HX64071146 RK531 W15 An atlas ot dental e \ v.- ' . ^, RECAP nmTA}. HXTRAGT W'MJAS College of ^f)j>£(idang anb ^urgeonfi! Digitized by tine Internet Arciiive in 2010 witin funding from Open Knowledge Commons http://www.archive.org/details/atlasofdentalext1909wall AN ATLAS OF DENTAL EXTEACTIONS WITH NOTES ON THE CAUSES AND RELIEF OF DENTAL PAIN C. EDWARD WALLIS, M.R.C.S., L.R.C.P., L.D.S. ASSISTANT DENTAL SURGEON KINO'S COLLEGE HOSPITAL ; ASSISTANT MEDICAL OFFICER (EDUCATION) LONDON COUNTY COUNCIL; LATE DENTAL SURGEON VICTORIA HOSPITAL FOR CHILDREN, CHELSEA, ETC. PHILADELPHIA P. BLAKTSTON'S SOX & CO. 1012, WALNUT STREET 1000 By the same Author. THE CAEE OF THE TEETH IN PUBLIC ELEMENTARY SCHOOLS With Special Reference to what is being done in Germany. With 6 Illustrations and Chart. PRINTED IN great BRITAIN. PREFACE. This atlas and notes have been designed for tlie use of medical students and practitioners with the object of assisting them to perform such emergency dental opera- tions as may be expected to occur in a country practice or on board ship where the services of a dental surgeon cannot be obtained. A minimum number of dental appliances has been recommended and various means of improvising a dental chair have been shown. I have to express my great indebtedness to Professor Underwood, Dr. Harold Austen, Mr. Norman Bennett, and Mr. Gr. K. Aubrey for many valuable suggestions, and also to Messrs. Allen & Hanburys for the loan of the blocks. C. E. WALLIS. .38, Queen Anne Street ; June, 1909. LJST OF PLATES. 1. EXTEACTIOX OF UpPEK InCISOKS AND C'aNINES. 2. Extraction of Lower Incisors, Lower Canines, and Incisor AND Canine Eoots. 3. Extraction of Eight and Left Upper Bicuspids. 4. Extraction of Eight Lower Bicuspids and Lower Eoots ON THE Eight Side of the Mouth. 5. Extraction of Left Lower Incisors, Bicuspids, and all Eoots on Left Side of Mouth. 6. Extraction of Eight Upper Molars. 7. Extraction of Left Upper Molars. 8. Extraction of Eight Lower Molars. 9. Extraction of Left Lower Molars. lU. Extraction of Upper and Lower Eoots and Lower Wisdom Teeth. IL The Use of the Elevator for Extracting Lower Stumps and Lower Wisdom Teeth. THE CAUSES AND RELIEF OF DENTAL PAIN. In studying the causes of toothache one must bear in mind the various structures of which a tooth is com- posed, and the surrounding tissues with which it is in close relation. A tooth may l^e regarded as a hard, unyielding box, enclosing a highly sensitive and vascular pulp or " nerve " as it is commonly called. The portion of tooth which is implanted in the jaw is more or less conical in shape and closely surrounded by its bony socket, which is therefore a hollow cone. Between the root and the socket is a fibrous mem- brane known as the " dental periosteum," in which a capillary network ramifies for the nutrition of the socket and the external surface of the root ; and through this membrane pass the blood-vessels that enter the pulp. Irritation applied to any vascular tissue produces hyjjersemia, which may l)e l)ut transitory or pass into the condition of mflcnmnation if the irritant be not speedily removed. It is important, therefore, to distinguish two different Hources of the pain of tootbache according as the pulp or the dental periosteum is the part primarily affected, for on the correctness of diagnosis will depend the chance of successful treatment. Inflanimofiov of the j)?//^>.— The hyperaemia of the 2 CAUSES AND EELIEF OF DENTAL PAIN. pulp occurring in this condition leads to swelling that causes a darting, shooting, or throbbing pain in the tooth, owing to the resistance offered by the unjdelding wall of the pulp cavity to the expansion of the pulp tissue. Heat or a lowered position of the head intensifies the throbbing, since either will still further increase the congestion. As the dental periosteum is not involved, pain is not usually felt on the tooth being pressed or bitten into its socket. Inffammation of the dental periosteum. — This membrane, on becoming inflamed, is thickened, and therefore raises the tooth in its socket ; hence it appears lengthened and is bitten upon before its neighbours when the jaws are closed, pain being produced from the periosteum being squeezed between the two unyielding surfaces of tooth and socket. The pain is of a dull, heavy, not throbbing character, not worse at night, and often relieved by heat and gene- rally in early stages by pressure. The tooth is tender to the slightest touch, and the gum surrounding it is swollen and feels velvety to the finger. Irritation of the dental pulp. — If the irritation be long continued and slight, an increased formation of dentine may take place from stimulation of the odontoblasts. Irritation of the dental pulp may arise from : (1) Caries with or without the presence of cavities. (2) Heat and cold ; contact of sweet, sour, or acid substances. (3) Conduction of heat and cold through a metal filling. (4) Exposure of dentine from any cause producing loss of the enamel, such as friction from bands or dental plates, wearing down of teeth from excessive use. CAUSES AXD RELIEF OF DENTAL PAIN. 3 Sjimpturiis. — The symptoms depend upon the amount of hypera3mia; thus shght discomfort may follow on taking hot or cold fluids, the contact of cold air, etc. The pain, however, is usually of a shooting or darting character and occurring at irregular intervals, sometimes brought on by heat or cold, especially cold, or by the contact of sweet, salt, or sour substances. The tooth may also be tender to the slightest touch owing to an extension of the hypergemia to the dental periosteum. Treatment. — When the pain is due to the presence of a cavity in the tooth it must be thoroughly syringed with warm water, and into the cavity must be inserted a small pellet of cotton-w^ool that has been dipped in one of the following local anaesthetic substances (it is essen- tial to squeeze the excess from the pellet, as it is undesir- able for the medicament to overflow into the mouth) : Oil of cloves. Eugenol. Creosote. Oil of cinnamon. Strong liquefied carbolic acid. Warm saturated solution of carbonate of soda. Oil of peppermint. Cocaine crystals, especially the crystals dissolved in glycerine 1 in o. Carljolised resin is a most convenient preparation for the purpose, as in addition to relieving pain it serves as a temporary stopping for two or three days until a dentist can be seen. Formula/or Carbolised Ream. Resiu 4 parts Carlwlic acid crystals . . . . 4 parts Chloroform . . . . 8 parts 4 CAUSES AND RELIEF OF DENTAL PAIN. In cases in which owing to the loss of the enamel the dentine has become exposed and highly sensitive to heat and cold, relief can be obtained almost immediately by the application of solid nitrate of silver to the sensitive area; the most convenient plan is to fuse a little of the powdered salt on the end of a probe or hair-pin so as to form a bead, which can be readily applied to any part of the mouth. When there is no visible cavity it is well to treat the pain on general constitutional principles with anti- neuralgic remedies, such as chloral hydrate, exalgin, antipyrin, gelsemium, phenacetin, and so forth. The application of iodine and aconite paint to the gums in the vicinity of the painful tooth frequently affords great relief by the counter-irritation and anodyne effect produced. Iodine and Aconite Paint. 5J: Liquor iodi fortis ^ , T • -J.- > equal parts, liin. aconiti J ^ ^ To be applied to the gums on a small swab of cotton- wool not more than twice daily. In severe and urgent cases it may be necessary to administer morphine hypodermically. In all cases, however, in which no cavity can be seen, the patient should be advised to consult a dentist, who may be able to find a dental cause not discoverable without the use of special dental appliances. Acute infiammation of the indp is usually the result of its exposure or infection by the advance of caries ; it may, however, be produced by the fracture of a tooth due to a blow, the application of arsenious acid for destroying the pulp, or as an extension of inflammation from the dental periosteum. If a section be made through a tooth the pulp of which is in a state of acute inflammation, the pulp tissue will CAUSES AND RELIEF OF DENTAL PAIN. 5 be seen to be bright red, whereas a healthy dental pulp is of a very pale pink colour. Symptoms. — Pain, usually of a shooting character, brought on by food pressing against the exposed surface or by the application of heat or cold, and in its early stages characteristically intermittent. The pain is icorse at night, when the patient lies down and becomes warm in bed, increased congestion l)eing thus produced ; the pulp is squeezed against the hard, unyielding walls of the pulp cavity. The pain may or may not be referred by the patient to the tooth really affected, a lower tooth being fre- quently indicated by the patient as the one in fault when the real source of pain is an upper one. Referred dental pain, however, never crosses the median line. Examples of referred pain. — Earache is frequently due to a carious molar tooth. Pain in the bicuspid or canine region may also be due to a carious wisdom tooth on the same side of the mouth. Course. — If the acute inflammation of the pulp be allowed to run its course untreated, the pulp usually becomes strangulated at the apical foramen and its death results ; death of the pulp, however, may not occur until a second or third attack. Treatment. — The first indication is the relief of pain, and this may be accomplished by the same means as for the pain due to irritation of the pulp, namely, the insertion of a pellet of cotton-wool dipped in one of the following : Oil of cloves, eugenol, creosote, oil of cinnamon, pure carVjolic acid, oil of peppermint, a warm saturated solu- tion of carbonate of soda, or crystals of cocaine; carbo- lised resin ^ is also useful for this purpose, and has the ' See " Formula for Carbolised Resin " on p. 3. 