm in its socket. The pulp was putrid. The tooth was extracted, and adhering to the posterior fang was a small sac. In a week the sinus beneath the jaw had ceased to discharge. PERIOD ONTITIS. 6 1 When upper teeth are affected pus may find its way into the palate, or open into tlie floor of the nose, or into the antrum. M. E., aged eiglit years. Measles three years ago, since which there has been a constant discharge from both ears. Five weeks ago left cheek began to ache and swell, A doctor removed a tooth and matter came away. A week later a lump was noticed below the left eye. The face being swollen and red, hot fomentations were applied. The patient was a well nourished-child, with fair hair and blue eyes. The face was considerably swollen on the left side involving mostly the cheek, the latter being red and brawny. There was a fluctuating swelling below, and external to the inner canthus of the left eye, and at its summit pus was oozing from beneath a thick yellow crust. The crust being removed, examination with a probe showed that the fistulous opening was in connection with the antral cavity. On inspection of the mouth, a scarcely healed wound was seen between the temporary incisor and molar tooth, indicating clearly that the temporary canine had been removed. The hard palate on the affected side was quite normal, but viewed from outside the anterior wall of the left antrum was more prominent than the right. No fluctuation could be obtained through the antral wall. The child was placed under chloroform, and with an ordinary gimlet, previously rendered aseptic, the orifice through the canine socket was enlarged". The developing permanent canine, lying quite loose and in front of the opening, was removed. A probe was then thrust into the antrum and out on to the cheek. The cavity of the antrum was carefully explored at the same time, the walls appearing healthy, except anteriorly. The sinus on the cheek was dressed with boracic ointment, and a pad placed over it. The antrum was syringed out with warm boracic lotion through the perforation of the jaw. The mother was directed to syringe it frequently with this lotion. The sinus on the cheek healed in a few days, and ten days later the wound in the mouth was closed up. A collection of pus in the antrum in connec- tion with temj)orary teeth is of rare occurrence. 62 CHILDREN'S TEETH. Owing to the small size of this cavity the tem- porary teeth lie well outside its walls, which are comparatively thick. In this case pus from an alveolar abscess at the root of a temporary canine had burrowed deeply beneath the per- manent canine, and, finding its way into the antrum, had pointed through the anterior wall and opened out on to the cheek. Far more serious injury is likely to occur as the result of periodontitis. Numerous cases are recorded by Tomes* and Salter*]* where pyaemia and death have occurred, Mr. Arbuthnot Lane, of Guy's Hospital, records the following case, an abstract of which is given. A L V E LA R ABSCESS. PYEMIA. Excision of Thrombosed Veins. H. E.., fet. four years. Suffering from a swelling over the left half of the lower jaw, which commenced with toothache about a week before. Five days previously an abscess burst into the mouth Temperature on admission, 105"4. There was an alveolar abscess in connection wdth a second temporary molar. This was removed, and the abscess cavity scraped and thoroughly cleansed out under an ansesthetic. The boy became jaundiced, and suffered from recurr- ing rigors. Mr. Lane excised the thrombosed veins, the external jugular, and branches of the facial. The abscess cavity and bone were cleansed thoroughly and packed with iodoform gauze Many inflamed lymphatic glands were removed. This operation * Manual of Dental Surgery. t Dental Surgery and Pathology. PERIODONTITIS. 63 was followed by disappearance of the jaundice ; but subsequently the child died, and it was found that there were a number of abscesses in the liver and lungs. These were produced by septic emboli before the operation took place.— i«?zce^, l^ov. 5, 1892. The case is instiuctive not only in showing how pyaemia may be caused by a tooth, but as showing that the remoA^al of thrombosed veins is effectual in staying the pysemic process while yet local and uncomplicated. It is really a matter of surprise, considering the frequency of such septic inflammation, that fatal cases do not more frequently occur. It is by no means an uncommon occurrence in ex- amining the mouths of children to find several sinuses or fistulse in the mouth, each one con- nected with a separate tootli, duly discharging its share of pus which is daily mixed with the food and saliva and swallowed. In connection with these teeth, or their roots, septic matter has escaped into the alveolus, periodontitis has followed ; with the swelling, formation of pus, its escape through the alveolus, and the subsi- dence of all s^^mptoms. Many such cases are of a passive type, passing through all the stages of inflammation and suppuration with very little pain and consequent distress, though it by 64 CHILDREN'S TEETH. no means follows that the results are less serious, as the following- case will show : — A. B., a boy set. five years, brought to the hospital because he had a sore mouth and bad breath. The mother stated that a few weeks ago the boy had a swelling on the side of his cheek. The patient, a puny child of dark complexion, had a foul breath and coughed incessantly. On examination all the temporary molars were found deeply carious. On the right side in the upper jaw both upper molars were loose, the gum was dark red, and round the necks of the teeth there was a greyish slough. Pus was oozing out opposite the apex of the roots. On removing the teeth, the fangs were quite dark in colour and necrosed. A good sized portion of the alveolus was found lying loose. This was removed, and also the crowns of two bicuspids which were offen- sive and almost black. The cavity was well mopped out with a solution of carbolic acid 1 in 10. The mother was directed to syringe the cavity, and to wash the mouth out frequently with a solution of Pot. Permang. Internally quinine and iron were prescribed. This child had suffered very little pain indeed, so little that it was the child's breath alone which attracted attention. Children who are wrongly fed, starved, or suffering from constitutional diseases, such as tuberculosis, rickets, or syphilis, are the sub- jects of periodontitis. It generally commences with marginal ulceration of the gums, affecting carious and non-carious teeth alike. Many teeth may be involved or one tooth alone. Sometimes it is symmetrical as in the following case : — PERIODONTITIS. 65 T. v., age 3 years. A delicate boy with well-marked Rickets. The mother says " food passes through him as soon as he eats it." . The child cannot masticate because of loosj teeth. On examina- tion the teeth are seen to be well-formed, none are carions. The lower and upper canines are much raised above the other teeth, and are somewhat loose. The patient cannot close his mouth properly as only the canines meet. The gum is ulcerated round the necks of the teeth ; the alveolus is expanded beneath the R. lower, and above the R. upper canine. Pus is oozing from sinuses. On removal of the teeth the jjeriosteal covering was found much thickened. The teeth however, were neither carious nor dis- coloured. Exfoliation of the alveolar plates following periodontitis is of frequent occarrence after scarlet fever and measles; and though it is in many cases intimately connected with carious teeth and roots, this is not necessarily the case. When associated with carious teeth or necrotic roots it would appear that the starting point may be through the fang of a tooth, or external to the teeth. The inflammation in the latter case spreads from a purulent gum margin which sur- rounds them. This latter condition is especially noticeable where the teeth are quite sound. The continuity of gum with periodontal mem- brane and the connection of the latter with the periosteum of the jaw, will serve to explain the means by which septic inflammation, either occurring within or outside may involve the deeper tissues of the jaw ; the symptoms in 66 CHILDREN'S TEETH. both cases are the same. The inflammation is of a passive type. A child is brought up for a swelHng of the face, generally a foul breath and a discharge from the mouth, but very little pain. On examining the affected side the gums will be found puffy, swollen, and deeply ulcerated round the necks of the teeth, leaving bare the alveolus. The teeth will be found quite loose, and pus oozing from the gum margins. Beyond removing loose and carious teeth, and seeing that the mouth is constantly cleaned, no treat- ment is required. In a month or six weeks the sequestrum will become quite loose and can then be easily removed. IRIiEG ULA RITIE V. CHAPTER VI. IRREGULARITIES OF THE TEETH. IRREGULARITIES OF STRUCTURE IN TEMPORARY AND PERMAMENT TEETH. IRREGULARITIES OF FORM IN TEMPORARY AND PERMA- NENT TEETH. IRREGULAEITIES OF NUMBER IN .TEMPORARY AND PERMANENT TEETH. IRREGULARITIES OF POSITION IN TEMPORARY AND PERMANENT TEETH. OVERCROWDING OF THE TEETH AND ITS TREATMENT, 68 CHILDREN'S TEETH. Irregularities of Stkuctuke. Teiwporary Teeth. That there is an intimate connection between defective teeth and Rickets, would seem obvious, judging- b}^ the references which are foun.d in most text books of Medi- cine and Surgery where rickets is discussed. Thus one writer says, '' Dentition is late and irregular. . . . The teeth themselves are im- perfectly formed, their enamel is defective ; in a ■ year or two they turn black and break off or fall out.''