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Full text of "Practical oral hygiene, prophylaxis and pyorrhea alveolaris"

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Columbia ^nibersitp 
in tijc Citp o! i^etu gorfe 

College of ^{jpgiciansi anb ^uitjconfi 




i^eference Ititirarp 




Presented oy 

I^DR. WILLIAM J. OIES/^ 

?o enrich the library resources 

available to holders 

of the 

GIES FELLOWSHIP 

in Biological Chemistry 




Digitized by the Internet Archive 

in 2010 with funding from 
Columbia University Libraries 



http://www.archive.org/details/practicaloralhygOOadai 



PRACTICAL 

ORAL HYGIENE, 
PROPHYLAXIS 



AND 



PYORRHEA ALVEOLARIS 



BY 

ROBIN ADAIR, B. S., M. D., D. D. S. 

Professor or Oral Prophylaxis and Pyorrhea Alveolaris, Southern 

Dental College, Atlanta, Ga.; Oral Surgeon, Grady Hospital 

(1910-1912); Member Fulton County Medical Society, 

Georgia State Medical Society, Georgia State 

Dental Society, National Dental 

Society. 



1914 

Byrd Printing Company 

Atlanta, Ga. 



Copyright 1914 by 
ROBIN ADAIR 

at the Library of Congress, Washington, D. C. 



All rights reserved, including those of translation into foreign languages. 



TO 
HIS FATHER 

who for forty-five years of active practice 

has advocated the principles of Oral Hygiene 

and whose highest aspirations have been 

for his son to further the cause 

THIS WORK 

is lovingly dedicated by 

THE AUTHOR 



PREFACE. 

This book is \yi'itten for those dentists who desire 
practical information on the subjects of oral hygiene, 
prophylaxis, and pyorrhea alveolaris. 

The hrst section is devoted to the great forward 
movement of oral hygiene. Here are given methods and 
forms for dental inspection of school children, and a col- 
lection of carefully selected lectures furnishing the proper 
material for those called upon to deliver popular talks 
before school children and women's clubs. The author 
has found that diagramatic pictures often prove the most 
convincing way to teach the facts of oral hygiene to a 
patient. This section contains illustrations which may 
be shown and explained to a patient while in the dental 
chair. 

The second section contains practical information con- 
cerning the most ethcient methods to conduct prophylaxis 
in a dental practice, and names the materials to use for 
such work. The training of female assistants and the 
dental nurse question are treated in a most practical 
manner. 

The third section is a comprehensive description of 
pyorrhea alveolaris. Here is described in detail the 
methods of treatment now prominent before the dental 
profession. The business phase of the question, so sel- 
dom mentioned in discussion or literature, is presented 
in a frank manner. The medical profession is now 
greatly interested in the question of ''oral sepsis." To 
meet this advance, the author devotes a chapter to their 
interests. 

I have frequently been asked (juestions on the above 
subjects. The articles I have written for dental journals 
have elicited numerous requests for further information, 
and I have become convinced that there is need of a book 
dealing with such matters in a thoroughly practical 
manner. 



VI Peeface. 

I have endeavored to familiarize myself with the 
methods of other specialists in this line of work, and, 
from time to time, have visited them in their offices in 
order to inspect their work, and discuss with them the 
methods used. A number of these men have been quoted, 
and, in some instances, they have prepared descriptions 
of certain parts of their work for publication in this book. 

I am fully aware that I have not always observed the 
proper literary obligations; for my accumulation of 
material collected for dental college lectures, with no idea 
of future publication, has come from a store of thoughts 
of many writers in common. 

''What he thought he might require. 
He went and took." 

All sources of information on these special subjects 
have been freely drawn on, and wherever possible, credit 
has been given for any matter used. 
Atlanta, Geoegia, 
February 1, 1914. 



MT LITERARY OBLIGATION. 



Below I give the names of those dentists and physicians who have 
written contributions especially for this work; and a partial list of those 
whose methods and writings haA^e been quoted: 



Adair, E. B. 
Black, G. V. 
Black, Arthur. 
Carmichial, J. P. 
Beetman, M. M. 
Belcher, W. W. 
Corley, J. P. 
Clapp, G. W. 
Deichmiller, Conrad. 
Dunlop, W. F. 
Ebersole, W. G. 
Fones, A. C. 
Fisher, Prof. 
Fletcher, M. H. 
Goble, L. S. 
Gearhart, C. M. 
Good, Eobt. 
Greenfield, E. J. 
Hunter, Wm. 
Harris, G. B, 
Howard, C. C. 
Hoff, N. S. 
Head, Jos. 
Hunt, G. E. 
Hay den, Gillette. 
Howes, Minnie. 
Harrell, H. B. 
Hyatt, T. P. 
Hart, C. E. 
Hutchinson, R. J., Jr. 



Hartzell, T. B. 
Jenkins, N. S. 
Jungman, J. W. 
James, A. P. 
Kelley, H. A. 
Kells, C. Edmund. 
Kirk, E. C. 
Lundy, E. A. 
Merritt, A. H. 
MeCall, J. O. 
MacKee, Geo. M. 
Marshall, J. S. 
Niles, G. M. 
Nodine, A. M. 
Patterson, J. D. 
Peek, A. E. 
Pickerill, H. F. 
Pierce, C. N. 
ELein, M. L, 
Solbrig, S. O. 
Stevenson, A. H. 
Smith, D. D. 
Sarrazin, J. J. 
Spalding, E. B. 
Skinner, F. H. 
Talbot, E. S. 
Visanska, S. A. 
Younger, J. W. 
Zarbaugh, L. L. 



I also acknowledge obligation to the following: The Dental Sum- 
mary, Dental Dispensary Record, Oral Hygiene, S. S. White Dental 
Mfg. Co., The Cleveland Dental Mfg. Co, and J. W. Ivory. 



THE AUTHOR. 



319 Grant Bldg., Atlanta, Ga. 



CONTENTS 

PART I. 

PRACTICAL ORAL HYGIENE 

Page 
CHAPTEE I. 

/ Oral Hygiene Movement. 

\ Progress Made and Prediction for the Future. — In Literary Colleges. — 



Personal Oral Hygiene for Dentists. 



CHAPTEE II. 

Oral Hygiene from Infancy. 
Some Fundamental Observations. — Sixth Year Molars. — Mastication of 

Food.— The Neglected Mouth 12 

CHAPTER III. 

Popular Lectures on Dental Subjects. 
Teeth and Their Care. — Dental Summary. Outline Lectures, (1) For 
Mothers' Clubs. (2) To Children. (3) For Nurses and Physi- 
cians. (4) To Kindergarten. — By Stevenson 20 

CHAPTEE IV. 

Popular Lectures — Continued. 
An Illustrated Lecture. — Zarbaugh. Lecture for School Children from 
Fourth to Eighth Grades. — Corley. Lecture for School Children. — 
Hunt 44 

CHAPTEE V. 

Dental Examination and Clinic for Public Schools. 
History. — Object of School Inspection. — How to Start School Inspec- 
tion. — Argument for Free Dental Clinic and School Inspection. ... 6S 



X CO^STTENTS. 

CHAPTEE VI. Pagk 

Forms Used in Dental Inspection and Clinics foe Public Schools. 
Instructions for Making School Examinations. — Dispensary. — The For- 
syth Dental Infirmary 78 

CHAPTER VII. 
Tuberculosis and the Oral Hygiene Mo\^ment 91 

CHAPTER VIII. 

Brushing the Teeth. 
Shape of Brush. — Teaching the Technique of Brushing. — The Direction 

Card.— "The Bad Breath Signal" 96 

CHAPTER IX. 

Cleaning the Teeth. 
Skill Required for the Work. — The Best Time to Clean the Patient's 
Teeth.- — The Use of a Disclosing Solution. — Instruments Used for 
Cleaning the Teeth. — Abrasive Mixtures to be Used in Cleaning 
the Teeth 110 



PART II. 
PRACTICAL ORAL PROPHYLAXIS 

CHAPTER X. 

Prophylaxis. 
Definition and Views of Smith, Spalding, Fletcher, Fones, Taylor, Rhein 

and Harper 121 

CHAPTER XI. 

Why is Prophylaxis Necessary? 
Where to Begin Prophylaxis. — Frequency of Treatment. — Object of 

Prophylaxis 130 

CHAPTER XII. 