6 CAUSES AND RELIEF OF DENTAL PAIN. additional advantage of serving as a temporary stopping for three or four days. Treatment. — If pain of a severe throbbing character has lasted for some time destruction of the dental pulp is usually advisable; this is effected by the application of some preparation containing not more than gr. Ye arsenious acid to the exposed pulp, the preparation being carefully retained in position by gutta-percha or wool soaked in sandarac or mastic varnish. Arsenic should not as a general rule be applied to temporary teeth. The process of " killing the pulp " should be in most cases a painless one ; in the cases in which much pain ensues the cause is usually the application of too tight a dressing, which does not allow of the expansion of the pulp due to the congestion produced by the arsenic. The application of arsenic for this purpose should not be undertaken by anyone without special training, as it is frequently a matter of considerable difi&culty, and may cause sloughing of the gums and necrosis of the alveolus if carelessly performed. Chronic suppurative inflammation of the pulp usually arises from infection of the dental pulp that has been exposed by caries. Symptoms. — Pain coming on at irregular intervals of a wandering neuralgic character, which the patient may not refer to a tooth at all; the presence of throbbing is not in- frequent, and may assist in locating the source of the pain. A paroxysm is often brought on by the sudden applica- tion of heat or cold, sweet or salt substances. The characteristic symptom of suppurative inflammation of the pulp is the production of great increase of pain on the application of heat. The tooth is not tender unless the periosteum is involved and the gum is not swolleii. CAUSES AND RELIEF OF DENTAL PAIN. 7 Treatmenf. — -Tlie application of local angestlietics and sedatives on cotton-wool as for irritation of dental pnlp ; opening the pulp chamber usually gives immediate relief, but is a procedure that can only be carried out with special dental instruments. General constitutional treatment must therefore be used to supplement local palliative ap- plications until skilled dental treatment can be obtained. Polypus of the pulp. — Sprouting granulation of the exposed surface of a chronically inflamed pulp may take place, the granulations growing till the carious cavity is completely filled by them, constituting what is known as pohiptus of the pulp ; a polypus of this kind is not usually very sensitive. Treatment. — The polypus must be cut away and the pulp destroyed by arsenious acid. Dental periostitis {periodontitis, p)ericementitis) . — In- flammation of the fibrous and vascular membrane which lines the socket of a tooth and covers and nourishes the cementum is called variously " dental periostitis," " peri- odontitis," and " pericementitis." It may be general, involving the periosteum of all the teeth, or local, being in that case confined to the socket of one tooth only ; like inflammation elsewhere, it may be acute or chronic. General inflammation of the dental periosteum is dependent on some constitutional condition, such as rheumatism, gout, tuberculosis, syphilis, or may be asso- ciated with one of the exanthematous fevers, the inhala- tion of the fumes of phosphorus as in match-makers, tlie administration of mercury. Localised dental periostitis may be acute, frequently running on to alreolar abscess, or chronic, in Avhich suppuration either does not occur at all or is restricted to the periosteum iwar the 'nLfm/iv of the sorfct. 8 CAUSES AND RELIEF OF DENTAL PAIN. Acute localised deiital periostitis. — Causes : (1) Inflam- mation spreading from a living inflamed pulp, througli the apical foramen to the periosteum immediately sur- rounding it. (2) Direct absorption by the periosteum of septic material from a putrefying pulp. (3) Stopping an imperfectly sterilised tooth from which septic material is unable to escape, except through the apical foramen. (4) Injury caused by a blow upon the tooth, injuring and perhaps leading to infection of the periosteum. (5) The escape of arsenic from a dressing applied for the destruction of a dental pulp. (6) Exposure and infection of the periosteum super- vening in the condition known as pyorrhoea alveolaris (Riggs' disease). Si/mptoms. — In the early stages the tooth or teeth may be merely tender and uncomfortable ; later, however, owing to the swelling of the dental periosteum the affected teeth become raised, as well as loose and tender to the slightest touch. The gums also become involved, since the dental periosteum is reflected outwards at the margin of the alveolus, and become swollen and deeply congested, presenting a velvety feeling when touched by the finger. Sudden changes of temperature or weather will often bring on or accentuate an attack of dental periostitis in those subject to this affection. When dental periostitis is produced by mercury or phosphorus, there is tenderness and loosening of the teeth, extreme congestion of the gums, which become spongy and readily bleed, together with great oral foetor. Ulceration with sloughing of the gums and necrosis of the jaw may ensue. CAUSES AND RELIEF OF DENTAL PAIN. 9 Ptyalism is especially marked in mercurial poisoning. General treatment— Conditutional : Remove the cause if possible, as in the case of mercury and phosphorus poisoning. Treat general condition if gouty, rheumatic, tuber- culous, or syphilitic. Local— Ken^ev the mouth as aseptic as possible by the use of mouth washes, of which sanitas combined with chlorate of potash lotion (gr. x to the ounce) is one of the best. In cases in which one or more teeth are involved, counter-irritation applied by first drying a large area of the gums near the aifected teeth and then painting it with iodine and aconite jMiint gives great relief. Formula. ^ Liquor iodi fortisl Lin. acouiti j* equal parts. This should not be applied more than twice or three times daily, as it tends to make the mucous membrane so sore that further applications become impossible. The application of a capsicum plaster, which is a sort of diminutive mustard leaf, to the previously dried gum also gives great relief ; it should be held over the root of the afPected tooth with the finger until it adheres, and then allowed to remain until it falls off. Chronic localised dental periostiti.s.— This condition must be treated in the same way as the above, by general constitutional treatment and l^y the application of the iodine and aconite paint night and morning, or if more convenient by the application of capsicum plasters. Chronic suppurative dental periostitis— pyorrhwa alveo- laris.— The pathology of this condition is very obscure ; it is apparently due to a pyogenic infection. 10 CAUSES AND RELIEF OF DENTAL PAIN. 8y7nptoms. — Those of suppuration of the dental peri- osteum, plus inflammation of the gums (gingivitis), accompanied by the formation of deep pockets, from which pus exudes round the necks of the teeth, leading to destruction of dental periosteum, absorption of the alveolus, and loosening of the teeth. . Treatment. — The treatment of this condition is exceed- ingly unsatisfactory ; at the same time efforts must be made to minimise the suppuration by the use of antiseptic mouth-washes, such as chlorate of potash in combination with sanitas, permanganate of j)otash, etc. Alveolar abscess. — An abscess arising from a tooth is known as an alveolar abscess or " gum-boil " ; it is usually situated at the end of the root of a tooth. Causes. — Extension of septic infection from the pulp or periosteum of a tooth. Symptoms. — Those of dental periostitis much inten- sified, e. g. the tooth is raised and tender ; the gums are swollen, deeply congested; pus frequently wells up at side of tooth. Sulcus between cheek and tooth instead of being hollow is filled up by a globular or diffuse swelling. Sometimes diffuse cellulitis of the face occurs, the whole cheek becoming swollen, tense, shining, very painful, and the eye closed if the abscess is connected with an upper tooth. The pus from an upper tooth may burrow into the antrum in the case of upper bicuspids (or molars), or be directed towards the palate (upper lateral incisor) either between the periosteum and the bone, when there will be great pain, or between the periosteum and the mucous membrane, when there will be but little pain, since the tissue in that situation is somewhat lax and therefore yields readily. When an abscess is situated at the root of a lower CAUSES AND RELIEF OF DENTAL PAIN. 11 molar, particularly a lower wisdom tooth, trismus may occur from : (1) Spasm of the masseter, Avhich symptom will dis- appear under an anesthetic. (2) Inflammatory infiltration of the masseter, in which case the administration of an angesthetic will simply enable the operator to apply the necessary force to open the jaw with a screw wedge or Mason's gag. An abscess from a lower wisdom tooth sometimes points beneath the angle of the jaw, and an abscess connected with any