* Another writer says : " Dentition is much delayed in rickets - . . the enamel of rachitic teeth is bad, rocky, or pitted in its disposition, the teeth are notched, or have horizontal ridges, and break away down to the gum, where they appear as black and jagged stumps. These conditions are not peculiar to rickets."t Another remarks, "Dentition is much delayed and the teeth when cut are * Fagge, third edition, vol. II., page 736-7. i" (ioodhart, fourth edition, page 646. IRREGULARITIES. 69 deficient in dental enamel, so that they decay rapidly."* Another says, '' The teetli are late in appearing ; the teetli, moreover, are specially apt to decay and become loose." f Another observes " The teeth appear very late . while they also rapidly decay or fall out, being deficient in enamel. '^I Others again state that modifications of dentition vary according to the period at which the active phase of rickets becomes manifest. If it be early, there are three ways in which the modifications may occur. 1. — The teeth are late in their erup- tion. 2. — The teeth are cut cross — that is, they appear in wrong order. 8. — They soon become carious and are often shed early. f I" Other authors might be quoted, but perhaps more than sufiicient extracts have been given to show that there is a concensus of opinion among medical writers. 1. — That in Rickets there is delayed dentition. 2. — That the enamel is * Quain's " Dictionary of Medici?Te," artich "Eickets,'' (Eustace Smith), p. 1373. t Bristowe, seventh edition, p. 930. :J: Roberts, seventh edition, p. 285. tl" Keating's ''■ Enci/dopcedia" Disfeases of Children, article, 'Rickets": Barlow and Berry, vol. U., p. 'l'2.Oi-Hi— icococo-H lOCir^lDCOOCDO (M ^ lO CO CO ^ Tt< 00 CO d CO'-iCOS^IX'O^COCOOt^iOrHCO 1— ii-(C?(N'MCO-*lTH'OrtiCO'hri8 with warm water from a syringe will help the practitioner to realise- whether he has to deal with decay which appears 195 CHILDREN'S TEETH. to be only superficial, or with a cavity of more or less extent. We say appears] such appearances, how- ever, are very deceptive. It may be stated generally, that if caries is superficial on the crown of a tooth it extends over a large sur- face. This is es])ecially true of the first permanent molars, because they are particularly liable to be erupted with defective enamel, showing that when in the soft condition these teeth have undergone a change in their nutri- tion which results in arrested calcification. In many teeth of this class the whole of the masti- cating surface will be discoloured, the dentine seems to have become carious and then hard- ened (" arrested decay"). Neuralgic pains are apt to arise in consequence of such bare surfaces of dentine. Salt or sugar, hot or cold water, readily convey transient impressions to the pulp which may be kept in a chronic state of irritation. The application of caustic to these teeth will often relieve pain. There may be a very small centre of decay in the crown of a well-formed tooth, only sufficient to admit the point of a probe or excavator ; and such an appearance is often TREA TMENT. 1 9 7 deceptive, for as the dentine is much softer than the enamel, when once admission has been gained {vide Caries) to this softer tissue, extensive decay may have gone on. As, how- ever, our present purpose is to relieve pain whether the cavity be large or small, the inser- tion of some carbolised resin, on cotton wool, will at once relieve the patient whether it be due to chronic irritation or acute inflammation of the pulp, with or without exposure. The fact of a permanent tooth being slightly loose, showing an extension of the inflammation to the periodontal membrane, does not militate against the use of this drug and the relief it gives. It is quite possible that the pulp of the tooth may (through long exposure) have become gangrenous, and the pain be due to the pent-up products of putrefaction, then no relief will follow the application of any druo". Here we have a distinction and a differ- ence between temporary and permanent teeth. Inflammation of the pulp in temporary teeth is rapidly followed by death and putrefaction, owing to the small size of the roots ; septic periodontitis sooner or later follows with expan- sion and perforation of the thin alveolar wall, 198 CHILDREN'S TEETH. and all the accompanying signs of alveolar abscess. Inflammation of the pulp in a permanent tooth is, as a rule, followed more slowly by necrosis and putrefaction ; the fangs are longer, therefore more deeply situated and the alveolus or cancellous bone which grows up around the neck of the tooth is each year denser, until maturity is reached. For these reasons the remains of the necrotic pulp are not so readily pushed through the apex of the fangs ; expan- sion of the alveolus does not so readily occur. How (it may be asked) is it possible to distin- guish for the purposes of relieving pain, between a tooth with an inflamed pulp and a necrotic pulp, if the tooth in each case will be loose ? The past history of the case, and the character of the pain may help us. What has been pre- viously stated with regard to temporary teeth will equally apply to permanent. Acute pain, paroxysmal in character, darting into the ear on the same side, if it be a lower tooth, or up over the side of the head if it be an upper tooth, and often wanderino^ from the source of trouble is mostly due to inflammation of the pulp. A dull heavy throbbing confined to the neighbour- TREA TMENT. 1 9 9 hood of tlie tootli itself, with a past history of great pain in the tooth which gradually sub- sided (showing a previous inflammation of the pulp and subsequent death) is very significant of pent-up pus, or gases, in the pulp chamber. An examination, however, is the final test. If the pulp is dead the crown of the tooth will have lost its translucent appearance, and have become darkened in colour. On carefully scraping away the carious dentine, no pain will be caused by approaching the pulp chamber, though moving the tooth bodily will produce it. On the other hand if the pulp be alive scraping of the den- tine in the neighbourhood of the pulp is acutely painful. Should the Practitioner decide that the pain arises from a pent up discharge or gases of putrefaction, in what the Dentist calls a " dead tooth," a careful attempt should be made to remove the carious dentine until the pulp chamber is reached, and these are liberated. If this can be done, relief will rapidly follow, and a small pledget of absorbent cotton can be placed loosely in the cavity sufficient to take up any discharge and prevent food from block- ing it up. Should, however, the symptoms be more pro- CHILDREN'S 2EETH. nounced, the alveolar plate expanded, the patient's face swollen and tense, and the tooth quite loose in its socket, in fact, with all the signs of an acute alveolar abscess, it is better to extract the tooth at once. This may be stated as a general rule, though it is an absolute necessity where pus threatens to perforate the tissues of the cheek or make its way out beneath the lower jaw. Just as with temporary teeth, the necrotic fangs of a permanent tooth may, and often do, cause an alveolar abscess and in every case such roots should be extracted. The lack of an elementary knowledge of what a carious tootli or root is capable of doing, may lead the Practi- tioner to treat the patient for necrosis of the jaw, when pus has found its way out on to the face. Whereas on the timely removal of a carious tooth, or root, the sinus would cease to exist. So far we have been considering the first permanent molar, taking it as a type of the permanent set, because of its greater frequency of decay. All we have said as to relieving pain, may be said to apply to all the permanent teeth with an exception to the general rule spoken of above, viz., extraction for an alveolar 2REATMENT. 2or abscess. Many cases occur where the tissues of the face are not tlireatened with perforation by pus, yet there may be a general swelling of the cheek. Though it might be quite justifiable to extract a six-year-old molar, where there is no chance of obtaining assistance from a dentist, it would not be so if the tooth be one in front of the mouth, say a central incisor or canine. On gently raising the upper lip fluctuation may or may not be found over the apex of the loose tooth. An attempt should be made to give vent to the pus by passing a small abscess knife (bistoury) through the gum and expanded alveolus to give immediate relief. Such teeth may be saved for years if the case handed over to a Dental Surgeon for further treatment. Should the crown of the tooth be gone and the fang alone left, this may be extracted. It is quite possible to find that with all the signs of an alveolar abscess the teeth may be free from caries. Examination with reflected light— by the aid of the mirror — will often enable the Practi- tioner to notice a change in colour of one tooth near the swelling, this, in addition to the fact that the tooth is exquisitely painful when pressed upon, will help to decide the source of trouble. 202 CHILDREN'S TEETH. SroppjNG OR Filling Teeth. A long meclianical training, no small amount of manipulative skill, and a wide experience, are the chief essentials required of the Dental Surgeon in order that he may perform, with efEciency and ease, the varied operations of filling teeth. Although to an observer it may very well appear that the methods are ex- tremely complicated, and that the instruments required are innumerable, it is nevertheless desirable that the Medical Practitioner should make himself acquainted witli the principles and some of the methods adopted, so that when occasion requires he may be enabled to carry out in practice such operations in their simplest form, when skilled assistance is not to be obtained, or as a temporary means of saving teeth until the patient can be handed over to the dentist. The objects sought to be attained in filling teeth are brieflv as follows : — To remove carious enamel and dentine. To replace the lost tissue with a stopping, which shall exclude moisture, prevent further decay, and cause no after-pain. TREATMENT. 