The Prophylaxis Class. 
Preliminary Work Before Entering on Prophylaxi.s'. — Prophylaxis Tech- 
nique. — Views of Kelley, Howes and Goble 140 



Contents. xi 

CHAPTEE XIII. Page 

Instruments and Polishing Material Useful in Prophylaxis .... 149 

CHAPTEE XIV. 

Prophylaxis Treatment of Fissures and Groo\t:s. 
Soft Spots. — Sensitive Area Treatment 155 

CHAPTEE XV. 
Kesults of Prophylaxis Treatment 159 

CHAPTEE XVI. 

Some Important Observations on the Teeth and Saliva 162 

CHAPTEE XVII. 

Methods of Notification Used by Kjells, Fones and Adair 16S 

CHAPTEE XVIII. 
Notification System of lMcCall, Kelley and Hayden 174 

CHAPTEE XIX. 

Training of Female Assistant. 
"When Should Such Help be Installed in a Dental Office? — The Best 
Way to Secure Good Help. — Methods of Training. — Telephone and 
Eeception Eoom. — Eecords to be Used by Female Assistants. — Of- 
fice Training for the Position of Dental Nurse 184 

CHAPTEE XX. 

The Dental Nurse. 
Vie'n'S of Fones, Merritt, Hyatt, Hart, Ebersole, Nodine, Kirk and 
Skinner. — The Proposed Law of Massachusetts as Endorsed by the 
State Dental Society 193 

CHAPTEE XXI. 

Teaching of Oral Hygiene, Prophylaxis and Pyorrhea in 
Dental Colleges. 
Practical Methods' Employed by the Author. — The Eesults Obtained. — 

The Need of Such Instruction 204 



XII COXTEXTS. 

PART III. 

A PRACTICAL DESCRIPTION OF PYORRHEA ALVEOLARIS 
AND ITS TREATMENT 

CHAPTER XXII. Page 

Pyorrhea Alveolaris. 
Synonyms. — Definition. — Causes. — What is Tartar and its Formation? 

— Black's Theory. — Kind of Calculi and Deposits 211 

CHAPTER XXIII. 

Pathology of Pyorrhea Al\^olaris. 
Recession and Congestion of the Gums. — The Changes in the Peridental 
Membrane and Alveolar Process. — Tooth Root Absorption. — For- 
mation of Pus and Pockets. — Alveolar Abscess in Pyorrhea 222 

CHAPTER XXIV. 
Symptom, Duration, Diagnosis op Pyorrhea 230 

CHAPTER XXV. 

Prognosis in Pyorrhea Alveolaris. 
Blood Pressure. — Artificial Teeth in Regard to Pyorrhea 236 

CHAPTER XXVI. 

Instruments por Use in Prophylaxis and Pyorrhea Work 243 

CHAPTER XXVII. 
Treatment and Instrumentation. 
The Younger Method. — Strong Drugs Used and Objection to Their 

Use.— The Joseph Head Method 250 

CHAPTER XXVIII. 
The Author's Method and System op Treating Pyorrhea 257 

CHAPTER XXIX. 

The Author's Method and System op Treating Pyorrhea — Continued. 
The Medical Treatment. — Practical Hints for Application. — An Unex- 
plained Chemical Formation in the Mouth 264 



Contents. xin 

CHAPTER XXX. Page 

Treatment — Continued. 
Treatment of Merritt, Patterson, Sarrazin, Dunlop, 

Lundy and Fletcher 272 

CHAPTER XXXI. 

TrexVtment — Continued. 
A Technical D-escription of the Surgery of the Root Surface, and the 

Instruments Most Useful in Achieving It. — ^By T. B. Hartzell 284 

CHAPTER XXXII. 

Implantation. — Bifuecation Treatment. — ^Removal of Puxps. 
Amputation of Tooth Roots. — Treatment of Pyorrhea! Abscess 290 

CHAPTER XXXIII. 

Vaccination Treatment. 
Bridge Work and Splints for Pyorrhea.- — The X-Ray and Pyorrhea. — 

By Geo. M. IVIacKee 298 

CHAPTER XXXrV. 

Sterilization of Instruments and Preparation of the Mouth for 

Surgical Work 309 

CHAPTER XXXV. 
Business Side of Pyorrhea Alveolaris 312 

CHAPTER XXXVI. 

The Medical and Surgical Aspect of Oral Hygiene and Pyorrhea. 
Views of Prominent Medical Men. — Suggestions to Physicians as to 
Care of the Mouth in Sickness. — Oral Preparation for Surgical 
Work 319 



PART I. 

PRACTICAL ORAL HYGIENE 



CHAPTER I. 
ORAL HYGIENE MOVEMENT. 

PBOGBESS MADE AND PREDICTION FOR THE FUTURE. IN 

LITERARY COLLEGES.— PERSONAL ORAL HYGIENE 
FOR DENTISTS. 

Only in recent years have some of the more progres- 
sive dentists begun to reahze their duty to the public in 
the matter of educating them on the importance of 
prophylactic and oral hygienic measures in the care of 
their teeth, and to teach them the great results which can 
thus be secured in the way of increased health, happi- 
ness, and freedom from disease. This propaganda has 
been termed the Oral Hygiene 3lovement. 

It must be admitted that the slowness of the dentists 
in realizing their duty along this line has been discourag- 
ing to those who have had the interest of the movement 
at heart, but we all know that the dental profession is 
a busy and hard working profession, having strenuous 
requirements on its time and resources. Still the timo 
cannot be far distant when the dentists of America will 
realize their great opportunity as well as their duty 
along the line of educating the people. It will mean the 
placing of the propaganda on a higher plane of useful- 
ness and the accomplishment of results in every way 
equal to the best work done in recent years by the medical 
profession in the line of preventive measures. 

It can already be noticed that the dentists of this 
country who are interesting themselves in this movement 
are taking the places at the head of the profession, and 
are reaping just rewards for their work in furthering 
the public welfare. 

It has been stated that only twelve per cent, of any 
community pays any attention to the teeth, but, since 



4 Peactical Oral HYGiEisrE. 

we know liow inefficient most of this care is, we realize 
that a very much smaller percentage practices oral 
hygiene in a really efficient manner. 

It is somewhat a reflection on the dental profession 
that a layman, Mr. Horace Fletcher, did more in a few 
years to acquaint the people with oral hygiene facts than 
did the whole dental profession in its former career. 

The public is beginning to be aroused on the subject 
of oral hygiene and they read eagerly the magazine and 
daily newepaper articles on the subject. The whole 
trouble to-day is that just such trustworthy (?) facts are 
given them as are to be found in the columns, "Advice 
to the Lovelorn," and "How to Eemove Freckles." 

Not all dentists are in possession of facts relating to 
the general health and welfare, which if properly pre- 
sented to the laity, would soon make the advice of the 
dentists as much sought after as is that of the medical 
man. The truth is that up to the present time, the laity 
and the medical profession have been ignorant on this 
subject, and for the simple reason that the dentists them- 
selves have not done their duty in the way of educational 
propaganda. 

One reason for the lack of knowledge on the part of 
the public is shown by the following quotations taken 
from a common school physiology: 

' ' The teeth are bony keys set in the jaw-bones. Those 
in the front part of the jaw are sharp, so as to bite lumps 
of food. Those in the back part of the mouth are flat, 
so as to grind food to pieces. Between the ages of 6 and 
13 the child loses its first teeth and gets a whole new 
set, and 8 additional ones. Biting hard things, such as 
nuts and wood, often breaks the enamel and causes the 
teeth to decay. When the decay reaches the nerve, the 
tooth aches and becomes very tender." 

These false impressions, gained at an early age, are 
very hard to overcome when the children grow older. 
We should bend our energies to correct this state of 



Oral Hygiene ^Iovemext. 5 

affairs by establishing in our schools a brief but thor- 
oughl}'- scientific course on these subjects. 

Not only does the proper dental attention give the 
owner the means whereby he can more comfortably 
masticate his food, but also serves as a preventive against 
those agents which make against his general physical 
welfare. The lack of this attention not only causes a 
filthy condition, which furnishes the bed where germs 
can readily grow, but also lowers the patient's resistance, 
and this results in jDhysical deterioration. 

A few years ago this fact was not generally recog- 
nized, but to-day the army and navy, the big factories, 
and even the base ball clubs often emplo}^ a good dentist 
for the purpose of protecting their employees. 