lower tooth may burst either through the cheek or beneath the margin of the mandible. The submaxillary lymphatic glands sometimes be- come infected, in which case they will be swollen and tender. The submaxillary lymphatic glands in children are sometimes infected with tubercle, probably conveyed to the glands by carious teeth with exposed pulps. Treatment of alveolar abscess. — When an alveolar abscess has already formed, great relief will usually be obtained by incising the abscess in the mouth. In cases in which the abscess is very large and is threatening to burst outside the cheek, it is wise to apply a piece of gauze with flexible collodion over the thinned area of skin, and thus to minimise the danger of or prevent the occurrence of an external opening; at the same time efforts must be made to make the abscess point in the mouth, and this is best done by the application of a roasted dried fig or a dried fig squeezed dry from boiling water and held in the mouth over the abscess ; it is often necessary to apply a succession of these fig poultices. Poppy-head fomentation, made by Ijoiling two ounces of bruised poppy-lieads for ten minutes in a pint of 12 CAUSES AND RELIEF OF DENTAL PAIN. water and held in the month, often gives great relief and may shorten the course of the affection. In severe cases of ah^eolar abscess extraction of the tooth is the only course open to the medical practitioner, and the sooner it is done the better for the patient ; the old idea that it is necessary to wait till the inflammation has subsided is often disastrous to the patient, as it may lead to the formation of an external opening in the cheek and permanent scarring of the face. An abscess arising from a lower wisdom tooth usually necessitates its extraction, this is often a matter of great difficulty, and can only be accomplished by using the elevator; it sometimes happens that it is impossible to reach the wisdom tooth, in which case it may be necessary to remove the second lower molar before dealing with the offending wisdom tooth. Local ansesthesia in the extraction of teeth. — Though still to some extent on its trial, the hypodermic injection of certain anaesthetic solutions is in a considerable number of cases successful in enabling the extraction of teeth to be performed painlessly. At the same time it is essential for the operator to know exactly what he is injecting and the exact amount and purity of the active ingredient contained in his injection. Nothing can be more dangerous than the injection of the much advertised proprietary local anaesthetics, most of which contain an indefinite amount of cocaine, and which within the writer's knowledge have over and over again produced serious results. Cocaine is certainly to be avoided in all these prepara- tions. There are no absolutely reliable and satisfactory pre- parations for the purpose, though novocaine (which is a white soluble powder of definite chemical composition) CAUSES AND RELIEF OF DENTAL PAIN. 13 and injections containing encaine combined with adrenalin frequently do very well. Novocaine can be obtained either in the form of tablets to be dissolved in sterilised water so as to make a 1 to 2 per cent, solution, or as a 2 per cent, solution ready prepared for dental use ; it is of the utmost importance that whatever solution is used must be freshly prepared and sterile. For difficult extractions the 2 per cent, solution should be used ; for simple extractions the 1 per cent, solution is sufficient. A very satisfactory syringe is that designed by Dr. Dawson, of Dublin, as it is readily sterilisable, and more- FlG. 1. over, l)y reason of its " finger-rings," affords a perfect command over the barrel and piston. Procedure. — (1) The patient's mouth should be thoroughly rinsed with sanitas and water or a perman- ganate of potash mouth-wash. (2) A swab of cotton- wool soaked in U) per cent. novocaine or cocaine (10 per cent.) solution is held by the patient over the part to be injected, so as to anfes- thetise the mucous membrane to the prick of the needle. (8) The syringe is next warmed and sterilised, and the needle should be boiled in a small test-tube before use. (4) If novocaine is used the syringe should then be filled with 17 minims (1 c.c.) of the 1 or 2 per cent, solution according to the difficulty of tlie extraction, and then an l-i CAUSES AND RELIEF OF DENTAL PAIN. injection made of about 12 minims on the external and 4 jninims on tlie internal side of the alveolus, the aim of the operator being to surround the tooth with a zone of anaesthesia, and for this purpose at least two punctures are necessary; the point of the syringe should be inserted about 3 mm. from the free edge of the gum adjacent to the tooth to be removed ; the needle should be inserted quickly and the injection made very slowly, the syringe being held in position for some seconds after the requisite quantity has been injected. When the gum becomes blanched, and not till then, the anaesthesia may be regarded as complete. Hypodermic Injection of Adrenalin and Eucaine. ^ Beta-eucaine . . . . §^- -k Adrenalin chloride . . . gr. yoVo Aq. ad. ..... "^ixvij. To be freslily prepared or used from an " ampoule." Hypodermic injections into the gums should not be made — (1) In inflammatory or suppurative conditions of the mouth. (2) In cases of alveolar abscess. In such cases the application of cotton-wool soaked in 10 per cent, novo- caine for some five minutes will much alleviate the pain of a dental extraction. The local anaesthesia that can be produced by freezing the gums with a spray of ethyl chloride is frequently very useful in the case of readily accessible single-rooted teeth, but it must be borne in mind that it has a great tendency to cause the teeth to become brittle owing apparently to the freezing of their " organic" matter, with the result that they may be very readily broken during the attempt at extraction and thus lead to much difiicultv. GENERAL NOTES ON EXTRACTION OF TEETH. 15 GENERAL NOTES ON EXTRACTION OF TEETH. The minimum number of forceps that can he expected to deal with an)^ ordinary case of extraction is five, and this num])er combined with a " fish-tail" elevator will be sufficient for practically every tooth. In Figs. 2 and 3 the patterns suggested are shown together with a pair of " conveying forceps " such as are very useful for apply- ing medicaments on cotton-wool for the relief of pain, and also a dental probe for ascertaining the exact position and extent of carious cavities. The use of so-called " straight" forceps for lower molar and bicuspid teeth is not recommended, as they are exceedingly difficult to use and do not provide nearly as much leverage as those of the so-called "hawksbill" pattern as shown here. The blades of all dental forceps must be bevelled so that they grasp the teeth on a flat and not a sharp edge, as is frequently the case with ill- designed forceps, which simply break the teeth instead of grasping them. The " straight " elevator is not recommended, as not only is it difficult to use but is an exceedingly dangerous instrument in the hands of one unaccustomed to its use. It is of the utmost importance that all instruments used for extracting teeth should be efficiently sterilised, either by boiling or else by prolonged soaking in a solu- tion of carbolic acid (1 in 20) or biniodide of mercury (1 in 8000) ; it is also essential that the forceps should be clean in the ordinary sense of the word before being placed in the antiseptic lotion. Inasmuch as few practitioners possess the luxury of a dental operating chair, a convenient substitute can be 16 GENERAL NOTES ON EXTRACTION OF TEETH. GENERAL NOTES ON EXTRACTION OF TEETH. 17 18 GENERAL NOTES ON EXTRACTION OF TEETH. readily devised as shown in Fig. 4 by placing two strong chairs back to back against a wall in snch a way as to prevent the chair in front from being tilted backwards by the flinching of the patient or the efforts of the operator. This plan, combined with such other positions as are A. Cushion on back of cLairs. b. Chair resting firmly against a wall. shown in dealing with particular teeth, is suflicient for every case. Special care must be taken when extracting a tooth that stands alone ; it frequently happens that the gum is firmly adherent to a tooth of this kind and may there- fore be seriously torn during the process of extraction ; in such a case it may be necessary to cut away the tag of gum with a lancet or scissors. THE EXTRACTION OF TEMPORARY TEETH. 19 THE EXTRACTION OF TEMPORARY TEETH. All the temporary teeth exce})t the molars have one root. There are no bicuspids in the temporaiy dentition. The position of the temporary molars is occupied by the bicuspids in the permanent dentition. The hicuspids erupt between the roots of the " tem- porary molars," and therefore occupy their position when they are lost. In extracting the temporary teetJi tli.e ixtticnt should he Fig. 5. The teniporaiy teetli. jjlaced in the same jjosition as for the corresponding j)er- manent teeth. General principles. — Grasp the crown of the tooth firmly in the forceps. In the case of a temporary molar it is important to avoid pressing the forceps upwards or downwards to any appreciable extent for fear of removing the crown of an on-coming bicuspid which lies between its roots ready to take its place. For niqjer incisors or rarrlnes use "straight" or bayonet root forceps. For upper molars use right or left up})er molar force])S or bayonet