203 In order to obtain the best results it is need- ful to keep in mind two or three important facts. The earlier a tooth is treated, when caries has once attacked it, the better for both patient and operator, for the patient will suffer less pain, and the operator will have less diffi- culty in stopping the tooth. Were it possible to fill teeth without regard to the nerve pulps which they contain, most of the difficulties and complications which beset one's path in the performance of such duties, would at once be swept away. Unfortunately this cannot be ; when once caries has passed into the dentine it approaches the pulp. It may be slowly, but surely, with pain or with- out. When once the pulp chamber is reached and the contents are exposed to bacteria and fluids of the mouth, the best time for filling that tooth, and the best opportunity of saving it, so that it may become useful once more, have passed away. A carious tooth may be likened to a simple fracture of a limb ; when the pulp is exposed, the simple fracture becomes compound, and not only is treatment far more compli- cated, but the chances of saving it aie very 204 CHILDREN'S TEEIH. much lessened. Moreover, complications are apt to arise which otherwise would not be thought of, or at any rate need not be taken into account. Parents are extremely ignorant or careless of such matters and require constant reminders. They bring their children, to have teeth stopped. '' Did you know that this child's teetli were decaying?" you may ask. "Oh, yes ! but the child had no pain, and I thought it did not matter," is the constant reply. Then one finds that the stopping resolves itself into relieving pain. For if a filling is introduced into an aching tooth, it simply means adding to the pain and the tooth will have to be removed. In addition to the instruments already men- tioned, it will be necessary for the Practitioner to be provided with several chisels, as illus- trated below. These are used for cutting away overhano-infr edg-es of enamel, which if left will break down after the tooth is filled ; at the same time they form obstructions which conceal decay beneath. A dozen excavators of various shapes are required; those illustrated will be found the most TREATMENT. 205 useful. These instruments arc made of tlie finest steel, hardened and care- fully tempered at their cutting- edges. The " excavators " as their name im- plies, are used for scooping' out, or preferably catting away the soft and carious dentine. •4 :1 Fig. 60. CHISELS. Stopping Tcmporarij Teeth. Wherever possible, temporar}^ teeth should be saved by filling, in order that they may be preserved until their successors are due. This is especially true of the molar teeth which are required for approximately 7 years, 2o6 CHILDREN'S TEETH. 7 EXCAVATOES. that is, from the time of their eruption at 2, until 9 years. It has already been stated, that they are the teeth most hkely to become carious, and which most fre- quently cause pain. Such teeth should be carefully sought out and constantly exam- ined. They are least likely to be noticed because they are out of sight. TREATMENT. 207 Caries in a temporary molar is either found in the centre of the crown or between two teeth (interstitial). Fig. 71, is a diagramatic representation of a lower tooth with caries commencinof in the centre of the crown. It Fig. 71. Section of a temporary molar showing caries on the masticating surface. Fig. 72. Section of temporary molar showing cavity shaped for filling, will be seen that the amount of enamel attacked is small compared with that of the dentine beneath, In order to expose the carious den- tine, the frail edges of the enamel should be carefully cut away with a chisel round the margins of the cavity. If this margin be left, it constitutes a source of danger after the tooth 2o8 CHILDREN'S TEETH. is filled. Great care must be exercised to avoid the possible slipping of the instrument into the cavity. This can best be accomplished while operating on teeth of the lower jav/, by hold- ing the chisel somewhat in the same manner as a pen is held, with the second finger near the cutting edge, its tip resting on the margin of the crown of the same, or the next, tooth. For teeth of the upper jaw the chisel may be grasped in the palm of the hand by the four fingers, with the cutting edge upwards guarded by the thumb, much in the position of a pen- knife when sharpening a pencil. Fig. 72 is intended to'show an ideal cavity with enamel margins cut away. When this is done, the dt^hris should be washed away with warm water from the syringe. Before proceeding to remove the carious dentine it is well to ascertain if possible whether caries has reached the pulp. Enquiry should be made as to whether the patient has suffered pain ? If so, whether the pain has been acute or not, or has been felt in the night. If not, we have presumptive evidence that the pulp has not been reached. This however, is insufficient, as abundant proof is forthcoming that caries may reach a TREA TMENT. 209 pulp and that it may be destroyed without a sign of pain. In order to test the matter fur- ther, a wisp of cotton wool should be rolled up, between the thumb and finger, of sufficient size to fill the cavity, and then conveyed with a pair of tweezers, to the tooth. This pledget of wool should then be gently pressed into the cavity. The process should be repeated as the child is apt to flinch with fear. If pain is entirely absent, further evidence is given of the oaries not having reached the pulp. The really painful part of tooth-stopping commences with the removal of carious den- tine. In order to reduce this to a minimum the application of lunar caustic as previously recommended (vide Toothache) is advisable. This not only renders the carious dentine insensitive but acts as a powerful antiseptic. The latter quality is of great importance in the stopping of temporary teeth, as the removal of caries by excavators should be almost entirely confined to the edges of the cavity. Owing to the large size of the pulp chamber, there is great danger of an exposure if much of the carious dentine is removed from the floor. There will be no bad results by leaving it there, p 2IO CHILDREN'S TEETH. and (unless the dentine is so thoroughly disin- tegrated as to be soft — powdery if dry, pasty if wet), the caustic will coagulate the albumen and turn it into a leathery mass. It is round the margins of the cavity that caries is likely to recur, and care should be taken to remove this so that the cavity is shaped as near like Fig. 72 as possible, the floor of the cavity slightly larger than the exit, in order to retain a stopping. It frequently happens that caries is found between two teeth, the front (or mesial surface) of one tooth, and the back (or distal surface) of another. Fig. 73.— SECTIONS OF TEMPOEAEY MOLAES. Showing interstitial cavities. In temporary teeth, and in temporary teeth alone, it is quite j ustifiable to treat such cases as one cavity. The same precautions should be taken to cut away frail edges of enamel, to ascertain whether the pulps are exposed, and in TREATMENT. 211 the removal of carious dentine. The proximity of the pulp should be kept in mind. The base of the cavity may be the gum and it is at the- sides where pulp exposure is likely to occur,, the pulps of two teeth being exposed instead. of one. In the cavities, both of crown centre and between two teeth, the filling may be of amalgam or gutta percha. These fillings will be described f ally when speaking of permanent teeth. If on enquiry one is told that the child has- had acute or persistent pain, and on examina- tion it is found that a pledget of cotton when pressed into the cavity gives rise to immediate- pain in the tooth, it is tolerably certain that caries has reached the pulp. Very careful removal of carious dentine will probably con-^ firm this by the pain it occasions, The cavity should be washed with warm water from the syringe and dried with absorbent cotton. A small roll of cotton wool or a piece of Amadou* should be soaked in carbolized resia and placed in the cavity. This may be changed every other day until all tenderness from the- * Soft Amadoa or German Tinder— a fungoid growth— is supplied. in sheets or pellets by the Dental depots. 212 CHILDREN'S TEETH. pulp has passed away. The carbolic acid and chloroform will in time destroy what vitality remains in the exposed pulp. They are, how- ever, soon washed away by the fluids of the mouth. The resin will remain in the meshes of the cotton or amadou to form an efficient covering. Dentists sometimes apply a trace of arsenic to the exposed pulp in order to destroy its vitality. So far as temporary teeth are con- cerned this is unnecessary. It often occasions Fig. 74.— SECTIOiS^ OF TEMPORARY MOLAR. Showing caries in the crown which has extended to pulp chamber. much pain and the same results may be obtained ■without it. Should the tooth remain sensitive after several applications of carbolized resin, lunar caustic should be applied. The cavity should be thoroughly excavated and the contents of the pulp chamber should be removed. No attempt should be. made to remove the TREATMENT. 213 pulp from the fangs. A wisp of cotton or pellet of amadou should be dipped into lodo- forai or moistened with a drop or two of Oil of Cassia and placed in the pulp chamber, over this should be placed a disc of card, cork, or tin, and over this again a gutta percha or metal stopping. The Iodoform or Oil of Cassia will prevent putrefaction taking place in any portions of the pulp remaining. Fig. 75.