The match factories were the first to recognize the 
benefits of protecting their employees against mouth 
infections. Previous to dental inspection and care, 
phosphor-necrosis was a dreaded and common affliction 
among those thus employed. Since the employment of a 
regular dentist, this condition has been reduced to a 
rarity. 

Morris and Co., one of the big stock yard firms of 
Chicago, have just installed a fully equipped dental 
office for the purpose of giving their thousands of em- 
ployees free dental attention. This firm was convinced 
that the health of its workers would be better, and that 
a great saving of time would result from having a 
dentist close at hand. This special inducement to these 
people saves many teeth which would otherwise be lost. 

This is in line with the efforts of many of the larger 
corporations to guard against any thing which would 
incapacitate the employees from giving good service. 
Undoubtedly, bad teeth are the greatest cause for loss of 
time, and these free clinics will, in time, l>e a regular 
equipment. 

Mam' of the larger southern cotton mills either em- 
ploy a dentist for their employees, or make it to his 



6 Peactical Okal Hygiene. 

interest to locate in the vicinity by giving Mm free rent 
or by other means. 

One mill in the Piedmont district, which owns the 
township, selected a well equipped young dentist and 
gave him free rent, assured him the influence of the 
officials in his oral hygienic endeavors, and guaranteed 
him freedom from competition by the more or less con- 
scienceless dentists who often infest such places. He is 
free to give these mill operatives much valuable advice 
and treatment, and in turn, they furnish their employers 
better work.- 

One not familiar with the ignorances and prejudices 
existing among these cotton mill operatives, cannot 
imagine the difficulties to be met with in trying to make 
better their conditions. Not long since, I was in the 
township mentioned and questioned some of these people 
about their teeth. I was congratulating them on having 

such a good dentist as Dr. . One of them said, 

''Dr. may be a very good fellow, but I am not 

going to let him work for me or my family any more, 
for," said he, ''I had the dickens of a toothache and 
went up to him to get it pulled and he commenced some 
rot about cleaning teeth and saving my tooth. I didn't 
have any time for such stuff, and went to Greenville 

and got Doc. to pull it. Dr. used to 

pull teeth, but he has got to talkin so much about clean 
mouths that he is losing some of his trade." 

"While the contemplation of such a clientele is not 
pleasant, it emphasizes more than ever the need of edu- 
cation on these subjects. 

If we have any patients who control mills, it is our 
duty to show them the benefits of such service, and sug- 
gest some good young dentist for the position. 

To ''some good young dentist" the suggestion is 
offered that he see some mill official with whom he is 
acquainted, and show him the immense advantages to 
be derived from having the right sort of dentist con- 
nected with the mill. The experience is well worth while, 



Oral Hygiene Movement. 7 

the good done incalculable, and the financial returns are 
generally satisfactory if the co-operation of the officials 
is secured. 

At the present time where wages are high and hours 
short, officials who control large numbers of operatives 
are rapidly awakening to the advantages of measures 
which will enable them to secure more efficient services 
from their employees. As regards medical advice they 
are always ready to have lectures on sanitation, and the 
suggestions of the resident physician are most readily 
carried out. 

Marshall, in his ' ' Mouth Hygiene, ' ' calls attention to 
the fact that practically no one escapes the diseases of 
the mouth, and that dental decay is, without doubt, the 
noLOst common disease that afflicts the human family. He 
further states that in his practice of about forty years^ 
he has not seen but about four instances where persons 
had reached mature life without some form of dental 
decay. 

If we could only realize that the condition of faulty 
mouths keeps our young men out from even such employ- 
ment as the Army and Navy, and that so few are able 
to pass the simple requirements, we might wake up on 
this subject. Even more so, when considered that, had 
the oral hygiene movement started back when these appli- 
cants were children, they would not be hampered in this 
way. In our Philippine Army thirty-five per cent, of the 
catarrhal dysentery is said to be traceable to septic 
mouth conditions. 

Thousands of applicants for our Army and Navy are 
rejected because of faulty teeth. Not only is this true 
in our Army, but in England also, it has been said that 
five hundred were rejected in one year because of im- 
proper oral conditions. Further than this, a report 
states that twenty-four per cent, of the English Army 
recruits have useless teeth. At Anapolis an average of 
only two per cent, of the men who apply for entrance pass 
without first having some dental work done. 



8 Pkactical Oeal Hygiene. 

Grermany lias recognized that the great efficiency in: 
her army is maintained by attention to oral hygiene. 
The present requirement is that each soldier shall brnsh 
his teeth at least once a day, and; the first sergeant in. 
each company must see that this order is carried out. 
Many other countries have taken steps along this line in 
regard to the armies. While America will probably 
never exercise this parental care, still we are bordering 
on this, for in the Philippine Army the soldiers are re- 
quired to have monthly examinations of their mouths by 
the Post Surgeons. 

The American Army and Navy employ the best of 
dentists, who secure their positions, not through any 
politics or favoritisms, but by standing the hardest kind 
of examination. These men not only do repair work for 
the soldiers, but they, working with the medical author- 
ities, see that their mouths are kept clean. It is a remark 
able story that the Surgeon General was willing to raise 
the dental requirements for admission into the Army and 
Navy, yet, when the raise was attempted, it was found 
that the number of recruits was so reduced that the old 
standard had to be again accepted. 

Undoubtedly, more and better oral hygiene will be 
taught and required each year in our Army, and the 
officials in charge will find that greater efficiency, better 
health, and a better fighting force can be maintained by 
having the men keep their mouths in a clean condition. 

The prediction can be made that the day is not far 
distant when our department stores and other business 
houses where the clerks come in contact with customers, 
will provide either by pamphlet, lecture, or by furnish- 
ing free prophylaxis, the necessary means for insuring 
a healthy condition of their employees' mouths, and it 
will certainly more than repay them for the time and 
money expended. We know that when a clerk with un- 
kept teeth, shining crowns, and bad breath waits on us, 
it makes a difference. It also makes for a sale, if the' 



Oral Hygiene for Literary Colleges. 9 

clerk has a pretty well kept mouth. Here is a fertile 
field for the oral hygiene worker; this class of people 
cannot pay for expert services. It costs too mnch and the 
loss of time is also an item. They are often the victims 
of dental parlors where their teeth are fitted with golden 
trappings which shine ont as the headlights on an 
automobile. 

ORAL HYGIENE FOR LITERARY COLLEGES. 

One of the largest and best military schools for boys is 
located some ten miles from Atlanta. The attendance is 
gathered from all over the United States, and many for- 
eign countries are represented. I have had the pleasure 
of having many of thse boys for patients. Almost with- 
out exception, they have presented mouths needing much 
attention, especially for oral sepsis. I have counted up 
the time lost by these boys going to and from the dentist, 
and the loss of study-time due to pain which I believe 
will show far greater than any other cause. The presi- 
dent realizes this condition and will in time accept the 
plans suggested. 

The same condition prevails at our educational insti- 
tutions situated in all our cities. While the dental in- 
spection of our public schools is productive of much 
good, it is undeniably true that we are neglecting just 
as great a field in the colleges. These institutions are 
filled with young ladies and gentlemen who are to be the 
future parents and who can be made our earliest and 
best missionaries. At this age, fourteen to twenty-two, 
they are very receptive to suggestions on oral hygiene. 
Not only owing to their ignorance of their mouth con- 
ditions, but also the great loss of time for the necessary 
dental attention, they delay until too late. Even those 
who endeavor to have their teeth looked after are some- 
times recommended to the poor operators. I have known 
of several cases where inferior dentists have secured 
some of the teachers in a school for patients, and have 



10 Peactical Okal Hygiene. 

done their work free of charge with the understanding 
that the teachers solicit work for them, among the stu- 
dents. In one of these instances, the college officials were 
unable to overcome a teacher's persuasive powers with 
the students, and the latter were led to patronize a man 
who was about on a par with those employed to work 
in dental parlors. This happened in a large institution. 
How much better it would have been for the president 
to have had on his staff, a reputable dentist to reside in 
or near the college, or to have a city dentist to come' to 
the college on regular days, and have a well equipped 
dental office in the college building. Think of the better 
service and the saving of time and trouble to the teachers 
and students. Every institution can afford a well 
equipped hospital, whereas the cost of a dental office need 
not be nearly so much as that of the hospital. 