root forceps in cases where the crown is much broken down. 20 THE EXTRACTION OF TEMPORARY TEETH. For lower incisors or canines use lower hawksbill root forceps; the same forceps can be used on either side of the mouth. For loujer temjjorarij molars use lower hawksbill molar forceps or lower hawksbill root forceps. Broken-down temporary teeth and roots can either be extracted with root forceps or prised out with the " fish tail " elevator, making use of an adjacent tooth as a fulcrum. It is quite unnecessary to have special forceps for temporary teeth. It is important to avoid extracting prematurely a second temporary molar; loss of this tooth may lead to a moving forward of the adjacent first permanent molar and consequent crowding and irregularity of the bicuspid teeth. The temporary canines should also be retained until their permanent successors show signs of erupting; premature extraction of the temporary canines allows the bicuspid teeth to move forward and thus may lead to the deformity of projecting canine teeth. Undue retention of the temporary teeth may, on the other hand, lead to irregularity of the permanent successors ; in cases of doubt it may be well to postpone extraction until the advice of a dental surgeon can be obtained. Dentition Table. The following table shows the order in which the milk teeth and permanent teeth appear, and the average age at their eruption. There are wide variations as to time, and great irregularity in the order of their appearance. MilJc teeth. — The first dentition begins at the sixth or HEMORRHAGE AFTER EXTRACTION. 21 seveiitli niontlij and is completed by about the second year. (1) lower, 6tli month; (2) npper, 7tli month. (1) upper, 9th month; (2) lower, 10th month. 12th month. 18th month. 2nd year (often later). The full primary dentition is 20 teeth; 10 in each jaw. Permanent f('(4]i .- Central incisors Lateral incisors First molars Canines Second molars First molars . 6. \ years Lower central incisors 7 L'pper central incisors 8 Lateral incisors 9 First bicuspid 10 Second bicuspid 11 Canines . 12 Second molars 1:', Third molars (wisdom) . 17 to 25 years, or at any later period The full permanent dentit ion is 3 2 teeth ; 1 6 in each jaw H/CMORRHAQE AFTER EXTRACTION: TREATMENT. Local. — In slight cases it is sufficient for the patient to sit quiet with cold or iced water in his mouth; where ice cannot he ol^tained holding very hot water in the same way is often successful, especially if alum be dissolved therein. It is not infrequent, however, that l)lood will continue to well 11]) fTT)ni the socket fi'oni Avliich the tooth has 22 HTEMORRHAaE AFTER EXTRACTION. been removed; in such a case it is necessary to syringe the socket with ice-cold or very hot water or boric lotion and then to apply pressure to the bleeding point by firmly plugging the socket with cotton-wool or lint soaked in fresh adrenalin or other supra-renal gland preparation ; the application of tannin, either as glycerine of tannin or on wool soaked in hazeline and powdered with tannin, answers in many cases. Perchloride of iron is a most unsatisfactory remedy, and should only be used as a last resource when nothing else is obtainable. Constitutional . — It is not uncommon for an operator to be warned by the 23atient that excessive bleeding has pre- viously followed the infliction of a cut or the extraction of a tooth. It has been shown that a large proportion of these cases are due to insufficient coagulability of the blood owing to an insufficiency of calcium salts ; it is therefore wise in such cases to administer one of the drugs which are known to rapidly increase the coagulability of the blood. Calcium lactate, calcium chloride, and magnesium carbonate have all been shown to produce this effect in a marked degree within the space of an hour or so ; the salt selected should be administered in a single dose of 5J the night before the proposed operation. The best and most pleasant to take is calcium lactate, which may be administered in compressed tablets or in a draught such as the following : 1^ Calcii lactatis . . . . . . 5j. Syrup ....... q.s. Aq. ad. ....... ^j. Fiat haustus. — Tu be taken as a draught the night before the dental extraction takes place. The effect of these salts appears to last about three to four days, so that in the event of dental extractions being performed on successive days a second dose is not called for. PAIN AFTER EXTRACTION. 