DISCUSSION OF DR. BLAISDELL'S PAPER.[1]
Dr. Smith:—Mr. President, the essayist this evening has presented a paper which is a resume of the methods of practice of many practitioners throughout the country, but although they have given their methods of capping exposed pulps, I do not see that they give their results, and he cites but one case and pronounces that a failure.
The most important thing to avoid in the treatment of exposed pulps, as held by the authorities, is pressure, and I endorse that opinion most thoroughly. I believe a large proportion of failures in the capping of exposed pulps is due to the lack of skill on the part of the manipulator. We speak of accidental exposures in excavating; I believe that that exposure is almost inexcusable. I don't believe any graduate of the dental school of Harvard College has any right to punch an excavator into a pulp unless he intends to do it when he starts. It may be a little personal to say that my experience in accidental exposures is very small, but such is the fact. I have had cases where perhaps the exposure was excusable. In cases of a malformation of the pulp or tooth, but under ordinary circumstances, in cases that we usually meet, such exposure of the pulp I believe to be wholly inexcusable. The practitioner of to-day in opening into a cavity knows, or should know, that he is liable to come into contact with the pulp, and he therefore ought to excavate with the greatest possible care, and with the careful instructions given in the schools to-day there is no excuse for his exposing that pulp.
The method cited of using gutta-percha, I do not believe in, and the placing of gutta-percha directly on the pulp, I condemn, not from my own experience, but from my observations of cases treated by other practitioners, the patients have come into my hands afterwards. Trouble has resulted in every case that I have seen, but they may have been cases which should not have been capped, and perhaps it is hardly just to deny that some were successes.
The pulp, while it is an organ of great sensitiveness and extreme delicacy of structure, I believe to be most persistent in its vitality. The capillary circulation of the pulp, as you all know, arising from the vertical vessels forming loops, prevents a combination near the surface, and the absence of lymphatics in the pulp prevents medicaments from doing much good, as would be the case upon serous membrane. Where the trouble is diffused through the entire membrane, in many cases the application of arsenious acid will only destroy a part of the pulp, and has to be re-applied again and again.
If a tooth has been aching, and there is congestion about the pulp, or an exuding of pus, I invariably destroy it. I don't believe a pulp can be brought to a healthy condition to stand capping after it has reached that stage. But there are many cases where patients have neglected their teeth and had a little pain, or after taking sweets, they have a severe toothache that soon passes off, so that at the time of examination there is no soreness nor inflammation; or if we have a strong, robust, healthy patient, and in excavating carefully around the pulp we remove a layer of decalcified dentine and find just a point of the pulp exposed; in such cases I do not hesitate to cap, and my mixture is as follows:
I take oxide of zinc, and mixing it with oil of clove or creasote, flow it carefully over the pulp, then fill out the cavity with either oxychloride, or oxyphosphate of zinc.
It is true, Mr. President, that I have kept a record of the pulp exposures and my method of treating them, and the condition that they were in, but in looking over my records I found that when I wanted to get at the results, it was not a very easy matter, and it has taught me in the future to keep a little book and enter the cases of pulp exposure and treatment of dead teeth, so I can turn to a person's name and find the result at once, but, you come to look through your record-book for a case which was treated twelve or fifteen years ago and follow out the record of the patient to find whether the pulp has since died, you will have an endless job. I have one case where I had five exposures of pulp in one mouth, of a right superior molar, mesial cavity, and of the bicuspids on the same side, and the bicuspids of the left superior. They were capped eight years ago, and last year—I have not seen the patient this season—they were all tested with warm instruments or ice, and every one of them was alive. How soon they will die, of course, I cannot tell, but they were apparently in good condition when I last saw them. Another case of which I have a record, was an exposure on the mesial surface of an upper right molar, which was exposed in such a manner that with a magnifying-glass you could look into the cavity and see distinctly the pulsations in the pulp. At that time I was with Dr. Shepard, and I called him to see the case. It was extremely interesting, more so perhaps to us than to the patient. As the patient was strong and healthy, the pulp was capped in the manner I have just described, and that pulp is alive to-day.
That is all the data that I can give you, Mr. President, excepting that I know, in my own practice that a majority of the pulps that I have treated and capped in that way are still alive, and I am a believer in capping certain exposed pulps. This is an exception: A patient came to my office something over two years ago. On a lower right second bicuspid was an exposure near the margin of the gum, which was capped, and that patient had not been in to see me since that day until yesterday, and would not have come then had there not been a pain in that locality. In examination I found that decay had started below the gutta-percha, upon the cervical wall, which I had placed there for protection, after the first capping, and had again exposed the pulp. The patient had suffered for two or three weeks with neuralgia before coming in. I thought it was useless to try to preserve any exposed pulps for that patient, so a new opening was made and the pulp devitalized.