Some years ago, I accepted an invitation to deliver a 
lecture on the subject of "Teeth," at one of our larger 
female colleges. One of the local dentists got interested, 
worked up some enthusiasm, arranged the date, secured 
a lantern, and introduced me. My whole theme was 
turned to what benefits they could secure by a course on 
"Oral Hygiene." I made this lecture as dignified and 
impressive as study and slides could do. The president 
and the dentists followed up the suggestions, and now, 
for several years, this institution has been giving the 
students a regular and systematic course by a professor 
in oral hygiene. There is a possibility that spasmodic 
lectures may do some good, but if the work is carried out 
in the regular curriculum, as in the college just men- 
tioned, great good can be accomplished. 

personal oral HyGIENE FOR DENTISTS. 

If you want to kill an oral hygiene movement, just let 
a dentist with a dirty, filthy mouth and foul breath lec- 
ture to the parents or examine the children's mouths. 
The President of a Dental Society, if he has the interest 



Peesoxal Oral Hygiene for Dentists. 11 

of the movement at heart, will select men with mouths in 
good condition to do this work. To show the inconsis- 
tency of the position, one of the greatest lecturers in this 
work, carries around with him a mouth that is extremely 
foul. Others, in just as bad condition, are doing the 
same work all over the country. Dentists must look after 
their own mouths first, if they desire their words to have 
any weight with the people. One of the greatest draw- 
backs in our work along the line of oral hygiene, is, un- 
doubtedly, the existing conditions of some dentists' 
mouths. A few years ago, I made an examination of some 
twenty dentists' mouths which reflects the average to be 
found, anywhere. The author is so ashamed of the re- 
sult that he declined to publish the table. 

To those dentists who think only the patient needs 
oral hygiene training, let them examine the mouths of 
a few of their brethren at any dental convention. The 
editor of the Dental Dispensary Record has well said 
''that the weakest link in the whole mouth hygiene move- 
ment is the dentist himself." 



CHAPTEE II. 
ORAL HYGIENE FEOM INFANCY. 

SOME FUNDAMENTAL OBSEKVATIONS. SIXTH YEAK MOLARS. — 

MASTICATION OF FOOD. — THE NEGLECTED MOUTH. 

Oral hygiene for the infant should start at its birth, 
and be maintained by the trained nurse until the child is 
turned over to the regular nurse and the mother, who 
in turn, should be taught to carry out our instructions for 
keeping the mouth in a cleanly condition. Milk, whether 
from the mother's breast or the cow, readily ferments 
in an exposed warm place, such as the child's mouth. 

If properly done, nothing but good can result from 
washing a baby's mouth. The manner of doing this is 
one of the simplest things, and yet, in mj^' college work, 
after lecturing on the subject, I have found that few stu- 
dents remembered it at thei time of their final examina- 
tions. The first requisite is clean hands. Around the 
index finger is wrapped a small amount of aseptic cotton ; 
the cotton is then saturated with a solution of boric acid. 
The child is held in the arms with the head slightly back, 
and, as most children when held in this position open 
their mouths, the finger can be inserted easily. The part 
of the mouth which needs the most attention is not the 
top of the gum surface, as many seem to think, but under 
the tongue, and at the lower surfaces on the buccal sides 
of the cheek in places where milk remains. Do not use 
gauze on the finger as it is entirely too rough. Rubbing 
is not necessary, but the simple cleansing by removing 
the milk debris is the proper idea. The best time for 
this is after the morning bath and the procedure may 
be repeated at night with good results. 

"When the child is about nine months old, the same 
method is used, and, in addition, care should be exercised 
in wiping around whatever teeth have erupted at this 



Sixth Yeae Molaes. 13 

time. About the tenth month, it is well to secure a soft 
camel's hair brush, one in which the hairs do not shed, 
and very carefully brush the teeth from the gums with 
a rotary motion, using a brush which has been dipped 
in boric acid solution. At this age, the child will not 
object to it, and it should be .done more in a spirit of 
play by the mother herself. Now, too, the child will 
enjoy the friction of the brush upon the gums. The gums 
can now be brushed and a small amount of massage given. 
This will stimulate the growth of the teeth and i3rove to 
be a great aid towards their eruption. If the spirit of 
play in this brushing is carried out, the child early learns 
to brush its own teeth, and, if kept up, the tooth brush 
habit will be so instilled into the child's mind that much 
pain and decayed teeth will be prevented for the future 
man or woman. 

SIXTH YEAR MOLARS. 

Dr. Woodbury, of Boston, calls the sixth year molars 
the "working tools of mastication. Their work begins 
at once and lasts throughout life; upon them rest full 
growth and development; upon them depends good 
health during life. ' ' If tliis is true, Ave have the key note 
for a great deal of dental irregularities due to mal-occlu- 
sion, food pockets, contracted jaws, and also a great 
many pathological conditions. One has only to examine 
the mouths of a moderate number of subjects to be 
astonished at the early removal of one or more of these 
sixth year molars. As these teeth come out just back 
of the temporary teeth, the parent is careless about the 
child brushing them ]n'operly, and thinking that they, 
too, are temporary teeth to be soon shed. They are 
generally covered with a mass of sticky food which 
furnishes nutriment for germs of decay. 

In examinations which I have made at the ^'Plome for 
the Friendless," of children from six to fifteen years 
of age, in our city hospitals, and among students of the 
dental colleges, there is one defect more than all others. 



14 Peactical Oeal Hygiene. 

and that is this condition of loss of the sixth year molars, 
especially in the lower jaw. If it were only the simple 
loss of the tooth, it would not be so bad, but nature, 
attempting to close up this space, tilts the next four or 
five teeth, causing them to get so far out of place that 
the proper mastication of food is impossible. 




Fig. 1. Models of a Youn^g Lady 21 Years op Age, Showing Irkeg- 

ULARiTY Caused by the Early Loss of the Sixth Year Molars. 

(Case of Dr. C. C. Howard.) 

It should be the duty of all teachers of oral hygiene 
to show on their screens pictures illustrating the result 
of this condition or to draw^them on the blackboard. 

Dr. Potter, in an article published by the '' Dental 
Hygiene Council," of Massachusetts, says, in reference 
to the statistics which he rejDorted in Brookline, Mass., 
"The sixth year molar has aptly been styled by Dr.. 
Bogue, the principal molar of man. All will, I believe, 
agree with this designation. If tlie tooth is in large 
measure or wholly destroyed, the efficiency of the teeth,, 
as masticating powers, is largely lost. In 345 pupils, 
from eleven to fourteen years of age, 18 per cent, had 
lost both crowns of the lower sixth year molars, and 
24 per cent, had lost one crown of a lower sixth year 
molar. In the same number of pujoils at the same age,. 



Masticatiox of Food. 15 

G.9 per cent, had lost both crowns of their upper sixth 
year molars, and 13 per cent, had lost one crown of their 
npper sixth year molars." 

The best remedy is that described under ''Technique 
of Propltylaxis," which is the covering of this tooth as 
soon as it erupts, but, as comparatively few people to 
whom we talk will be receiving regular prophylaxis care 
from a dentist, we should in all our lectures particularly 
stress the brushing of this tooth. 

MASTICATIOlsr OF FOOD. 

In our former races, not only the skulls of adults, 
but of children as well, exhibit a smaller number of caries 
than we are accustomed to find to-day. This is undoubt- 
edly due to the fact that they had coarse food to chew, 
for the cusps of the museum specimens are worn nearly 
to the pulp. Such a thing in children to-day would be 
a dental rarety. Thus, we must conclude that it is the 
duty of the dentist to acquaint their patients with these 
facts, and instruct them always to provide their tables 
with some food which will require very thorough masti- 
cation. While such teaching may not at first be very 
popular, there are many of our good patients who would 
undoubtedly put this into practice if acquainted with the 
beneficial results which would surely ensue. 

It is unfortunate that the temporary teeth of our 
children, just at the stage when thorough mastication is 
of greatest importance, are allowed to decay to such an 
extent that it becomes a painful operation for the child 
to masticate food at all. It is at the age of eight or 
twelve that the greatest developments should take place, 
but the examination of school children has shown that 
a large majority of them are dental cripples. It is time 
the dental profession is waking up to its opportunity 
and duty, and trying in some way to instil into the minds 
of, not only their patients, but also the people at large, 
these important facts about the care of the teeth and 



16 Peactical Oral Hygiexe. 

the prevention of disease. Instead of pies and soft foods, 
the children should be taught to eat the food which re- 
quires thorough mastication. I am always telling my 
students that the tough meat at the boarding houses is 
one of the greatest Godsends which they have, if they 
will only take advantage of it, and learn to thoroughly 
masticate their food. I have been told that some of them 
found a certain amount of consolation in the experiment. 
. Nature furnished man's jaw with a series of muscles 
strongly attached to the jaw bones, in order that the 
food may be given the proper amount of mastication. 
The muscles in this position are subject to the same laws 
of development and increase of power through exercise 
as the muscles in other parts of the body. It is a fact 
which can be easily demonstrated that the person who 
chews well has a much larger set of muscles than the 
person who chews but little. 