28 PAIN AFTER EXTRACTION. Pain after the extraction of a tooth may be due to the lateral displacement of the alveolus which is brought about by the application of the forceps ; this can be minimised by applying firmly a finger and thumb after the tooth has been removed and so restoring the alveolus to its former position. Besides this, owing to the socket becoming septic either from the operator making use of unsterilised instruments or else operating in a mouth that is very foul, pain may continue in a tooth socket for a consider- able time. To avoid this every mouth, before operation, should be made as clean as possible by the use of tooth-powder and sanitas and permanganate of potassium mouth- washes, and after the extraction has taken place every effort must be made to keep the socket free from the remains of food and other decomposable matter. If, two or three days after the extraction, the patient complains of pain in the socket, the treatment is to keep it syringed out with sanitas and water. A pledget of cotton-wool soaked in liquor potassse and pure carbolic acid, equal parts, usually affords immediate relief from pain after the socket has been syringed out in this way. INDEX. Aconite and iodine paint. 4 Acute inflammation of pulp, 4 Adrenalin and beta-eucaine injection. 14 Alveolar abscess, 10 Ansestliesia, local. 12 Anodyne applications. 3 Arsenic for dental pnlp. 6 Beta-eiicaine, 14 Bicuspids, extraction of right and left nppei", plate 3 — — of I'ight lower, plate 4 of left lower, plate 5 Biniodide of mercury, li") Calcium chloride, 22 — lactate, 22 Canines, extraction of upper, plate 1 of lower, plate 2 — temporary, preuiature extraction of, 20 Carbolic acid. 3. '> Carbolised resin. 3 Carbonate of magnesium, 22 Chaii-. operating, 18 Chloride of ethyl, 14 Chronic dental periostitis, 7 ChroTiic suppurative inflammiition of pulp, (> Collodi 2^ •^ "O r^ '^ Or; i-S| T- CS • S =1-1 O rrt ^^ •" oj -ij y <" r^ - '^ C/) '^ s g a '^'^'^ s 4> u a> a •" a) m OJ ,-/j CD o rt . o cc r; t-i 2 ^ rH cG 03 r— ( ^ O SS o c o "q. a < b^ ■^ ^ P'5 O ^-5 =c g ?5 ^§ 01 ^ (V o !=1 -S PLATE 2. EXTEAC'Tinx OF LoWER CaXIXES, ALL LoWER TnCISORS, AND Incisor and Canine Roots. p^ O o •v ;^ -^3 1— 1 o o 1^ rH < r^ C/J Tr W 'm O OJ , CO H (M O ;^ dJ ^ t— 1 "S EH /»p 03 3 o 'T3 P-\ H^ f o III "3 s < «^ S 02 > W o ^ ^_i ^ ci 03 y S ^ 1^ &c '-;'-' • ^ o •5 cc! -(-- cpl _!3 tS ,^ >i M ."ti c3 ^_ CO p: 05 •-+H ^ -y r^ ^.2f'- 35 m /i!^ C^ +i cc ^j C m „ ;h . ■r, ^ T* c5 -^^ ~I^ ^ P O '^ ■^ o .S^ o .bf ^ ^_| In Ci 'ce rt O ^ =« ^, ce r-. "^ +j CO '" S ■f H- rH CJ o O ,^j. ci z^ ^ r^ (X> M O 0) ^ ^ ^:3 I-' ^^ S3 1 — 1 a3 0) ^ CO CO O CO ^ o.S iVj •• ^'^ 1 — 1 _j^ M o. s g • rH rH CJ u 3 o ^S ^ o ■-'- <•/: Pt -^ s u. 3h2 Oi '3^ 'Td o ^^ £^. •;::; c 't; o '*- -♦-• ifj d _o ^ a Tt a ^ < ^ -M ei h Q) Oh O PLATE 5. ExTKACTiox OF Left Lowek Inoisoes, Bicuspids, and ALL Roots on Left Side or Mouth. w p o ^ pq o ^ p 03 'S J^ '& m ^ o ^ h^ ^ >^ rj c3 P5 CO ij -tJ 05 16 <: ^ u <1 pi! in PQ P3 'co i>-^ 5£) -S •z 'S 1— 1 rC 05 P3 S 05 h:1 ^ H C^ l-^l f^ ^ m f=^ ;z; ;2i H <1 ps ^ X ^ 2 ^ o .^ ■73 fl cS f.B &f g •-I 1 — 1 r— ' ^ ^ d =1 c3 D I- 5- :3 a "^ ^ fe 2.S --^ L, *—? 'tr' -M -^ >-. % a; 121o rf iC CO . i „ 32 r- 1 1 72 r^ •-*-' 32 -^j — ' o ^^ o o ':n s . -<, Jl t. 71 is' U. o 3, ,x 2i a. ^ .'/) c _o :^ -^ '•5 '~'r^ CQ ^ ."t^ u a < PLATE G. Extraction of Right Upper Molars. ^<-^. Oh o o I— I EH O "apuxci '^s^^^O •epuxq. JS^iiQ <^ ® 15 "o &» IB oj n o CS g^ § s ^ -t^ J ce o) o ■g -^ bD S >, g CD ,5 * ^ 2 -p S c 2 ~S ^ '^ ^*-t =4-1 a; I o O O S CO 4j >4 rt S o V3 ■ be 5; -e .2 bC^ 4- « g_bn S r^ ^ ca -£. fii y Oi !3 ic ^ ri &i ci ^ O oa &H r3 T3 ,• ^ >;^ • rt c« M ^ r3 IS R o g c3 ai -*J -f^ +J d -4^ I— 1 53 (u cj qn y 5 =* cc P^ u o u. 7 .EP S .o C _o '•5 a a < PLATE 7. Extraction of Left Upper Molars. '^» O a o (U i^ Oi ZJ l- '-+3 .^ ts X "le Ph c5 ?> ^ 'ts r^ o -^ :o -iaii oj b€"^ 'S ■"■ 15 o '' i^ -S bc^ o , . g o * •-- -1^ ^J ^ O « § § s ^ o o o^ o S « IK II Pi o o Ph.S ^.2 5+-I p rp-^ (^ 2 S =^ '^ ,S a (U u o I— i' 03 C) -^^ --2 ^ -M O "o'm ^ 2 -M (V, O O S !^ 2 =*H -M r^ Ol Oh o <1 P^ c o o "a a PLATE 8. Extraction of Right Lower Molars. 00 o E- p2 o p= >> s % ft c3 -s ^ nS -P O ,r3 rJ:^ be -p 'fH a> f-t s cS be O fl -P ■? o r^ 02 ■ \ Wi-^iii AttBHi /r« nuif ' jwAirt^ V * :ii 1^^ ^ ^WTfej ^^■k =^ .5 ^. o -f^ •Jl Oi "^ "o o !^,0 _c3 '^ ^ ^ ^ 1^. c3 r^ a> =i rf ^ g^ &D ^ !>^S .9 . +-i ■^3=" 'm a S3 rt ^. p ^ o Oi c3 p , ^t oT 4-> ■3C ci O) ^ o S ^ =i5 r^ p . 1— 1 <72 S o ^ ,• p r; _g % ri ^* o P © 73 ^i r3 "^ o be o 2 % •^ >-l o 03 03 2 o , 1:5 =^ 3 o 11 © O , I-H O i» ^ 1-^ ► © ^'^ o -'-' -i-i -M d -"^ " rt o o o Ml 'A 11 2 -+-' ^ xn © rrS fl © 1^1 "1 9^ £ cS © s =* o © "^ "P •—*' "^ ■Jl =^ 03 ■| 03 ? o tfl a a> u II Ci_i ^ 0) 03 o o P- O 1 S t^-i Si ;_, 03 e same time, il" elevator se of " fisli-t o <^ ' rj} Pi ;_, O- ri^ ^ c« P U. <*- o tH ? <1 P= is :i 'o3 •~ c !=3 \ ^ ^ = !?^ ^ r^ ^o Oi OI *-3 ^1 0) P (J ^ -M «<-( •?3 c < PLATE 9. Ex'i'h'ACTiON OF Left Loavek Molaes. 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