— EXCISING FORCEPS. Should caries have reached the pulp chamber the pulp being quite insensitive, and the tooth discoloured, it will be evident that the pulp is dead and probably putrid. If cotton is intro- duced into the cavity and has a j)utrid odour on removal, this amounts to a certainty. To stop such a tooth is dangerous, for the products of putrefaction will if pent up be driven through the apex of the fangs, If left alone the tooth :2i4 CHILDREN'S TEETH. ivill form a receptacle for decomposing food. "What then should be done ? If the tooth is fiim in its socket, it should be cut down level with the .gum. This may be done with a pair of excising forceps, and without pain. One blade of the instrument should be pushed into the cavity, ihe other on the outside of the crown. In most cases on closing the forceps the whole crown 'Comes away. Should it not do so, it must be Temoved in pieces. If the tooth, however, be loose and painful to bite upon, it should be extracted at once. Stopping perm (mcnt Teeth. In the stopping of permanent teeth much skill is required. For while in the stopping of temporary teeth we are well aware that within a short time they will be lost, the object of filling permament teeth is to save them for many years. They should last the life-time of the owner, and although it is a fact that a carious tooth is liable again to become carious, it is neverthe- less true that when care is exercised teeth filled may be useful for one or forty years. The Practitioner who has had the oppor- tunity of watching and treating the temporary teeth of a child should very carefully examine TREATMENT. 215 the 6-year old permanent molar from time to time. Reflected light should be thrown on to each tooth with the mirror ; and the fine probe should search the centre of the surface for com- mencing caries. A cavity may be only of sufficient size to admit the point of the probe, either in the centre of the tooth or some part of the grooves, or fissures, which separate the cusps, Wiierever the probe sinks in by careful pressure, the surface of the tooth should be wiped dry with absorbent cotton, and on closer examination, it will be seen at the point of entry that the enamel is dark, or semi-opaque, on all sides of the cavity. The enamel should be cut away, as mentioned when dealing with caries of a temporary tooth only/«r more thoroughly , with chisels. It will be found convenient to commence with a narrow blade, and as the cavity becomes larger to use broader ones. So long as a reasonable amount of care be taken there need be no risk of driving the chisel into the softened dentine. Fig. 76 is intended to repre- sent the crown of a molar with commencing caries in the centre and in the fissures. Fig. 7 7 shows the same tooth when enamel has been cut away so that frail edges are removed and 2l6 CHILDREN'S TEETH. the carious dentine can be reached thorouglily. After washing all d^hvk from the cavity the softened dentine must be carefully taken away. Fig. 76— CEOWN OF A MOLAR TOOTH. Showing the method of using a chisel. Fig. 77. CEOWN OF A MOLAE TOOTH. With the frail edges of enamel removed. There is not so much danger of exposing the pulp as in a temporary tooth, though sufficient care is needed in removing the carious tissue from the floor of the cavity, that the pulp is not too nearly approached. It would be well for the Practitioner to cut in halves, or break in a small vice, such teeth as he is obliged to extract in order to become well acquainted with the TREATMENT. 21 7 position of the pulp chamber. A few ^w-ohfost mortem examinations will be valuable in more ways than one. He will also learn the condi- tion of the pulp, where acutely inflamed, gan- grenous &c. A certain amount of discoloured Fig. 78. CROWN OF A MOLAR TOOTH. Showing orifice of cavity shaped with a drill. dentine may be left on the floor of the cavity ; but great care should be exercised in removing all sign of such round the walls and especially just beneath the enamel. Fig. 79. SECTION 0? A PERMANENT MOLAR. Showing cavity shaped for filling. With the excavators already illustrated all parts of the cavity can easily be reached. Smaller instruments may be used at first (as 2i8 CHILDREN'S TEETH. with chisels) and larger later, as the cavity will admit of them. Although in Figs. 72 and 79, ideal cavities have been shown, it is not to be supposed that all can be shaped in this way. Where caries is slight a saucer-like hollow is seen when all disorganised tissue is removed. It will be necessary to cut away (and this can be done with sharp instruments) sufficient of the sound dentine to make the base of the cavity broader than the orifice, or no filling can be retained. This simple fact should be remembered in the shaping of all cavities for the retention of fillings whatever the teeth may be. For the removal of caries and the shaping of cavities the Dentist uses a dental engine. This is an upright stand, with a long arm contain- ing a spiral spring. By means of a band round a fly wheel and connected with a treadle, this may be driven at great speed while kept under perfect control by hand and foot. Drills of 3 inches in length of every shape and size can be attached to such a machine and by a simple mechanism can be locked and unlocked in the free end of the arm. This is a formidable instrument in the hands 2REATMENT. 219 of a novice and requires special training for its use. As a substitute for simple cavities, a crutch drill handle may be used, into which tlie different drills may be fitted. Some of the i'ig. 80.— DRILLS. most useful shapes are shown and it is advisable to have duplicates. The rotatory motion is given by the thumb and forefinger, which grasp the instrument, the crutch resting on the soft tissue between them. Fis. 81.— CRUTCH HANDLE. In order to lessen the pain of drilling, the cavity should be constantly moistened with carbolic acid, or chloroform, after wiping away all moisture. It is not advisable to use lunar 220 CHILDREN'S TEETH. caustic in excavating small cavities in perma- nent teeth, as the staining which rapidly takes place is apt to prevent the oj^erator from dis- tinguishing between healthy and unhealthy tissue. The exclusion of moisture is one of the diffi- culties to be overcome in preparing cavities for filling. In some mouths this is easy of accom- plishment, in others it is extremely difficult. The introduction of an instrument, or even a finger, into the mouth is often sufficient to excite an increased flow of saliva; and the necessary cutting of a tooth is often sufficient to flood the tooth and the cavity. In the upper jaw the chief supply is from the Parotid gland through Steno's duct inside the cheek opposite to the second permanent molar. In the lower jaw from the sublingual and submaxillary glands. To exclude moisture the Dentist generally uses a thin sheet of rubber, about 4 inches square ; 3 small holes are punched out the size of a pin's head, for the tooth to be operated upon, and one on each side of it. The rubber is then stretched over the crowns of the teeth and tightly encircles their necks. TREATMENT. 221 For all ordinary purprises a soft table napkin will answer the purpose. One corner of this should be rolled up, and placed beneath the upper lip, or tucked up between the gum and the cheek, according to whether teeth are being treated in the front or back of the mouth. The necessary position for stopping teeth of the upper jaw (with the head well back in order "to obtain light) makes the exclusion of the saliva a comparatively easy matter as it gravi- tates towards the back of the mouth. With the lower jaw it is difficult ; the chin being depressed the saliva gravitates toward the front of the mouth. In mouths where the saliva flows freely it is well for the Practitioner to accustom himself to excavating under water, occasionally mopping the cavity to find out how far unhealthy tissue is being cut away. When the cavity is prepared for filling it is well to have all the instruments ready and the stopping prepared close at hand on a small table, so that each may be reached with the right hand, without the necessity of leaving the patient's side. Supposing a lower molar tooth on the left side is to be filled. A pledget of cotton wool CHILDREN'S TEETH. should be rolled up and placed between the cheek and gum, in the upper jaw on the left side, to control the flow of saliva from Steno's duct. Another pledget should be introduced Fig. 82. Showing Napkin in position on the lower jaw of the left side. just under the side of the tongue on the floor of the mouth on the left side, no attempt being made to press the tongue down, A roll of the napkin should then be placed in the sulcus TREATMENT. 223 between the gums and lip on the same side, with its free end lono^ enoug-h to be bioug-ht round the last molar tooth and forward, so as to cover the cotton wool. (Fig. 82.) This may bG kept in position by the thumb and fore- fingers of the left hand of the operator (who should be standing on the R. side of the patient, the L. arm being brought round the head) or if the patient is old and intelligent enough, by two fingers of the patient, one finger on the outside, the other on the inside of the tooth or teeth to be kept dry. The cavity being prepared for filling, it is desirable to know what stopping may with safety be put into it, and how it is to be done. If the tooth has not previously ached, and the cavity is of moderate size with no exposure of the pulp, no stopping will answer better at the back of the mouth than an amalgam. Amal- gams are mixtures of a metal, or metals, with mercury. They are used while soft and set hard within an hour. When a good amalgam is introduced under favourable conditions, it will last for many years on a masticating sur- face. The simplest method of making an amalgam 2 24 CHILDREN'S TEETH. is to file down a silver coin. Place the filings in the palm of the left hand, add a small quan- tity of mercury, and rub them together, with the forefinger of the right hand into a paste. This should then be placed in a small piece of wash leather and squeezed until all super- fluous mercury is removed. A far better amalgam for filling young and delicate teeth is that known as SuUivarCs. It is a mixture of pure copper and mercury. This is sold in pellets of suitable size already mixed ; and differs from other amalgams in this respect, that it can be melted up over and over again without adding fresh mercury. A pellet is Fig. 83.