It having been shown heretofore that primitive man 's 
immunity to decay was due to the perfect mastication 
of his food. The one factor in our future work on pro- 
phylaxis which must be stressed more than heretofore, 
is the use of our jaws. Dr. Gr. B. Black, in his book on 
''Operative Dentistry," has an instrument, the Gnatho- 
dynameter, by which the force of the ordinary bite may 
be measured. This has been found equaled to three 
hundred pounds. Nature certainly intended us to make 
use of this tremendous power with which we are supplied. 
However, we are, rmfortunately, not given this oppor- 
tunity often, for our housewives would feel chagrined if 
there appeared upon our tables am^thing which would 
necessitate any large amount of chewing before it is 
swallowed. The whole idea of cooks seems to be to 
eliminate anything which requires much mastication and 
deprive us of this exercise which is so important to 
health and comfort. 

The idea is often held by the laity that the teeth are 
easily injured by the measures for cleaning and brushing 
them. Many of the patients, I have found, look with 



The Neglected Mouth. 17 

horror at the simple cleaning of the teeth, or the direc- 
tions for use of a dentifrice, with the idea that the enamel 
of the teeth can be easily removed. This is one of the 
illusions that I first try to get out of the minds of the 
freshman dental students, as well as the new patients 
who come for prophylaxis. They must be brought to 
realize that the enamel of the teeth is one of the hardest 
substances in nature, and it is made to stand the hard 
usages that a life time service may demand. The 
abrasion that ensues from prophylaxis, the cleaning of 
teeth, and the brushing of teeth -will not in any way 
measure up to that destruction which is sure to follow 
the lack of these precautions. 

THE NEGLECTED MOUTH. 

By editorial in the Dental Bispensary Record (March, 
1910) Dr. Belcher thus expressed himself: 

''A child cannot be expected to develop into a healthy 
adult if they are deprived of efficient means of chewing 
their food properly, or if the food must pass through 
an uncared for mouth that is more like a cesspool than a 
receptacle for the transmission of food to the human 
body, every ounce of which must pass through this dis- 
ease-breeding area on its way to the stomach, burdened 
with numerous colonies of poisonous germs, of which over 
twenty harmful varieties have been found in unclean 
mouths. No wonder such children are sickly and lacking 
in strength to resist disease, or that they are not con- 
sidered bright and intelligent, and figure many times as 
members of our mentally deficient classes in the school 
work. Not only this, but an unclean mouth is the direct 
cause of many ear aches, enlarged tonsils, adenoids, 
stomach ills, and that most dreadful of children's dis- 
eases, diphtheria, is invited." 

Under the title of ''Clean Teeth on the Market," 
Dental Dispensary Record (March, 1911) Dr. Agnes de 



18 Peactical Oral Hygiene. 




Fig. 2. Child, Age Six, With Full Complemekt of Deciduous 
Teeth. Note Symmetry of Features.. 

Second Picture. — Same eliikl. Picture taken three years latei', dur- 
ing which time the four six-year molars were lost through neglect. 
Note mal-development of jaws, Avhich is partially, if not entirely, due 
to the absence of these most impoiiant teeth. (Case of Dr. C. C. 
Howard.) 

Lima of the Bureau of Municipal Eesearch of New York, 
says: 

''Doctors still prescribe tonics for invalids whose de- 
caying teeth are draining their vitality, more than any 
other cause, and fortunes are spent to attempt to cure tu- 
bercular parents who reinfect themselves every time food, 
medicine and saliva pass over their diseased cavities and 
gums ; millions are spent on purifying the water supply 
and the soil ; medical institutes are endowed to stamp 
out the contamination of food and air by "pathogenic 
bacteria," but the prime breeding plan for germs — the 
human mouth — is neglected and uncared for," 

From the same journal, (Nov., 1912) H. N. Holmes 
writes some strong arguments : 

"When the slightest eruption of the skin occurs, from 
no matter what cause, we begin treatment for it, and if 



The Neglected Mouth. 



19 



it doesn't heal in a short time we consult a physician, 
and if he fails to get results, we are thoroughly aroused 
and seek a specialist without delay, but with the mouth 
it is quite the reverse. 




Fig. 3. Same as Fig. 2 at Age 18. Wixiiout the "Keys to the 

Arches" (Six- Year Molars) Normal Development of the 

Remaining Teeth Never Occurs. (Case Dr. C. C. Howard.) 

''Not One Person in Twenty after the age of Thirty 
has a Mouth in a Healtl^y Condition, and not One in Ten 
has a Mouth Free from Pus at Any Time. 

''We wash our body once a day and our faces and 
hands several times, but, alas, some of us have our mouths 
cleaned once or twice a year — maybe. Even then it is 
seldom well done, for dentists as a rule slight such jobs, 
for if the patients haven't enough decency, pride, self- 
respect or what you may term it, for others, than to 
present themselves with a chloride of lime breath, far 
be it for the dentist to turn iiolicoman at this ago." 



CHAPTEE III. 
POPULAE LECTUEES ON DENTAL SUBJECTS. 

TEETH AND THEIE CAEE. DENTAL SUMMAEY. — OUTLINE 

LECTUEES: (1) POK MOTHEES' CLUBS, (2) TO CHILDEEN, 

(3) FOE NUESES AND PHYSICIANS, (4) TO 

KINDEEGAETEN. BY STEVENSON. 

Tlie subject of oral hygiene is now causing such inter- 
est that even dentists in small towns are being called 
on to deliver lectures before the various schools in their 
localities. This often places the dentist in a difficult 
situation, because, in the first place, the subject is new 
and he is often not acquainted with it. Dentists are not 
in the habit of writing papers and delivering lectures, 
and this new request, pu.t before them, sometimes startles 
them. Again the subject matter is hard to collect and 
get in shape for a suitable lecture. 

Many times I have heard of lectures that were utter 
failures owing to the fact that ,they were too scientific 
and did not give elementary facts. Every dentist who 
does any lecturing along this line has been called upon 
by his various friends for facts which will constitute the 
right sort of lecture in this regard. With these facts 
before me, I have determined to give the frame work of 
some good lectures at some length, so as to meet this 
rquirement. One of the best that was furnished me on 
this subject was sent in by the Dental Summary, issued 
by the Michigan Dental Society. 

While this lecture seems very elementary, it was de- 
livered l)efore the senior class of a high class female 
college, and the results which followed it show that it 
contained the proper material for this kind of lecture. 
The great trouble is that we forget how little the people 
know on this subject. This is one of the points which 
will have to be guarded against. This lecture and those 



PopuLAE Lectures on Dental, Subjects. 21 

following, are among tlie best which have appeared in 
dental literature. 

A LECTURE ON THE TEETH. 

'^Eecent examination of the teeth of school children 
in many parts of the world shows that about 9G in every 
100 children have diseased teeth. 

' ' Think of it : Only about four children in a hundred 
who are not suffering more or less from diseased teeth. 

"This would be bad enough if the toothache were all 
the little ones had to suffer as the result of somebody's 
neglect ; but, as simply a matter of well known fact, the 
toothache is the smallest part of the trouble. In fact, 
toothache is not the trouble at all, nor any part of the 
trouble; it is simply the cry of the nerve, trying to 
arouse attention of the fact that something is wrong; 
the call of the nerve to be relieved from the poison that 
is killing it. 

"Statistics show that on account of poor teeth the 
mental and physical development of the child is seriously 
retarded. 

"The more the physical and mental development of 
the child is disturbed and retarded, the less is, of course, 
the general capacity of the child. 

"The worse the teeth, the lower, as a rule, is the 
school-standing of the child. 

"Dr. Luther H. Gulick, of New York City, is respon- 
sible for the statement that of 40^000 school children 
examined, those with two or more bad teeth averaged 
five months behind the grades that they should occupy, 
and Avould occupy were their teeth sound. Adenoids 
were responsible for lagging to the extent of eleven 
months. 

