THE DENTAL COSMOS, 18678 (7): 355-357
DEVITALIZING AND REMOVING DENTAL PULPS.
BY J. S. LATIMER, D.D.S., NEW YORK.
THE first part of my subject has had so much said and written upon it, and is such an everyday process in our operating rooms, that I cannot expect to advance any new ideas upon it, but shall content myself with a description of the method I commonly practice, with cursory reference to others.
Some gentlemen who claim not to require the assistance of arsenious acid-tell us that they uncover the pulp thoroughly, apply creosote, move the pulp from side to side with a hatchet excavator to permit the creosote to work well up to the foramen, then, when the pulp is thoroughly obtunded, they remove it with a broach, and are ready to fill the canal, all within thirty minutes from the uncapping. Others omit the creosote, and plunge the broach at once, and without notification, into the pulsating pulp.
The descriptions of the agony endured, and of the subsequent nervous prostration, have, combined with the golden rule, prevented me from trying this method. When arsenic fails (as it sometimes will) I have tried to obtund the sensibility of the pulp with creosote, chloroform, and tr. aconite separately applied, but have met with very little success. In such cases I have sometimes put the patient under the influence of an anesthetic, the safest and best I have employed being nitrous oxide.
If Dr. Richardson's method shall come into general use, or shall prove as efficient as it now promises, we shall have little need of arsenious acid. No longer ago than yesterday (July 6th) I examined two teeth in one mouth, against the pulps of which arsenical paste had been plastered for four days, and yet those pulps were as lively as possible, responding to the first attempt to tickle them. I have had them so after several weeks' contact with the destructive agent. Extirpation under the influence of a local or general anaesthetic is the only resort left of which I am aware.
As to my method of applying the paste, I have nothing peculiar. The pulp being fairly exposed and the cavity dried, I take up a small particle of the thick paste on the point of an excavator and carefully plaster it upon the pulp, then cover with a small pellet of cotton-wool. Next a piece of adhesive wax is melted on one of Wood's pluggers and permitted to run on and saturate the cotton. This I deem far better than sandarac varnish, for the reason that it has no alcohol to dilute the creosote and has no disagreeable taste. Some cover the paste with dry cotton alone, and profess to have results quite as good as with wax or varnish in the cotton. They may be right, but the fear that in mastication the cotton may become displaced and that some of the arsenious acid may be brought in contact with the gum, has so far prevented me from trying it. Besides, I am of the opinion that creosote tends to lessen the pain consequent on the action of arsenic, and hence wish to prevent its dilution by the saliva. If a pellet of cotton saturated with varnish, a plug of wax or gutta-percha, is forced into the cavity over the medicine, it will generally produce pain by pressure, and is liable to force some portion of the medicine out of the cavity and in contact with the gum. Sometimes a mixture of paraffin and wax will be found preferable to wax alone, as it melts at a much lower temperature.
If, from sensibility of the tooth or the fears of the patient, I am unable to fully expose the pulp at first, I excavate as much as possible under the circumstances, apply the medicine, and send the patient away, with the request to call next day, at which time I am able to excavate thoroughly, and apply the medicine to my satisfaction. The arsenious acid is left in the tooth from one to four days, then removed, and the cavity left open to prevent discoloration, though I recently had a superior lateral incisor discolor in spite of all my care. In from eight to fourteen days I remove the pulp, though I do not often find the dead tissue separated from the living by suppuration, even in two weeks. Generally a little pain follows the application of traction.
Preliminary to the removal of the pulp is cutting away with drill or chisel such portions of the crown as I may deem essential in order to get free access to the roots.
In the cases of the molars and bicuspids this would always include opening through the grinding surface with chisels and drills, while in other teeth the approximal or palatal surfaces are preferred.
In any case free access must be had to pass a straight broach into the canal, or we cannot be sure of our operation.
This preliminary attended to, we may select a well-cut broach of size corresponding to the supposed caliber of the canal.
Thus, for a superior incisor, canine, or the palatal root of a superior molar, the larger instrument will answer a better purpose, but in other canals smaller ones will be required.
In removing pulps from the posterior teeth it will be found convenient to cut off nearly all of the handle, and in some cases it may be made even shorter than that, and a globule of sealing-wax melted on to the shaft to assist in rotating it. Broach-holders and long handles are only in the way.
Having selected the broach, dried the cavity, and mopped it with creosote, we pass the broach gently, carefully, and without rotating, as nearly to the apex as possible, and then steadily rotate it three or four times, or until we feel sure it has wound the pulp upon itself, then withdraw. Occasionally you will split the pulp from one extremity to the other; frequently you will fail to get more than a trace of pulp; but you must persevere, take a new broach and try again.
Do not cease your efforts to remove the pulp until you are sure you have it all, or, at least, have done your very best.
I know that even at six and a quarter cents each, broaches are really the most expensive instruments we use when we are faithful to our trust; but we should remember that the benefit of a perfect operation is to accrue mainly to the patient, and that the patient is to pay the expense of time, labor, and material.
Economy in broaches is penny wisdom and pound folly.
In a large proportion of cases I am unable to remove all the pulp from the canals of the buccal roots of superior molars, and too often I cannot even find them.
The canals of the anterior roots of inferior molars and those of the first superior bicuspids are often the objects of prolonged and perplexing search. In such cases it is a doubtful expedient to make canals with a drill, as some have taught.
A better method, to my mind, is to saturate the tooth with creosote, or, which is sometimes more practicable, to place a little dry tannin where canals ought to be, and fill immediately. It is consoling to believe that if the canal is so small that we cannot find it, or, finding, cannot introduce a very fine broach, the amount of destructible matter in it is very small, and, even if it should fail to be converted into the tannate or carbolate of albumen, can do but little injury.
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