— AMALGAM SPOON. placed in an amalgam spoon (Fig. 83) and is held over the flame of a spirit lamp until beads of mercury are seen to exude from the surface. It is then dropped into a small mortar made for the purpose — Fig. 84 — and with a pestle is ground up into a powder or paste. TREATMENT. 225 Bath coin silver and copper amalgam turn quite black in the mouth. Copper amalgam stains the tooth tissue ; but it has the advantage of being the only filling as yet known which is antiseptic in its action. In addition to changing colour amalgams have other disadvantages. They contract more or less and thermal changes are rapidly felt. Fig. 84.— PESTLE AND MOETAR FOE AMALGAM. Therefore, they should not be put into a cavity where there is a suspicion of nerve exposure, where the tooth has ached or where there is only a thin layer of dentine covering the pulp. The pulp may be irritated, and this will cer- tainly be the case if a stopping is placed over it when exposed. Acute inflammation will follow ; and the tooth will be more easily removed than the stopping. With care, how- ever, this need not happen. Q 226 CHILDREN S TEETH. ^ When the cavity is prepared and dried, the amalgam may be con- yeyed in small pieces to the tooth between the points of a pair of tweezers, or better still with an instrument, which is round or oval shaped at one end and has a small cup at the other. (Fig. 85.) A small piece may be taken up in the cup placed into the caT'ity and thorough- ly pressed with the round end into all parts. This must be repeated until the cavity is filled to the sur- face of the enamel. Any superflu- ous amalgam should be wiped off with cotton wool and the surface made quite smooth with the ball- ended plugger, or spatula. (Fig. 86). Should caries attack the posterior (distal) surface of one tooth and the anterior (mesial) surface of another, each tooth should be treated and filled separately, and a piece of tape, or ribbon, be passed between them to remove fragments ^ I td > m o TREATMENT. 227 of a stopping. Teeth are always more or less movable, and the effect of joining two teeth by one amalgam plug, is that the latter will sure to be loosened in at least one of the- cavities. Instead of a small cavity in the crown which has to be enlarged, caries may have extended so far beneath the enamel as to thoroughly undermine a portion of the biting surface. This may (and often does) proceed until, on- masticating, the frail wall of enamel is broken down, the patient for the first time becoming- aware of the fact that a cavity exists. More caution will be necessary to prevent an exposure- of the pulp. Should the dentine be extremely sensitive it will be advisable to fill the cavity witli a permanent filling, which shall prevent further decay, and at the same time act as a non- conductor. A hard gutta percha filling will for this purpose be most suitable. Gutta Percha fillings are of the greatest value for stopping children's teeth. They are easily introduced and should trouble arise can be readily removed. They expand slightly, thus preventing the access of moisture round the margins of cavities, and the renewal of decay. :228 CHILDREN'S TEETH. The greatest failing is that of wearing rapidly 'On a masticating surface, though they are insol- uble in the secretions of the mouth and do not •change colour. In consequence G. P. may be used as freely in the front as at the back of the anouth, It is desirable to have two kinds, hard and ■soft^ and they may be made as follows : Into a Wedge-wood mortar of good size 3 'drachms of china clay and 4 drachms of Oxide of Zinc should be thoroughly mixed with the pestle and then turned out on a sheet of paper. The mortar and pestle should then be gradually warmed over a small gas burner or paraffin lamp, a piece of wire gauze being placed between the flame and the mortar to prevent the latter cracking. 2 drachms of pure Gutta Percha — tissue answers well — «hould be cut up small and put in the mortar until quite softened without hurning. The oxide of zinc and china clay should be gradually added, and thoroughly incorporated with the ■G. P. into a mass. While warm, this should be €ut in pieces and rolled down into sticks, between two pieces of wood or glass, and when cold, cut into pellets. TREATMENT. 2291 A ^oft Gr.P. stopping may be made in exactly the same manner of the following ingredients. China Clay ... 3 drachms. Oxide of Zinc ... 2 ,, Gutta Percha ... 1 ,, White Wax .... 1 ,, Carmine 2 grains. To introduce a gutta percha filling, the- cavity should be prepared and dried as above mentioned. The instruments required are three or four spatulas and pluggers of various sizes. The most useful are those with a plugger at one end and a spatula at the other. — Fig. 87. The- plugger should be heated gently in the flame of a spirit lamp and pressed upon a small pellet of Gf.P. so that it adheres. The instrument with the pellet attached should be passed to and fro- over the flame until it is softened, care beino- taken that it is not burnt. It should then be- conveyed to the cavity, gentle pressure being exerted to spread it out upon tlie floor. Fresk pieces should then be added and pressed into all parts of the cavity until it is filled. Any super- fluous material may be cut away with a warmed ^3° CHILDREN'S TEETH. Fig 87. GUTTA PEECHA FILLING INSTEUMENTS. TREATMENT. 231 spatula and tlie filling smoothed over with cotton wool moistened with chloroform or Eucalyptus oil. A hard filling of G. P. thus carefully introduced, will often last for years, and can when worn down be renewed or a more perma- nent stopping may be used. Fig 88. In large cavities where more or less pain had been experienced (thus showing that the puis is in an irritable condition), gentle pressure with a pledget of cotton wool — as above men- tioned — will almost always be enough to show whether the pulp is exposed, as well as irritated. Should pain not follow the pressure of cotton wool. Lunar caustic should be applied, and the cavity (after 'drying) should be filled Avith a soft G. P. Should the introduction of this stop- ping give rise to pain, it may be removed and carbolised resin on cotton wool, or amadou, 2 32 CHILDREN'S TEETH. sliould be placed in the tooth and changed each day until all tenderness has ceased, when the Gr. P. filling may again be tried. It will far too frequently happen that patients will come in an agony of pain ; on examining the tooth a cavity varying in size will be found and whether the pulp is actually exposed or septic matter have reached the pulp through the disorganized dentine, the pulp will be acutely inflamed. We have already stated above that Fig 89.— FRONT VIEW OF LOAVER MOLAR TOOTH. Showing exposure of the Pulp at A. the application of carbolized resin arrests the pain : but now the question will naturally arise, is it possible to save the tooth so that it may be useful to the patient in after life ? In young children when such trouble arises (as it will in the majority of cases) in a six- year-old, or first permanent, molar, we believe it is better to TREATMENT. 233 extract tlie tooth at once. The repeated ajopH- cation of carbolized resin although stopping pain, will not allow of the patient eating with comfort on that side of the mouth. Especially is it advisable to extract such teeth if the child be delicate, and under 8 or 9 years of age, while the fangs of the teeth are not yet completely formed. Should it be considered desirable to save a permanent molar, or a front tooth with a pulp exposed, it will be far better to seek skilled assistance. The method of procedure adopted by the Dental Surgeon will be to apply a trace of arsenic on cotton wool to the exposed pulp in order to destroy its vitality, Eemove the con- tents of the pulp chamber, and as much from the fangs as is possible, with barbed instruments called nerve extractors. Fill them with an antise^^tic root-filling and then stop the tooth. In children of robust health and above 10 years of age this operation is frequently performed with success. In adults such operations are the most successful and teeth when properly filled last for some years. If, in excavating a large cavity of a molar tooth, it is found that the pulp is gangrenous, 234 CHILDREN'S TEETH. the tooth quite firm in its socket, and not pain- ful, it is better to cut the crown off level with the gum as advised with regard to temporary teeth, than to attempt to fill it and run the risk of shutting up septic material, or leave the tooth to become a receptacle for the d^hris of food. Summary of Instruments, Drugs, and Stop- pings, etc., as mentioned above : Instrument, Dental Mirror and Probe, Dental syringe, A pair of tweezers. Chisels 4, Excavators 12, Excising forceps, Crutch handle and 12 drills^ Amalgam spoon. Pestle and mortar. Cup and ball pluo^ffer) r , p,,. -^ ;, , . \ lor amalgam liilmgs, ±5all and spatula ) . Pluggers and spatulas for G.P. fillings. Drugs ^ etc. Lunar caustic. Liniment of iodine Carbolized resin. TREATMENT. 