"As decay spreads from the rotting apple to the 
sound one by its side, so does it spread from the first 
decayed tooth in the temporary set to the next and the 
next; and so does it spread from decayed first tooth to 



22 Peactical Oral Hygiene. 

sound second, or permanent one, coming in alongside of 
it. In a very short time, if neglected, tlie second teeth 
are as bad as the first. 

"Because of poor teeth, the child swallows its food 
unchewed, and the habit of bolting is formed. The youth 
also, for the same reason, swallows his food unchewed, 
and the habit becomes fixed. The unchewed food is not 
digested; indigestion and bowel troubles follow, and the 
child, if it survive, becomes a weakly, undeveloped man 
or woman, an easy prey to tuberculosis and the host of 
other ills that prey upon people of low general vitality. 

"This is no overdrawn statement; it is amply proved 
by experience and statistics. 

"Xo claim is made, of course, that bad teeth are the 
sole cause of disease. Abuse, in like manner, any other 
part or organ of the boch^, as important as the teeth, 
and disease is sure to follow. 

"Now, a very large part of this suffering — the half- 
starved body and the weak brain that follows it 
naturally, grow out of pure neglect; and by far the 
greater part of this neglect is due to ignorance. And it 
seems strange indeed that the world should have been 
so tardy in realizing the importance of the teeth, and 
the necessity for their intelligent care. This condition 
of ignorance may be charged to what seems to be an 
innate tendency upon the part of scientific men generally 
to dig and delve in search of the obscure and the com- 
paratively unimportant, while overlooking the much more 
important and perfectly obvious facts immediately under 
their observation. 

"Let it be understood at the outset that a clean mouth 
and sound, well cared for teeth are positively essential 
to perfect health; even to the average of good health; 
and that such teeth, used to masticate the food as 
intended by nature, will go a long way toward inducing 
and conserving that degree of health. 

"If we would intelligently care for the teeth, we must 
first learn to know something about them; how many 



PopuLAE Lectures on Dextal Subjects. 23 

there are in the first set aucl what they are; how many 
there are in the second set and when they are cut; the 
relation of the first set to the second, etc. 

''It will, perhaps, help us to remember the number 
of the first or temporary teeth if we associate them with 
the fingers and toes. Ten fingers — ten temporary teeth 
in upper jaw ; ten toes — ten temporary teeth in the lower 
jaw; five on either side, both in the upper and lower 
jaw. 

''The first teeth are usually all in by the end of the 
second year. The first to be cut are the lower front 
teeth, the central incisors appearing, as a rule, about the 
seventh month, and lasting usually, until about the sev- 
enth year, when they are replaced by the permanent 
incisors. 

"The incisors are the cutting teeth. From the same 
root word we have the word 'scissors,' you know. 

"The other temporary teeth appear at short inter- 
vals, until, by the end of the second year, the entire 
twenty are in place. 

"Now, it is of the utmost importance that these 
twenty teeth remain in place with their crowns undim- 
inished in size by decay, until the loermanent teeth are 
ready to replace them. The first teeth should be dis- 
placed and pushed out by the second or permanent set. 
Why is this so important? Many parents think that the 
first teeth amount to very little, and the sooner they are 
gotten rid of the better. There could not be a more 
serious mistake. Let us see. 

"We already have considered the effect that decayed 
and aching teeth have upon the habit of chewing the food. 
Teeth, especially teeth that are just coming in, require 
exercise precisely as do other parts of the growing body. 
When the first teeth are decayed, painful or lost, the 
permanent teeth do not liave the exercise they need, be- 
cause the food is bolted ; that is, swallowed without being 
chewed, or after beiug only partially masticated. And 



24 Peactical, Oeal Hygiene. 

there is another reason why the retention of the first 
teeth is so important : 

^' About the time that the first front teeth are begin- 
ning to loosen, anotlier tooth, the largest and most im- 
porant tooth of all, is pusEIng its way up through the 
gnm, right behind the first 'baby molar,' or double tooth. 
If this last baby tooth or those in front of it, have been 
made narrower than normal, or have been lost altogether 
on account of decay or premature extraction, this big, 
new tooth, which is a permanent one, the sixth from the 
center in front, and coming in at the sixth year of age, 
and not being guided into its proper place and kept there 
by sound first teeth, comes in out of place, too far 
forward. 

'^ Sometimes it is the width of the tooth, sometimes the 
width of the whole tooth, too far toward the front. AA^iat 
difference does that make, some may ask? Isn't the tooth 
there? Will not the other teeth, coming in later, force 
it to its proper place? No; that's just the difference it 
makes; that's just the trouble. 

''When the first big, strong, permanent, most im- 
portant tooth comes in too far forward, the jaw is short- 
ened by just that much, and it remains too short. 

"It is generally supposed that the jaw controlls the 
location of the teeth in what is called the arch; that is, 
the semi-circle in which the teeth are located; but that 
is only another of the many mistakes most people hold 
in regard to the teeth. The jaw does not control the 
teeth, but the teeth control the size and the shape of the 
jaw. 

"Now, into this shortened jaw, in front of the sixth- 
year molar, five permanent teeth must find a place. How 
are they going to do it? Well, most of you have seen 
mouths filled with crowded, jumbled, crooked, overlap- 
ping teeth; and that's how they do it. They come in 
where they can, following the line of least resistance,, 
with nothing to guide them. (*) 



Popular Lectures on Dental Subjects. 25 

"The sixth tooth, the six-year molar, coming as it 
should do and usually does, before the first or temporary 
teeth are lost, is usually regarded as a temporary tooth 
also, and is allowed to decay, even by joarents who mean 
to give their children the best of care, under the mis- 
taken impression that it will soon be replaced by another 
and a permanent one. But it will ne^^er be replaced. 
The six-year molars, and all the other molars, are cut but 
once; once lost they are gone forever. They never will 
be replaced, excejat by artificial substitutes, a very poor 
dependence at best. 

"And this six-year molar is the most important of all 
the teeth. Upon its proper location and preservation 
depends, to a very large degree, the safety, the beauty 
and the usefulness of all the other teeth. 

"When the teeth are all in their proper positions, 
they form a beautiful even curve, the sort of curved line 
that nature delights in ; and the features possess the con- 
tour and balance that make the face so attractive. 

"When the teeth are lost, or all jumbled together, 
the jaws are too small, the lips hang open, and the 
harmony of the face is marred, when not entirely 
destroyed. (*) 

"There is, of course, a much more important phase 
of the subject than mere appearance, although that is 
certainly important enough, often making or marring 
the entire life. The more imj^ortant fact is the use of 
the teeth as they should be used, to conserve health and 
strength of the entire body. 

"When the teeth are all in their proper places, and 
stand at the proper angle with the jaw, the grinding 
surfaces of the upper and lower teeth fit together very 
closely; and, like the mills of the gods, they grind ex- 
ceedingly fine, preparing the food as it ought to be for 
the digestive process that follows. But if one is lost, es- 
pecially if that one be this first permanent molar, the 
grinding surfaces drift apart ; and, if the difficulty is not 



26 Peaotical Okal Hygiexe. 

quickly and sldlfully remedied, the worlv tliat the teeth 
should do, never can be done properly. 

"Then, too, of course, crowded and irregular teeth 
are much more difficult to care for, to keep clean, they 
are much more likely to decay, and the gums are mucli 
more subject to disease. 

"Remember, then, that the tooth coming in at the 
sixth year, the sixth tooth from the center in front, is 
the first of the thirty-two permanent teeth, which, with 
the care that all of the teeth should have, ought to last 
each of us to the end of life. (**) 

"If the child is to have strong, tough, resistant teeth, 
it is essential that its food contain an ample supply of 
the bone-building salts of lime. These salts are essential 
for other purposes as well. When it is known that the 
epidermis or skin, the bones and the teeth are all built 
of the same kind of cells, and that these cells depend 
for their perfection upon salts of lime, the importance of 
this kind of food readily will be recognized. 

"The bottle-fed baby, brought up on the prepared 
foods so abundantly on the market at this time, starts 
life with a ver}'' serious handicap. According to the 
authority of scientific men, who are making these sub- 
jects the study of their lives, these prepared foods, nearly 
all of them, are altogether deficient in the bone-building 
elements. 

"Tlie best substitute for the nursing baby's natural 
food is cow's milk. Don't forget this; don't be deceived 
by alluring advertisements written by men who either do 
not know or care to know what they are talking about. 

