Further on the author says that while the trepanning of incisors or canines almost always causes the pain to cease, by opening up an exit to the morbid matter retained within the cavity of such teeth, the same is not the case with the molars, these having several roots and several cavities, of great variety, which lend themselves but little to accurate trepanning. “Hémard,” he adds, “judges it necessary to extract these teeth, or at least to break off the crown (les déchapeller), in order to give exit to the corrupt matter that is closed up in the cavity; this sometimes causes the pain to cease. He (Hémard) says that he has seen many abscesses in the interior of teeth, which were not externally decayed, and that after having broken off the crown he found within the cavity a corrupt matter of an insupportable smell.”
Relative to such cases, Fauchard says that, besides the teeth, also the surrounding parts suffer and are imperilled by these conditions. “The greater part of the violent fluxions deriving therefrom often terminate in abscesses and fistulæ of the gums and of the surrounding parts, and sometimes with considerable and dangerous decay of the bone, as I have related in some of my observations.”
One sees that Fauchard was clinically very well acquainted with the grave forms of pulpitis and their possible consequences, although ignoring the true nature of this process, which has only been studied and illustrated much more recently.
Chapter XL (page 177) treats of dental tartar, of its cause, of the harmful effects it produces, and of the prophylaxis and therapy relating thereto. Three illustrations which are added to this chapter represent the different aspects of a mass of tartar of exceptional size formed around the body of a lower molar. The surgeon Bassuel, a friend of the author, had removed this mass of tartar, together with the entire molar, from the jaw of an old woman. The mass itself was almost the size of a hen’s egg, the superficies being very irregular; it rendered mastication altogether impossible and caused the cheek to stand out in such a way as to give the appearance of a tumor.[427]
In the following chapter[428] the author enumerates the various dental operations: “Cleaning the teeth, separating them, shortening them, removing the caries, cauterizing, stopping, straightening crooked teeth, steadying loose teeth, trepanning, simple drawing of teeth, replacing them in their own alveoli, or transplanting them to another mouth, and finally substituting artificial teeth for those wanting.” He then adds: “All these operations require in him who carries them out a light, secure, and skilful hand and a perfect theoretic knowledge, by which he may decide on the opportuneness of performing them, of deferring them, or of abandoning them altogether. In fact, one may know perfectly well how to carry out an operation and nevertheless undertake it in a case in which it is not at all proper to operate. Into such an error no one can fall save through sheer ignorance of the cause of the disease or of the right means of curing it. From this it must be concluded that the knowledge required in order to be a good dentist is not so limited as some imagine, and that the imprudence and the danger of placing one’s self in ignorant hands is as great as the temerity of those who undertake to exercise so delicate a profession without the knowledge of even its first elements.”
Before speaking in detail of all the above operations, the author dedicates a lengthy chapter[429] to describing with the greatest minuteness the position to be given in general, as well as in special cases, to the head and body of the patient, and the manner in which the dentist should place himself with regard to the former, so as to be able to make a proper use of each of his hands. As a rule, Fauchard made the patient seat himself in a convenient arm-chair; in exceptional cases he placed him on a sofa, or on a bed. He draws this subject to a close with the following words:
“It is, indeed, surprising that the greater part of those who practise tooth drawing should ordinarily seat the patient on the ground, this being both indecent and not very clean. This position is not only uncomfortable, but causes sometimes a sense of fear, especially in pregnant women, to whom it may, besides, prove very harmful. But it is still more surprising that certain authors should even nowadays affirm this to be the most convenient position, while it is instead one to be entirely rejected.”
In speaking of extraction of the teeth,[430] Fauchard begins by saying that the milk teeth, although destined to be shed, should never be extracted, except in cases of absolute necessity, as, for instance, when being decayed, they give rise to intolerable pain. The alveoli of the infantile jaw are weak, whilst the roots of the deciduous teeth are sometimes firmer and more solid than one would believe, and hence it is that in extracting a milk tooth one runs the risk of injuring the alveolus and even of carrying away a portion of it altogether with the tooth, not to speak of the danger of damaging or even destroying the germ of the permanent tooth lying below. Besides, Fauchard adds, there are sometimes deciduous teeth that are never shed and never renewed. One must, therefore, defer drawing children’s teeth as long as possible unless they are loose. When, however, intolerance of pain or a caries endangering the integrity of the neighboring teeth oblige one to recur without delay to extraction, one should carry out the operation with prudence and judgment, so as to avoid the dangers alluded to. It sometimes happens, says Fauchard, that one finds in children a crooked tooth by the side of a straight one; in these cases ignorant tooth-drawers have often been known to remove the crooked (permanent) tooth, and to leave the straight, viz., the deciduous one, which afterward falls of itself, the individual thus remaining deprived of one of his teeth for the rest of his life. The rule to be observed in order to avoid a similar error is always to extract the older of the two teeth and to leave the one that has been cut more recently, which is easily recognized by its being ordinarily firmer in the socket and of a better color than the first.
And here the author inveighs against all the charlatans of his day who dared, without being dentists, to perform dental operations, and whose number, it would seem, was ever increasing, so much so that he is led to exclaim: “There will shortly be more dentists than persons affected with dental diseases!” In proof of this he relates the case of a cutler of Paris, who extracted the molar tooth of a young girl because black spots having appeared on it, he believed it to be decayed; but perceiving that he had only removed the crown (it was a deciduous tooth about to fall out), and thinking that he had broken the tooth, proceeded to extract the root, removing, in his gross ignorance, the permanent tooth on the point of coming through.
Returning to the indications for the extraction of teeth, Fauchard says that when a tooth planted irregularly in the mouth cannot be straightened by any of those means to which he afterward alludes, and occasions damage or inconvenience or constitutes a deformity, the sole remedy is its removal. As to decayed teeth and the pain that they produce, when the evil cannot be remedied with oil of cinnamon or oil of cloves, with the actual cautery, or by stopping, one must have recourse to extraction, and this to satisfy four different indications, that is, before all, to procure the cessation of violent pain; in the second place, to prevent the caries from being communicated to the neighboring teeth; thirdly, to remove the fetid smell deriving from the substances that are retained within the carious cavity, and to impede the teeth on the same side from becoming covered with tartar, as inevitably happens when by reason of painfulness in eating they are forced to be inactive; fourth and lastly, because the dental caries, not infrequently gives rise to other diseases, which ordinarily cannot be cured unless the cause from which it arises be recognized and suppressed.