Dr. Bigelow:—I don't know whether all the symptoms were absent or not, and that is just the point; there may have been heat, but not knowing positively there was an increase in temperature, an inflammatory condition might exist, and we might work blindly.
Dr. Smith:—I know of a prominent physician who treated a woman for the "Grippe" when her real trouble was fatty degeneration of the liver. He worked as near to the symptoms as he could get, but he diagnosed the case wrong. He is a prominent, eminent physician, and I simply speak of it to show the uncertainty of symptoms in a diagnosis. So in this case, there might be inflammation, but if there was an absence of all the symptoms, I should conclude that there was no inflammation and should treat it accordingly.
Dr. Bigelow:—Suppose there was an absence of all the other symptoms, how are going to get at the heat?
Dr. Smith:—Well, I don't know of any thermometer that has been made to register the amount of heat in a pulp. The only way you can get at it is by the symptoms which the patient gives you. Of course we can suppose lots of things, but we must act on the actual facts presented.
Dr. Clapp:—The gentleman has answered Dr. Bigelow. I would like to have him give his opinion on my question.
Dr. Smith:—Mr. President, it is hardly fair to consider me the encyclopedia of the Society, especially when we have the professor of materia medica of the school here. He ought to be able to answer all these questions.
I don't speak as an authority, but if decalcified dentine is soft and punky, I don't believe in leaving it. I believe you had better take it out and destroy the pulp at once, but if by decalcified dentine you refer to dentine that can be easily removed with an excavator, and yet has a certain amount of hardness about it, I should leave it rather than expose the pulp. I had a case—the patient was a child—where this soft dentine was left in the cavity. It was treated by a dentist whom I knew, and at first I was surprised that he should have left it, but when I found what a subject he had to deal with, I did not blame him; in fact I think I can compliment him for getting out as much as he did. I took occasion to speak to him about it, and he said he could not do much with the patient, so he left this punky condition, treated it with antiseptics and put in an oxyphosphate filling over the surface; but yet it set up an irritation, and it would have been better if the tooth, a six-year molar, had been extracted at the time. As the better way out of it, I had the tooth extracted, and the twelve-year molar came right into place. So if you mean decalcified dentine of that nature, I believe in removing it and destroying the pulp.
Dr. Clapp:—The gentleman has answered my question completely; I did mean just this leatherly condition that we often find in the deep portions of the cavities, and it is just this soaked condition of the dentine that I wanted his opinion concerning the advisability of removing it, but I referred more particularly to the teeth of adults than of children.
Dr. Smith:—Now that I have given the gentleman my views on the subject, I would like to have his.
Dr. Clapp:—I have left this softened dentine in a great many cases, and so far as my experience goes, I have not afterwards had very much trouble. I think that, rather than expose a pulp in a patient of good health, the surrounding conditions being favorable, I should prefer to leave a small layer, disinfecting and drying as much as possible before filling. It appears to me to be a great calamity whenever I expose the pulp in this way or in any other way, and I do the best I can to avoid doing so. It has been my practice, where I thought I should expose the pulp, to leave this softened dentine, but I have seen a few cases where decay has undoubtedly continued underneath the oxyphosphate or oxychloride fillings. I think it is a matter of great importance, and one where the best judgment will sometimes go astray.