Indeed it seems to be that the whole process of successfully filling a decayed tooth is one of the most perfect examples of antiseptic treatment I am acquainted with. I doubt not there will be further advances made in your technique, but the principles will not change. I believe it quite likely that it will prove desirable to more thoroughly disinfect the carious cavity before filling than is always done now, and it may prove possible to devise some material which, either by its hardness or by its chemical constitution, or by some antiseptic incorporated with it, will longer resist the destruction due to attrition and to chemical and micro-organic action than the ones now in use.
To recur to the main problem of our paper—the relief of pain—is it not true in this class of cases that after the first effects are stilled, its recurrence is prevented by affording artificially that immunity to the pulp from peripheral irritation which it possesses in health?
Disease of the peridental membrane causes a characteristic pain, but one which need not long detain us. From the fact that it is nearly always secondary and not primary, its treatment should first of all necessitate the removal of the originating cause. The spread of inflammation or decomposition from the pulp to the periosteum which so often occurs can be better accounted for by the hypothesis of the action of micro-organisms than by any other supposition. Moreover, in the advanced cases, where pus has formed, the same cardinal indication of treatment, viz., proper drainage, obtains here as in other departments of bone surgery.
We have already spoken of the constitutional poisons, syphilis and mercury and phosphorus, which may be causes of this form of trouble, and I would only like to say one more word, and that is in the way of treatment.
Occasionally it has seemed to me that you can stop the further progress of a periostitis, if you get it in an early stage, and prevent it from going on to suppuration. I remember one case of a gentleman who applied to me for a very painful gumboil in his lower jaw opposite the first molar. The gum was swollen and reddened, and a well-marked phlegmon could be felt. I gave him fairly large doses of mercury for a couple of days, and it gradually melted away. There was no suspicion of syphilis in this case.
Another remedy I believe to be of great value in treating neuralgia of the face starting in periosteal irritation, is phosphorus. The best form in which to administer this remedy is the preparation known as Thompson’s solution. I can testify to this from personal experience. Some twelve years ago I suffered from periostitis of the first bicuspid of the upper jaw on the right side. A couple of years later, while working hard, I had an attack of intense neuralgia of the entire second division of the fifth. When it subsided, it left some periosteal thickening at the exit of the nerve from the infra-orbital foramen; and ever since then, whenever I get run down by overwork or worry, the same pain crops out. But I have found that a few doses of phosphorus will completely hold it in check; and in one or two patients, since then, I have seen the same fact, that in the neuralgia due to periosteal irritation this remedy holds a high place.
It has seemed to me highly significant that the two drugs, mercury and phosphorous, which in continued toxic doses cause this very class of diseases, should in physiological doses be curative. But this is in entire consonance with the general laws of tissue irritation, and the therapeutic fact that certain drugs acting through the nervous system stimulate in small doses and narcotize in large ones.
The last type of dental pain I will speak of is that arising from pressure due to hypertrophy of the cement. Where this is not due to the peripheral irritation of a carious tooth, the causation is both interesting and obscure. It has seemed to me that we must postulate the agency of a constitutionally acting cause to account for certain of these cases. I think it quite probable that in certain cases a well-marked gouty diathesis will be found underlying this form of disease; and a similar constitutional error must be invoked to explain the allied cases of calcification of the pulp.
We have now briefly reviewed the main forms of peripheral irritation, which act as the efficient causes of dental pain, just as we have glanced over the main constitutional causes that predispose to it. I think you will all agree with me that for the successful treatment of these cases, especially in the chronic and inveterate type, local and constitutional treatment have both to be employed. It seems to me there is great need for the more intelligent co-operation of physicians and dentists to attain the best results. Attention to one side of the question is not sufficient. For the permanent cure of our patients, the treatment of the local mischief has to be supplemented by attention directed to the constitutional conditions that predispose to it. One of the cases I quoted illustrated the important fact that a local irritation may set up a condition of pain in other nerves which the cure of the original lesion entirely failed to relieve. This fact is borne out by many similar conditions which we meet with in other departments of medicine. On the other hand, while a particular attack of pain may be relieved by constitutional remedies, its recurrence can only be prevented by curing the local condition, which acts as the exciting cause. The enormous preponderance of cases of pain of the fifth nerve, compared with other nerves, is to be accounted for by the liability of the delicately adjusted mechanism of the organs supplied to get out of order. This is especially the case with the eye and the teeth.
It is beyond the scope of my paper to take up the various constitutional remedies of which we can avail ourselves, rest, the influence of food, the use of the various drugs, the employment of counter-irritation, of electricity, and, lastly, of those surgical procedures, exsection and stretching of painful nerves, which are our last resort.