"The eruption, or cutting of the deciduous, or tempo- 
rary, or first molars, indicates that the system of the 
child is ready to assimilate solid foods, and if he is given 
really solid foods, and taught to thoroughly masticate 
them, it will be well with that child 

"Every meal should contain something that requires 
good, vigorous chewing; like every other part of the body, 



Popular Lectures o:n Dental Subjects. 27 

tlie teeth, gums and jaws require and are developed by 
exercise, and suffer from lack of it. 

''Among the foods rich in the bone-building phos- 
phates of lime, wheat stands high. But, in the process 
of making fine, white flour, half of the lime-salts are lost 
and withdrawn with the bran. AVhole-wheat liread, while 
usually not so easily digested, is a much better bone- 
builder, and any form of Avhole-wheat, containing every 
particle of the grain as nature makes it, is a perfect food, 
and should be largely used. 

"No bread should be eaten until it is twenty-four 
hours old. Fresh bread, especially that made from fine, 
white flour, forms a soggy, fermenting mass in the sto- 
mach, and is not only very indigestible, but furnishes 
a breeding-place for the germs of fermentation, result- 
ing in sour stomach, colic and many other ills. 

' ' Whole wheat and whole wheat preparations, such as 
shredded-wheat, triscuit, etc., are excellent. Eggs, oat- 
meal, cornmeal, rice, and nearly ail vegetables contain 
the lime-salts essential to bone-building. So, also does 
beef. A simple diet, mixed, composed of the natural 
foods, will contain all of the elements necessary to good 
health and good teeth, provided they are well masticated, 
and i^rovided also that digestion and assimilation are not 
impaired. 

''Experiments made over and over again prove that 
animals fed on poor foods, that is, such as are deficient 
in mineral salts of the kinds necessary to body-building, 
have poor teeth and weak bones ; and that, if such foocls 
are continued, animals will starve to death rather than 
eat it. In this the animals are guided by a sure instinct 
that no amount of 'tasting good' can deceive. 

"Adding the necessary salts to the food artificially 
or giving them in doses as medicines, does not alter the 
case in the least. 

"These experiments and their results a]iply equally 
to the child. If it is unable to obtain a sufficient supply 
of the necessary salts from a mixed diet of natural foods, 



28 Pkactical Oral, Hygiene. 

the use of bone-meal, or the so-called bone-building drugs, 
is likely to prove of no avail. 

"Whatever promotes good health — air, sunshine, nu- 
tritious foods well chewed, hygienic surroundings at all 
times, plenty of sleep, good habits, all these tend toward 
the building up of good, strong, solid, healthy teeth. 

"Good teeth being acquired, good care is necessary in 
order to preserve them during life. If the teeth are not 
good, if they are soft, decay easily, or are lacking in any 
degree, they require even greater care than good teeth. 
With propr care, even poor teeth may be preserved al- 
most indefinitely. "* 

"Until within the last few years dentistry has con- 
cerned itself chiefly with repairing the damage done to 
the teeth by decay, and with replacing them with artificial 
substitutes when too far gone to be saved. 

"To-day the aim of progressive dentistry is to pre- 
vent dental disorders rather than to cure them. 

"To keep the teeth clean, highly polished, free from 
all sharp angles, irritating deposits, fields for the pro- 
duction of pathogenic or disease-breeding germs, or what- 
ever tends to invite disease or promote decay, is the 
most useful field for the exercise of the best skill of the 
progressive dentist. In other words modern dentistry 
aims to put the mouth into h3''gienic condition and keep 
it there. 

"The special method employed to bring about this 
natural, healthy, hygienic condition, and to maintain it 
after it has been brought about, is known as prophylaxis 
— oral propyhlaxis. Oral refers to the mouth; prophy- 
laxis means warding off or preventing disease; or that 
which makes for the preservation of good health. Oral 
prophylaxis then, means treatment that is efficacious in 
the prevention of dental disorders ; of diseases of the 
mouth and the teeth, and of conditions in the oral cavity 
tending to cause diseases in other parts of the body. 

"So important has this preventive idea become in the 
minds of the dental profession that there are now. i,n 



Popular Lectures on Dental Subjects. 29 

many cities, prophylaxis specialists, who devote their 
entire time to the practice of this important branch of 
dentistry. 

■^'The creed: of oral prophjiaxis is that cleanliness is 
the salvation of the teeth; that a clean mouth and clean 
teeth mean a healthy mouth and sound teeth; and, as a 
natural consequence, a bettered, more resistant, physical 
condition generally. 

"Based upon statistics, it is estimated that 72 men, 
women and children die every hour in the United States 
from diseases that might be prevented; and it is now 
known that many of these preventable diseases have their 
origin in an unhygienic condition of the mouth and teeth. 

"The aim of oral prophylaxis is to do its share and 
a large share, in the prevention of this needless loss of 
life ; to bring about a condition of health and well-being 
so far as the mouth and teeth are concerned; to keep 
that part of the digestive tract that is under our control 
in a normal, healthful condition ; and, with the help of 
the patient, to keep it there permanently. 

"How is the patient going to do his share in the work 
of maintaining the health of the oral cavity? Certainly 
not by the ordinary thirty-second-lick-and-promise clean- 
ing indulged in by the vast majority of people who use 
the tooth-brush. 

"In the first place, it must be understood that the 
purpose of the cleaning is not merely to make the front 
teeth fit to be seen, but to make all of the teeth, on all 
of their surfaces, positively clean. And this means in- 
telligent and conscientious effort, regularly and faith- 
fully applied. 

"To properly clean the teeth, begin by rinsing the 
mouth with salt water, about a teaspoonful of salt to a 
pint of water, warm or cold, as may be preferred, forcing- 
it vigorously back and forth between the teeth. Do this 
with the same vigor and determination that you would 
put into doing any thing that you thought would ]^vo- 
long your life, increase its happiness or usefulness, or 



30 Peactical Oeal Hygiene, 

increase your income. It is just as important as proper 
mastication, or as the proper setting of a broken arm. 

''After using the salt water, put a quantity of good 
tooth-powder into the palm of one hand, with the other 
moisten a good tooth-brush with the salt water, and dip 
it into the powder. Then proceed to scoue the teeth. 

''Use the tooth-brush as you would a scrubbing-brush 
on your kitchen floor or in your bath tub. Scrub your 
teeth; do not be satisfied merely to brush lightly over 
the surfaces. 

"Do not use the brush crosswise of the teeth. You 
will only touch the high surfaces that are naturally elean^ 
anyhow, and you may work great injury by sawing cavi- 
ties in the teeth above the enamel, at the gum-line. 

"Begin at the gums on the upper jaw and brush 
downward ; begin at the gums on the lower jaw and brush 
upward; inside and outside alike. As the inside or the 
tongue side of the teeth is harder to reach with the brush 
than the outside, more time and care are necessary to get 
them clean and keep them clean. As a lamentable matter 
of fact, it must be said that because they are not seen 
they usually get much less care. Ignorance on this score 
is much to he lamented. A wealthy, prosperous and suc- 
cessful man of sixty, recently stated that until he was 
well past fifty, he never had tried to clean the insides of 
the teeth, thinking that they did not need any care at all. 

"Scour the grinding surfaces back and forth, cross- 
wise. Dip the brush into the powder often enough to 
apply it equally to all of the teeth, and remember that 
the surfaces that are the hardest to reach need cleaning 
most. 

"Make the cleaning of the teeth as necessary to your 
comfort as the bath, or the washing of the hands and 
face. It is far more important. Take plenty of time. 
Ten to fifteen minutes per day is none too much time to 
spend at this most important Avork; make work of it; 
make it a duty. The teetli should have three to five 
cleanings each day, in addition to the thorough scrubbing- 



POPULAK LeCTUEES OlST DeNTAL SUBJECTS. 31 

described. Eemember, that the mouth is a veritable 
breediug-grouud for disease-germs, and that they mnlti- 
-plj with astonishing rapidity if undisturbed, while the 
raking and scraping given to them by the pro^Der use of 
the brush, to say nothing of the frequent dosing with 
disinfectant germicides in the shape of tooth-powders 
and mouth-washes, prevent their increase almost wholly. 