235 Oil of cassia Iodoform, Absorbent cotton, Amadou. Stoppings. Sullivan's amalgam, Hard a. P. Soft G. P. The Extraction of Teeth. In former pages it has been pointed out where treatment by extraction is absolutely essential. There will, however, occur to the Practitioner — as so often happen to the Den- tist — cases about which he may have some doubt whether the removal of one or more teeth is justifiable or not ? Especially if, as has been urged, a careful examination of the mouth be made in the case of every child for whom medical advice is sought. The condition of a child's mouth is often unknown until it is found upon a bed of sick- ness, and in many cases it will be impossible— 236 ■ CHILDREN'S TEETH. and that for obvious reasons — to do more than to see that the mouth is repeatedly washed out with some antiseptic lotion. When the patient is sufficiently well, all loose carious teeth, necrotic roots, and carious teeth or fangs from which pus is oozing through the alveolus, should be extracted. These will be found, for the most part, among temporary teeth. They not only prevent the child from eating, but poison the alimentary canal and form infective foci for the spread of disease to other tissues of the body. Whenever teeth can be saved, they should be treated according to directions already given. Should any doubt exist as to the removal of a permanent tooth, it is wiser to seek the aid of a Dentist than to remove a tooth, which by care- ful stopping might be made useful in the future. What the Practitioner should do, however, is to give his patient a clean and healthy mouth ; and where no efficient dental aid is to be obtained he must determine for himse If whether mastication is performed with comfort or not. Even though a tooth be filled, unless a child can eat upon it, more harm than good will be done by keeping such a tooth in the jaw. TREATMENT. 237 In order to properly extract a tooth it is essential that the practitioner should provide himself with a set of forceps. These are made of the best steel, are of liglit construction and are so formed that their blades accurately fit the necks of the teeth. The blades are wedge-shaped, the outer sur- faces smooth and polished, the inner surfaces finely serrated in order that the tooth may not slip. The handles are roughened on their outer surfaces and their extremities blunt, and some- times curved, in order to afford sufficient hold when grasped, and that upward pressure may be used from the palm of the hand when need- ful. In removing a tooth it is necessary that the gum and the alveolar process should be injured as little as possible. The cutting edges of the forceps are made sharp, so that they may be introduced beneath the gum, and between it ' and the tooth. No more force should be used than is abso- lutely necessary. It is not by pulling, but by twisting, or lateral movements, that a tooth can be removed skilfully. In grasping a tooth, sufficient care must be exercised that it shall 238 CHILDREN'S TEETH. not be crushed within the blades of the forceps. The movement must be very dehberate and sure. When the tooth is grasped, it should never be lost sight of until it is removed from the mouth. Any sudden movement, such as a jerk, or a pull, may result in a fracture of the tooth within the socket. If successful so far as the extraction is concerned, the tooth may be accompanied by a portion of the alveolar plate and gum. The forceps should be kept scrupulously clean. It is best to dip them in boiling water before using. After being used, the jaws may be dipped in a strong solution of Carbolic Acid, and then wiped dry. It is necessary to see that no moisture remains between the joints. This seems a small matter ; but where such instru- ments are not in frequent request, it is annoy- - ing to find the jaws rusted, and not freely movable, a contingency easily avoided by the application of a drop of oil, before the forceps are put on one side. There are two points in the extraction of teeth which require special attention. 1. The application of the blades of the instrument to TREA TMENT. 239 the tooth. 2. The separation of the tooth from its socket and its removal from the mouth. 1. The handles should be opened sufficiently wide for the blades to pass well over the crown of the tooth. They should then be closed lightly ^ just enough to feel that the tooth is grasped ; the blades should then be pushed well up (in extract- ing an upper tooth) or (in extracting a lower tooth) well down bettveen the gum and the neck of the toothy and, if possible, loithin the alveolus. An exception to this will of course be made in extracting loose temporary teeth from the front of the mouth where the alveolus has practically disappeared, but whenever a tooth is at all firm in its socket it is essential to obtain a sufficient hold of the sound portion of a tooth without crushing. If this is not very carefully carried out, and sufficient force is used to remove the tooth, the blades will simply break into a carious crown or root ; and should the pulp be still alive, the result will be for the patient an agony of pain and for the operator great discouragement. 2. — Having grasped the neck or sound por- tion of the tooth, the handles should be held sufficiently tight to steadily force — not pull — it 240 CHILDREN'S TEETH. from its socket. The movements required to complete this part of the operation will depend upon the form and the position of the tooth in the jaw. Later, the extraction of individual teeth will be mentioned, but in general terms it may be stated that teeth at the back of the mouth require a rocking or lateral movement from side to side, in front of the mouth in the upper jaw a slight rotatory motion, in front of the mouth in the lower jaw an outward and upward move- ment. Teeth are separated from their surroundings in the lines of least resistance. It is by no means necessary that the alveolus should be fractured, though in some cases where the alveolar plate is very thin, or closely adherent to the fangs of the teeth such fractures are unavoidable. Apart from these possibilities, it is well to bear in mind that by forcible expan- sion alone, most teeth are removed from their sockets, and that it is the external plate of the alveolar process which most readily yields. Extraction of Teeth from the Upper Jaw. The patient, when seated, should face a> good light with the head well back, and, where a choice TREATMENT. 241 is possible, the seat of the chair should be high. The operator standing on the right side of the patient, with his left arm encircling the patient's head, will be in the best position for controlling involuntary movements. Of course- it is assumed that the patient is seated on an ordinary chair. The fingers of the left hand may be used to keep the lips apart, and when extractino^ a front tooth one fino^er should ba placed in front of, and another behind the alveo- lus above the tooth. When extracting teeth at the back of the- mouth this is usually impossible, as the fingers will obstruct the light. Although forceps are made to fit the necks of the teeth, it is unnecessary to have a set for the permanent, and another for the temporary teeth. Those which have been chosen and illustrated are well adapted for both. The fangs of Upper Incisors are conical. When the blades of the forceps are fitted on to- the neck, a slight semi-rotary motion, or twist- ing of the tooth in its socket, is necessary to sever it from its attachments. Then it can be- puUed downwards and slightly outwards. Should the crown of the tooth have been lost R 242 CHILDREN'S TEETH. and decay have left little else than a hollow €one, the cavity, (dWdehris having been washed away) may be packed with cotton w^ool, and the forceps pressed well up between the gum and the root until a sound portion is reached. The Canines are slightly flattened from side to side. It will, therefore, be necessary, when the forceps are applied, to force the tooth back- wards and then forwards, before pulling down- wards and outwards. Bicuspids. These teeth, it is well to remem- ber, are not present in the temporary set. They succeed the temporary molars, in the permanent dentition. Their roots are flattened and the first bicuspid has generally two fangs. When the tooth is grasped it should be forced inwards, then outwards and downwards. The forceps required for the extraction of Upper Incisors, Canines, and Bicuspids have straight handles and narrow beaks, as shown in Fig. 90. Upper molars. These teeth have three fangs, one internal, or palatal, and two external. It is necessary to have two pairs of forceps, one for each side. The external blade is triangular at its edge, and the apex or terminal point TREATMENT. 243 should be applied to the division betweea tlie two external fangs, the inner blade fitting close iiiiin -iiiiiwill Q ^/vdo"^ B if III Iff wm W m Fig. OO.-UPPER IXCISOR FORCEPS. against the neck of the palatal root. It is, generally speaking, advisable in extracting 244 CHILDREN'S TEETH. tipper teeth from the back of the mouth to apjoly the internal blade first and then the external. The blades must be pushed well up before Fig. 91. SlioAving position of the hand and forceps in the extraction of an Ui)per Molar Tooth. attempthig to extract the tooth. In order to regulate tlie force required in grasping the TREA TMENT. 245 handles, the pulp of the thumb should lie be- tween the handles as they are closed. If the tooth is squeezed hastily the crown will probably be crushed. Should it not be held Figs. 92 and 93.