Dr. Gillett:—Will Dr. Taft please to outline his treatment of congested pulp, by which he brings it back to normal condition?
Dr. Taft:—I must say that I do not have a great many cases of congested pulp, but where I do have one which has been exposed for some length of time, and has given pain, I first apply local treatment, using something of the nature of oil of cloves, then fill the cavity with cotton and let it go for a few days. I had a case about three weeks ago of a tooth that I had filled, a year ago, with gutta-percha. At the time the tooth was filled I was unable to decide whether there was an exposure or not. The tooth had been previously filled by a well-known Boston dentist with gutta-percha, and was very sensitive to excavating. The cavity extended far up under the gum, and I refilled it with gutta-percha and it kept quiet for about a year. Three weeks ago the lady came to me, complaining of great pain. I took the gutta-percha out, and upon re-excavating I exposed the pulp and found it alive. It had been troubling her then for about a week. I thought at first I would try to save it, and began treatment by putting a pledget of cotton, dipped in oil of cloves, into the cavity, sealing it up temporarily with gutta-percha, and applying the little capsicum plasters to the gum, hoping to reduce the inflammation in that way, but after working over it a week I destroyed it. I think congestion of the pulp can be reduced by internal treatment much better than by any local treatment, and if we were physicians and had the knowledge of materia medica that we should have under those conditions, I think we would find it possible to easily and quickly get rid of the inflammation and bring the pulp around to a healthy condition, so that it could then be successfully capped, provided there had been no suppuration. When it has reached that stage, the only thing to be done, in my opinion, is to apply arsenious acid and destroy it.
Dr. Werner:—I look upon the treatment of a pulp principally from the standpoint of whether such pulp is absolutely necessary for the welfare of the tooth. The pulp is a formative organ. Its function decreases as the tooth develops. In young persons it is largest; grows smaller and smaller, and in old age it is nearly ossified or obliterated; that is, its retrogressive stage begins materially after the crown of the tooth erupts through the gum. I have seen three different times what Dr. Smith spoke of—the actual pulsation of the pulp—which in a large exposure, in a favorable light, is easily seen. All of those three pulps were capped and they seemingly are alive to-day, but I think the teeth would be quite as serviceable had the pulp been destroyed. From a surgical standpoint the amputation of part of the pulp may at times be successful, for we know how resistive they often are to any kind of arsenious acid treatment, yet I should never do it unless it were in a partially developed tooth, where the life of the pulp is essential. What the surgeon does after trepanning the skull, we should do in capping or bridging over the pulp cavity. He does not flow escharotics like oxychloride or oxyphosphate of zinc over the brain. He mechanically covers and takes good care not to press on the contents of the cavity. The tooth pulp must be treated in the same way; a simple mechanical covering over it being all that is necessary. Whether you put a metallic cap, or whether you put court plaster, or one of gutta-percha (though I should hesitate about using the latter), makes little difference, only be sure that you do not press upon the pulp. With the knowledge we have to-day in treating devitalized teeth, there seems little reason for a young man to risk trying to save bad cases of exposed pulps. It is in extreme practice successful only for the time being—sooner or later ending in failure. To me many so-called successful records are only apparent successes, the operations only hastening the pulps to degeneration. The flowing over of all escharotics, I think, is highly unscientific.
Dr. Clapp:—The last speaker has made the statement that after the tooth is formed it no longer requires the presence of a pulp. I would like to ask him when he considers a tooth formed?
Dr. Werner:—In many cases the pulps of teeth are very large at twenty-five years. A tooth, however, is usually formed and the apical foramen closed up at from three to five, or, at the latest, ten years after the eruption.
Dr. Clapp:—I had occasion yesterday to cut off two central incisors for a lady eighteen years of age. The pulp chamber was entirely obliterated, entirely filled. I imagine that the pulps near the apex of the root are still alive, and it seems to me that the presence of the pulp is a great advantage to the teeth as long as they are in a healthy condition, and I must say that I hesitate to destroy pulps. As Dr. Taft says he has not destroyed the pulps in half a dozen teeth in four years, I do not believe that my proportion is greater than that in eighteen years.
I would like to inquire of the Society its opinion of the advisability of removing softened dentine over the pulps that would be undoubtedly exposed by the removal of such softened dentine.
Dr. Bigelow:—I do not rise to relate any experiences in capping pulps, but there is one question that has come up in my mind many times that I would like to have answered, if possible, by some of these gentlemen that believe in capping, and practice it regularly. We were taught in the school that in an inflammatory condition we might expect to find heat, pain, redness, swelling—we might expect to find one or all of these symptoms in an inflammatory condition of the tissue. It is said of the bones, that an inflammatory condition might exist and yet have neither swelling, redness, nor pain, but there might be heat. Now the question that comes up in my mind is, how are we to know, really, when the pulp is in an inflamed condition, and what treatment to give it before capping? Very often patients come to us with teeth that have been aching, and there is perhaps a swelling of the pulp and a certain redness; I say swelling—the throbbing generally indicates a swollen condition, in which cases the pulps are evidently inflamed; but what I would like to know is, how are we going to tell whether these pulps are in an inflamed condition or not? I would like to know the proper treatment for an inflamed pulp. In cases where I have attempted to subdue the inflammation, I have not had great success.
Dr. Smith:—In the absence of all symptoms, I should conclude that there was no inflammation.