The choice between contour fillings and separation of the teeth in the case of approximal cavities, must, I think, depend in a measure on the aptitude and judgment of the operator, since the two plans when successfully performed, may be made equally efficient. The latter however—separation—seems to afford greater facilities for operating, and also for cleanliness in those patients who are unable or unwilling to devote the time and attention necessary for that object.
The professed incompatibility of gold as a filling material with tooth bone, seems to me to be at variance with the frequent success which we all must have experienced, in the use of that filling in cavities on the labial surface of the roots of the upper incisors. I mention this particular position as being easy of access for operating, and also as being one where the enamel, tooth bone, gold, and saliva, are in constant contact with each other. In those cases where the success of the operation has not equalled our expectations, in endeavouring to estimate the probable incompatibility of the filling material as a cause of failure, it is, I think, necessary to consider whether in the ordinary operation for filling, the whole of the diseased dentine has been so thoroughly removed, as to admit of its proving a satisfactory test case, for the microscope reveals to us a change in the dentine in the sides of a decayed cavity, even when it appears sound to the eye, and also to the feel of the instrument; and in those portions of the margin of the cavity which we undercut for the retention of the filling, we have the dentine not only denuded of its nutrient covering, the periosteum, but also deprived of its nutrition from the pulp by the severance of the tubes of the dentine, and the intervention of the filling material, and in this deteriorated condition, in all probability still exposed to the continuous action of the same deleterious influences (whatever they may have been) which first caused the decay; and I cannot but think that the failure when it occurs, is in a greater measure due to the above named causes, rather than to the incompatibility of the gold with the tooth bone; but with all the success that has attended the use of gold for so many years, we must still, I am sure, be willing to admit the want of a perfect plastic filling, which shall be able to withstand the friction of mastication, and also the deleterious action of the fluids of the mouth.
The dictum that, “a tooth that can be so treated as to be satisfactorily filled with anything, is worth filling,” is one, I think, that all who value conservative surgery must readily agree with.
That “unskilful and unscrupulous Dentists fill with tin covered with gold, thereby causing galvanic action, pulpitis, death of the pulp, abscess, and loss of the tooth,” has certainly not been an accepted creed in this country, for I was early taught the use of this material both alone, and in combination with gold, when I first commenced the study of my profession with Mr. Sheffield, of Exeter, and long experience, and the retention of a tin filling in my own mouth, in a perfect condition for over five-and-twenty years, has fully proved to me the value of this metal. When used in combination with gold, and exposed to contact with the fluids of the mouth, it certainly undergoes a chemical change, becoming nearly black in colour, but without staining the tooth as some amalgams do; it also becomes harder, and cuts harsh like an amalgam filling, but the change does not appear to cause any alteration in its bulk, or in any respect to interfere with its efficiency as a filling, nor have I ever found it produce any of the evils suggested in the creed, and I cannot but think that it would be more used, were it not for the universal prejudice that exists in the mind of the public in favour of gold, partly arising from the magical charm which resides in the word gold, and partly from the nothing but gold theory (if I may so call it), which has been so largely spread by our American brethren.
That “a filling may be the best known for a tooth and yet leak badly,” seems a simple admission that in some cases bad is the best that we can do for them. If experience has taught us anything, it certainly has proved that it is the leak which does the mischief; and as in warfare no fortress is considered stronger than its weakest part, so is it with a tooth that is filled. A small leaking point will soon undermine the filling, and prove its ruin.
The statement that “gutta-percha properly used is the most permanent filling material we possess,” must make us wish to know the meaning of the words, “properly used,” for the rapidity with which it wears away, in any position in which it is subjected to friction in mastication, seems to me to prevent the possibility of its ever being permanent.
The force of the article which says that “a poor gutta-percha filling, in its proper place, is better than a good gold one,” seems to depend on the question as to what is the proper place for a gutta-percha filling: surely not the place where we can insert a good gold plug, if by “good,” is meant one that is not only solid, but also sufficiently tight to exclude all moisture from the cavity.
It certainly is rather startling to hear from the country from which have come the severest criticisms on the use and the users of amalgam fillings, the admission that “amalgam per se, is an excellent filling material.” With amalgams, as with the other plastic materials, a perfect filling of its kind has yet to be discovered, for a measure of uncertainty seems to exist in all of them; but as a proof that an amalgam may make a good useful filling, I can say that I have seen more than one apparently in a perfect condition after thirty years’ wear, and I cannot but think that much of the discredit attaching to its use, arises from its being the filling we naturally have recourse to in all cases of doubt and difficulty.
That “the use of plastic filling material tends to lower the standard of Dentistry, thereby diminishing its sphere of usefulness,” is scarcely a fair way of stating the matter. The indiscriminate use of them would certainly do so, but the judicious selection of them in cases unsuited for the use of gold, need not necessarily interfere with the acquirement of the manipulative ability necessary for making good gold fillings, nor is it desirable that it should do so, as the power of manipulation required for the successful use of gold, must tend to perfect the powers of the operator in the use of all plastic materials, and must thus extend the sphere of usefulness of that Dentistry which has for its standard of excellency, ability to save teeth.
Time has only permitted me very briefly to notice some portions of this new creed, to show that it contains much that might be productive of profitable discussion, but I think from what has been said, we may reasonably conclude that each material has its own particular advantages, and that until we are in possession of a filling suitable for universal application, a judicious selection is necessary on the part of the operator in each particular case.