— UPPER MOLAR FORCEPS. Right and Left. sufficiently tight, the inner blade may slip over the edge of the crown. When the tooth is care- fully grasped, it should be moved slightly in- wards (to disengage the two external fangs) and 246 CHILDREN'S TEETH. then steadily, and firmly, outwards and down- wards, the external plate of the alveolus giving way. It is very necessary for the practitioner to determine beforehand whether the molar he proposes to remove belongs to the temporary or permanent dentition. Temporary molars often require a great deal of force to extract them owing to their divergent fangs ; but a permanent molar requires much more force, and the older the patient is, the firmer will be the alveolus round the fangs. Fracture through the crown or neck of a tooth, may, and often does, occur, however careful the attempt to extract, or however skil- ful the operator may be. As already mentioned, this will happen if the blades of the instrument are not pushed up far enough to secure a sound portion of the neck. Often it is the result of a sudden movement, either on the part of the patient or the oi^erator. The removal of a tooth causes an agony of pain, and not the least painful is the first part of the procedure, due to the necessary pressure of the blades of the forceps in order to secure a sufficient hold of the tooth. The patient will probably 2REATMENT. 247 move away, unless a counter force is used, and the head kept well under control, On the other hand, the screams of a child will, at times, require all the calmness one is possessed of, in Fig. 94— UPPER STUMP FORCEPS. order to complete the operation without undue rapidity of action. Carious molars are very deceptive in appear- ance ; the walls may look to be comparatively CHILDREN'S TEETH. sound, but when the forceps is applied the €rown may collapse, and it will then be found ihat caries has extended far up the neck of the iooth almost to the fangs. Carious and necrotic teeth are often very brittle and break off at the slightest attempt to remove them. This is most frequently the case with temporary teeth vt^hich break up and have to be removed in pieces. Whenever the crown of a molar tooth is sufficiently decayed as to appear likely to break, the full molar forceps should be discarded, and a pair of upper stump forceps should be used. The inner blade should be pressed up so that the palatal fang may be grasped, and the outer blade should grasp the anterior external fang. If these two roots are removed there will be no difficulty in extracting the remaining root either at the same time or at a later date. Upper Stumps. For the removal of stumps in the front of the mouth the incisor forceps (Fig. 90) may be used with advantage, but at the back of the mouth as the position differs so will the forceps. Although the blades of the forceps are similar in both cases, those used to extract 'molar roots are somewhat curved for- TREATMENT. 249 ward, so that they can be used without touching the lower teeth. If the position in the jaw is remembered there is little difficulty in removing a stump of an upper molar tooth, when once grasped. A slight lateral, or side to side, movement will loosen it from the its socket. The real difficulty is when the fangs are united at the neck of the tooth. The blades of the forceps must be passed up rather high and then by squeezing the handles the diver- gent fangs will be forced together aud can be removed singly. Extraction of Teeth from the Lower Jaiv. The patient may be seated, as in extracting teeth from the upper jaw, but instead of placing the head well back, it should be inclined slightly forward, that is, instead of raising the chin it should be depressed. It is necessary that this be mentioned, as in both cases, the head and body must rest against the back of the chair. For the removal of a tooth on the right side, the operator should stand behind so that he may stoop over the patient. The left arm should encircle the patient's head, and the wrist be bent so that the thumb may press down the tongue while the forefinger keeps back the lip, 250 CHILDREN'S TEETH. three fingers passing under tlie jaw to give support. When extracting teeth from the front of the mouth, or on the left side, the operator should stand on the right side, and facing the patient. The forefinger of the left hand being placed on the outer side of the alveolus, removing the lip, the second finger, on the inner side, depresses the tongue, while the thumb is natur- ally passed under the jaw to support it. The jaw is thus grasped between the fingers and thumb. In many cases it will not be possible to put the fingers into the mouth of a small child, but the jaw should always be supported. When it is possible it is always advisable to introduce the instrument before placing the fingers in the mouth, or the latter may be bitten by the frightened child. The extraction of lower teeth on the left side will necessitate the operator reaching across the patient. This is a little awkward at first, but it is better than standing in front, for by so doing the operator will intercept the light, and have less control over the jDatient. Lower Incisors and Canines. The fangs of these teeth are com|)ressed laterally, and when a TREATMENT. 25T tooth is g-rasped, it must first be forced outward and then upwards and outwards Lower Bicuspids have cone-shaped roots, and in order to displace them, a slight semi-rotary or twisting movement is necessary. The forceps required for the extraction of lower incisors and bicuspids have fine blades at riffht ano^les to the handles. Fig. 95. -LOWER STUMP FORCEPS. Lower Molars. The lower molars have two fangs, an anterior and a posterior. When ex- tracting it is well to remember that the crowns of the permanent teeth are inclined slightly inwards. The blades of the forceps at their edges are triangular. When fitted on to a tooth the apex of the triangle should pass between the fangs. The handles of the forceps should be opened 252 CHILDREN'S TEETH. sufficiently wide just to pass over the centre of the crown, the inner blade being applied first and then the outer. The forceps must be well pressed down, the thumb of the left hand being used to exert pressure, if necessary, though care must be taken that the tooth is not hidden from sight. Fig. 96.— LOWER MOLAR FORCEPS. Fig. 97. Should the crown of the tooth be very deeply carious, it is better to use the incisor and bicuspid forceps. (Fig. 95.) Choosing the anterior or posterior part of the tooth, which- ever appears to be the most sound, the blades of the forceps are passed well down so that one fang may be grasped^ In most cases the other TREATMENT. 253 will follow : but if not it can be removed after bleeding lias almost ceased. The movements required for the extraction of a lower molar are slightly inwards, and then outwards. The handles of the forceps are first raised; and then are forcibly depressed, the the tooth being then lifted from its socket. One pair of forceps for either side is all that is needful. The Elevator. This instrument is extremely useful for removing roots of teeth, both tem- porary and permanent. It has a straight handle with a curved or straight blade. The one figured tapers to an edge, one side is serrated and flat, the other side is polished and round. In using, it should be held firmly in the palm of the hand and the blade should be guarded by 254 CHILDREN'S TEETH. the thumb or forefinger to within an inch of its termination. Thus it will be prevented from injuring the tissues of the jaw should it slip, as it is liable to do. It is a simple lever, the ful- crum being a neighbouring tooth, the alveolar process, or the fingers of the left hand of the operator ; the latter method is necessary in the removal of temporary roots, where the alveolus has disappeared. Fig. 99.— ELEVATOR. The point of the blade must be pushed well down between the root and the gum, with the flat side against the tooth. The handle should then be twisted and the root prized, or lifted out of its socket. Injuries of the Teeth. Falling over a carpet, or stool, tumbling downstairs, or a blow on the mouth while at play, are the usual accidents which cause an injury to the teeth. Those of the upper jaw TREATMENT. are most likely to suffer, and, as a rule, the cen- tral incisors are affected. Amongst poor child- ren, the habit of drinking from a water tap is common, and the front teeth are often injured b)^ the child, in the act of drinking, being pushed from behind. The effects, of necessity, will vary as the force of contact, whether the mouth is open or closed, and will also partly depend upon the condition of the patient's health at the time. Such injuries may be briefly described for the sake of convenience under the headings, — Concussion, Displacement, and Fracture. Concussion. A tap or blow upon a tooth, biting upon a piece of bone, or other hard sub- stance in the food, is usually followed by periodontitis. The tooth becomes loose in its socket, and tender to bite upon for a few days. Should the blow be severe, or the child in delicate health, the periodontitis may be preceded, or followed, by acute inflammation of the pulp (pulpitis). A dull aching, or, if there be pulpitis, acute pain, with exquisite sensitive- ness of the tooth on biting, will prevent the patient from eating, and later, an alveolar 256 CHILDREN'S TEETH. abscess may point opposite to the apex of the fang. If concussion of a temporary tooth causes much pain, and an alveolar abscess is threatened, it is advisable to remove the tooth. If left, pus may find its way to the developing permanent teeth and injure them. A permanent tooth should be left alone. Should an alveolar abscess form beneath the lip this should be opened through the gum with a small abscess knife. As a rule such teeth become quite firm in their sockets Displacement or Dislocation of a tooth may be complete or partial. A tooth may be forced out of, or driven up into, its socket. The absence of a tooth from its socket, and which cannot be found after an injury, should always lead to a careful examination of the alveolus. A temporary tooth which has been driven up into its socket, should at once be removed with a pair of incisor forceps. In some cases a per- manent tooth may be drawn gently down and ligatured. The question of restoring a tooth to its former position only arises with regard to permanent teeth. Should the patient be TREATMENT. 257 healthy, and the fang of the tooth fully grown, (and this with the incisors is between the lOth and 11th years) the tooth should be carefully cleansed and replaced in its socket. The death of the pulp is almost inevitable ; but such teeth liave been known to remain firm (though discoloured) from h to 15 years, even though they had been out of the mouth for two or three days. * A ligature of silk attached to adjoining teeth will suffice to keep the dis- placed tooth in position. Should two teeth have been displaced and restored, a small gutta- percha cap may be moulded over them includ- ing a tooth on each side. This will effectually protect the injured teeth from being bitten upon. Fracture. Fractures of the teeth are of fre- quent occurrence, and are generally confined to those of the permanent dentition. Sufficient force to break a permanent tooth will, as a rule, completely displace a temporary tooth. The fracture may be in almost any direction. Where the corner of a tooth is broken off, as so frequently happens with incisor teeth, the * A tooth freshly extracted from the socket, and immediately replaced may not even become discoloured, and, stranger still, may even be found to be sensitive afterwards. 258 CHILDREN'S TEETH. dentine will be exposed and the tooth become sensitive. The surface should be painted over with caustic, and any sharp edges should be smoothed down with a file. Should the fracture extend to the pulp, leaving it exposed as an exquisitively sensitive spot, such exposure will, if left alone, be followed by pulpitis, and later, if the opening become blocked by food particles or other foreign body, by periodontitis with alveolar abscess. Such teeth should at once be extracted if the child is under 12 years of age, because the fangs will not be completed. Beyond 12 years of age there may be a reasonable hope of sav- ing the root of the tooth, and placing an artifi- cial crown on it which may last many years. If the fracture is transverse through the crown, so that the fang of the tooth is not injured, it is often possible to save the fang by destroying the pulp and crowning the tooth artificially. It is, however, necessary that the root of the tooth should be fully developed. If a child is more than 12 years of age the Dental Surgeon would adopt this treatment and such a crowned tooth will last for many years. Under 12 years of age the tooth should be extracted. The gap TREATMENT. 259 thus made will be readily filled up by the approximation of the other teeth. Tai{Tak ; AND irs Removal. The Saliva holds in solution a certain propor- tion of lime salts, chiefly Calcium Carbonate and Phosphate. Under certain conditions these are deposited upon the teeth; and the deposit is known as Tartar. According to Miller* the lime salts are held in solution by the presence of carbonic acid; and when this escapes the salts are precipitated. In the absence of carious teeth, the friction which occurs during mastication, and the cleans- ino- of the surfaces of the teeth with the tootli brush tend to remove any trace of Tartar. A favourite site for its formation is the outer surfaces of the molar teeth, where the saliva from the parotid gland is poured out of Stono's duct. In adults, even in the healtliiest mouths, Tartar is apt to accumulate behind the lower * Mioro-Or(janisms of the Mouth, -^ 100. 26o CHILDREN'S TEETH. incisors and may be very hard- With children this is very rare. Tartar when formed on the teeth of children is usually very soft, contains a large admixture of the debris of food ; and has an offensive odour. One of the diagnostic signs of imperfect mastication is the deposition of Tartar, gener- ally on one side of the mouth, sometimes on both sides, and occasionally in front. When- ever such a deposit is found it may be taken for granted that on the same side, one or more tender or carious teeth are present, and the patient is unable to eat with comfort. The teeth may be so covered as to entirely obscure a carious cavity. The child's breath is gener- ally offensive. All tartar must be carefully removed, and the operation is known to Dentists as Scaling. This can be done with sharp excavators, and especial care should be taken to remove it from the necks of the teeth, where it rests upon the soft tissue. As the gum surrounding the teeth will be very tender a 5 per cent solution of Cocaine may be painted over its surface. If tartar is allowed to remain, a further TREATMENT. 261 deposition takes place, and ulceration of gum tissue with a sanious or purulent discbarge is followed by absorption of the alveolus and the loss of the teeth. Amy J. H., aged 6 years 3 months. The mother says the child's mouth has been bad for the last 9 months. She has constant head- ache. Cries every morning " about her forehead." The teeth on the left side of the mouth are coated witli a soft brownish deposit of tartar and dehrh of food. The gum margin round the necks of the teetli is deeply ulcerated Avhere the tartar rests. The ulcer- ated surfaces are surmounted with greyish slough. The discharge is profuse, and very foul, staining the pillow and night gown " shocking." Treatment. — Removal of all tartar, also a deeply carious molar. A mouth-wash of Pot. Permang. ordered and R. Mist. Pot. Chlor. c Acid. (Evelina.) This child was quite w^ell in 7 days. .(2/1 ®. INDEX. 263 UYDEX, teeth Actinomycosis PAGE Absorption of bone ... 19 ,, „ cementum 25 „ „ dentine ... 25 ,, ,, gum ... 19 „ temporary .. 47,88,108,111 3 Alimentarj' canal, diseases of 159 Alveolar abscess 51, 62, 192, 200, 201, 258 Alveolar process 23, 192, 237, 240 Amadou 211 Amalgam 211,223,225 „ method of using... 226 spoon 224 Sullivan's ... 224 Antrum 61 Arrested decay 196 Arsenic 212,233 Articulation of teeth ... 90 Attrition 26 Bacteriology 2 Bicuspids 17, 26, 30, 57, 81, 85, 106 „ absence of Bones, diseases of ... Boracic Acid Bristowe, Dr., catarrhal in- flammation and dental caries ... Brushing the teeth ... Calcificatiox ... 9, 13, 46,70 of pulp ... 47 Canines, outstanding 27, 118 „ „ treat- ment of ... 121, 124 174 181 160 181 page 191,197,211,231 33 Carbolized resin Caries ,, arrested „ artificial „ cause of „ and civilization „ colours of ,, and domestic servants „ forms of „ in Hospital patients... „ and mastication 162, 177 „ and micro - organ- isms ... 39, 133 „ and nervous diseases 153 ,, predisposing causes 39, 43 „ prevention of „ and recruits ... „ and sick children . „ stages of, „ superficial, 38, 188, 196 „ in temporary teeth 207 „ and tuberculosis ... 172 Carious Dentine, removal of 209, 211 „ teeth, and infec- tious diseases „ teeth and various diseases Cassia, Oil of. use of, in cari- ous temporary teeth 213 Cavities, deceptive ... 196 „ interstitial ... 210 „ saucer-shaped ... 218 Cavity, shaping for filling 207, 210, 218 ... 196 ... 39 ... 3.5 42, 133 ... 34 148 37 150 134 147 175 35 177 178 264 INDEX. PAGE Cemeiitum 10, 25 Chisels, dental • 204 Chisels, dental, use of 208, 215 Chlorate of ]3otasli ... 181 Chloi'ide of sodium, as a mouth -wash ... 181, 193 Chlorinated lime water . . . 181 Chorea 156 Cleansing the mouth 135, 180 Cocaine 260 Coleman, Mr., Epilepsy and diseased teeth 154 Colic 20 Concussion of teeth ... - 255 Convulsions 21, 75, 154 Crutch-handle, for drills ... 219 Decalcification' 36 Decay, " arrested " ... 196 Dental chisels ... .. 204 „ use of 208,215 Engine, The ... 219 Mirror, The 185 Probe, The 186 Syringe, The 188, 195 ,, Tweezers 189 Dentinal Fibril, The 9, 12, 13 Dentine, 8,25 „ sensation in 9 " sensitive " 190, 196, 227 Dentition, delayed ... 68,152 difficult 163 Development of jaw ... 19 of teeth 18, 25 Diarrhoea 20, 162 Diseases of alimentary canal 159 „ bones and joints 174 „ nervous system 153 „ respiratory or- gans 168 Dislocation of teeth ... 256 " Double Eows " of teeth ... 124 Drills, dental ... ... 219 Drugs for treating teeth ... 234 Elevator, The 253 Enamel 7,25 „ colour of ... 8 „ defective 196 „ opaque 186 PAGE Enamel, " ridged" ... .;. 73 „ of temporary teeth 29 Engine, the dental 218 Epilepsy 154 Eruption of teeth 15,85 „ ., dates of 24 „ faulty 93 Examination of the mouth 179, 184 Exanthemata 75 Excavators 204 Excising forceps 215 Exfoliation 65 Expansion of the dental arch 123 Extraction of teeth ... 235 , , of first permanent molar 233 ,, fracture during 239,246 „ general rules of 237 et seq. ,, of hollow molars 248 ,, of incomplete teeth 258 „ of lower bicus- pids and molars 251 „ of lower incisors and canines 250 „ for overcrowding 117 ,, position of oper- ator and patient 241, 249 „ symmetrical ... 118 „ oif upper bicus- pids 242 „ of upper canines 242 „ ,, „ incisors 241 „ „ „ molars 242 „ ,, „ stumps 248 Extractors, nerve 233 Fermentation in the mouth 7, 34, 36, 134, 142, 159 Fistula, dental ... 57, 63 Food, selection of 136 Forceps, dental, 237, 241 et seq. „ cleaning ... ... 238 Fracture of teeth 246, 2.57, 239 Fraenkel's pneumococcus 170 INDEX. 265 PAGE Gkminatio.v 77 General tuberculosis ... 172 Granular layer of dentine 8, 10, 13 Guni-hoil ... . 54,192 Gum-lanci't, use of, ... ... 21 ims ; croup- ous pneumonia 171 N:) COLUMBIA UNIVERSITY LIBRARIES (hsi.stx) RK 301 .P34 C.I The diseases of children's teeth: 2002343886 PK301 Pedley P34