''Two or more tooth-brushes should be used, of a 
rather small or medium size, preferably those with 
wedge-shaped points on the rows of bristles, as the points 
work in between the teeth, where most care is necessary. 
Use your brushes alternately, so that they will have a 
chance to dry out before being used again. Never buy 
a cheap brush. And never use a brush, no matter how 
much you pay for it, after the bristles begin to fall out. 
An over-used, soft brush, is the poorest kind of economy. 
After using the brush, rinse it thoroughly in the salt- 
water and hang it on the rack to dry. Any good mouth- 
wash will do in |)lace of the salt-water. Powder need 
be used in most mouths but once each day, preferably 
at bed-time, if used as suggested. 

"A larger proportion of the cavities in teeth start 
between them, where the brush, however skilfully used, 
cannot reach. To thoroughly clean these spaces is, there- 
fore, of utmost importance. For this, waxed floss silk, 
preferably flat, should be used. Insert between the teeth, 
and draw back and forth until all these surfaces are per- 
fectly clean. Do this at least twice each day; better, do 
it after each meal. 

"Be careful in the selection and use of tooth-picks. 
If wood is used, select those of some wood of dense close 
grain, that does not splinter, such as orange-wood. The 
end of the i3ick used between the teeth should be flat. 
Picks are made of special woods and rendered antiseptic 
b}" being treated with aromatic solutions which aid in the 
preservation of the health of the spaces between the 
teeth. Be careful not to puncture or irritate the gums-, 
when picking the teeth. 



32 Peacticajl Oral Hygiene. 

"It is no easy matter to teach the children to keep 
their teeth clean, but the necessity of the case makes it 
the duty of every parent to keep constantly at their child- 
ren until the habit becomes fixed. 

"In spite of the best care we are able to give our 
teeth, deposits will slowly form on them in most mouths, 
and there will still be some decay. Therefore, it is neces- 
sary to visit the dentist at regular intervals. The fre- 
quency of these visits should be governed by the needs 
of the individual, and this should be left to the knowl- 
edge and judgment of the dentist. In very few cases 
should these visits be less frequent than twice each year. 

"As to why teeth decay, an illustration may help to 
make the cause and process clear. If a drop, of acid is 
spilled upon the marbel top of a wash-stand, it boils and 
bubbles, and, if allowed to remain, will dissolve out the 
lime and leave the surface roughened. Nearly everybody 
is familiar with the experiment of soaking an egg in vine- 
gar until the lime in the shell has been dissolved, and 
the egg, unbroken, then put into a bottle, having a neck 
half the normal size of the egg. Decay of a tooth is 
caused by a similar process of dissolving the lime. 

"The lime in the tooth is eaten by an acid. This 
•acid is known as lactic acid, familiar to nearly everyone. 
It is the acid present in sour milk. Its presence in the 
mouth is due to the fermentation or souring of food par- 
ticles adhering to and between the teeth. 

"In the mouth that is not cared for, the teeth are 
bathed in this acid practical^ all of the time, and all 
the time the acid is at work, dissolving out the lime-salts 
in the teeth, ji^st as the acids do with the marble slab 
and the egg shell. This shows why teeth start to decay 
at the points that are hardest to keep clean. It also 
shows why extra care should be taken to keep those points 
as clean as possible. Decay rarely starts on the exposed 
surfaces of a tooth. 

"Now, as to the structure of a tooth. A tooth con- 
sists of the crown (the part above the gum), and one or 



POPULAK LeCTUKES ON DeNTAL SUBJECTS. 33 

more roots embedded in the jaw. The outer coatiDg of 
the tooth, the part that we see, is called the enamel. It 
is nearly all lime-salts, 98 per cent. It is very hard, very 
compact, comparatively thin, and has no nerves; there- 
fore, it is without feeling. Its purpose is to stand the 
wear of grinding, and to protect the softer, sensitive 
parts of the tooth beneath. (***) 

"Beneath the enamel is the dentine. It forms the 
bulk of the tooth. It is only about three-quarters, 75 
per cent, lime, and is, of course, not so hard as the 
enamel. It is something like bone, having tubes and hol- 
low jDlaces, within it, along which the germs of decay 
can spread and multiply without much resistance. 

"In the center of the tooth, surrounded by the den- 
tine is the pulp, commonly but improperly called the 
nerve. It has a great many exceedingly fine, thread-like 
branches outwardly through the dentine, forming a very 
complete signal-service, the duty of which is to warn 
us when danger from decay or other source threatens 
the health and usefulness of the tooth. 

"A tooth that aches, after one has been eating, for 
instance, is a tooth in distress. Some of the little pulp- 
branches are exposed and are calling for protection. If 
they do not get it, the pulp itself will be calling next, 
and by that time the chances are that the labor, pain and 
expense of saving the tooth have been increased mnnv 
fold. 

"Here is a case in which a stitch in time may save 
not only a great deal of suffering, but, by a simple, inex- 
pensive filling, the tooth may be saved to usefulness and 
comfort. If, on the other hand, the warning is not heeded, 
the pulp, after protesting with all its might with some 
pretty severe aches and pains commonly called neuralgia 
and other things, gives up the fight and dies. Because 
the pain is felt not so much in that particular tooth 
as all over the face on that side, the tooth may not be 
suspected, and frequently physician's bills of large size 
are contracted in the vain search for relief. 



34 Peactical Okal Hygiene. 

'^ Facial neuralgia, so-called, of this character and 
from this cause, is very common. Facial neuralgia from 
all other causes combined is very, very rare. Therefore, 
when suffering from neuralgia in the face, suspect your 
teeth, and at once consult the dentist. 

"It is a common notion that a tooth having a dead 
nerve or pulp can ache no more. This is a delusion. A 
dead tooth, like any other unburied dead thing, is dan- 
gerous, a menace to the health not only of the mouth, 
but of the entire body. It is a breeder of poisonous 
germs. If these poisons escape into the mouth, they are 
mixed with the food and the saliva and swallowed. And, 
in the case of mouth-breathers especially, the foul gases 
created are carried to the lungs and thence to the blood, 
paving the way for tuberculosis and a general undermin- 
ing of the health. 

"To one who knows how vile a dead pulp becomes, 
the very thought of having one in the mouth makes 
him sick. And how, are we to have pure air in our homes, 
our schools, our opera-houses, our churches, when, with 
every breath from such a mouth, these poisons are poured 
into the atmosi^here? As a matter of simple self-pro- 
tection, we should avoid inhaling the breath from such 
a mouth. 

"If, instead of escaping into the mouth, the poison- 
ous gases get out through the end of the root, the tooth 
becomes sore, the face swells, pus is formed and bores 
its way, usually with great pain, out through the jaw- 
bone and gum, forming the so-called gum-boil. This pus. 
is also a poison, a dead thing; and this, too, is swallowed, 
making a much more serious condition than generally is 
known, or may generally be believed. No one can long- 
be well under such a state of affairs, a veritable poison 
factory within the mouth. 

"Many people are constantly ill, constantly under the 
care of the physician, doctoring for all sorts of troubles, 
who are simply the victims of blood-poisoning, due tO' 



POPULAK LeCTUKES ON DeNTAL SUBJECTS. 35 

neglected teeth. Tlie troubles commonly calld 'nervous 
diseases' are largely due to these causes. 

"Every year thousands of preventable deaths occur 
from causes originating in the condition described, al- 
though very seldom is the true condition suspected by 
anybody — except the dentist. He doesn't suspect; he 
knows. 

''Offensive as is a tooth of this character and in this 
condition, and dangerous as it is to health, and life itself,, 
it may be restored to full usefulness, health and comfort. 
While it is very desirable to have the teeth frequently 
examined and all the cavities filled while small, a tooth 
is not beyond redemption and salvation even when noth- 
ing is left of it except the root, providing that root is 
firmly held in its socket. A root broken off level with 
the gums may be crowned so skilfully as to appear per- 
fectly natural and defy detection, and it may be so ap- 
plied as to be as comfortable, as serviceable, and, in many 
cases more lasting, than a well-cared-for natural tooth, 
that is perfectly sound. 

"Another disease to which neglected teeth are sub- 
ject, is loosening, due to deposits of lime in the form of 
tartar, and to collections of decaying matter, which are 
allowed to gather and remain on them. This causes the 
gums to swell, to become tender, to bleed easily, and 
gradually to waste away, together with the bony socket 
that holds the teeth in place. 

"This is a very serious condition, not only preventing 
the proper chewing of the food, because of the tenderness 
of the teeth and gmms, but the teeth themselves become 
exceedingly filthy, and in mam^ cases large quantities 
of very rank pus are being continually swallowed, the 
health being thus most surely and certainly undermined 
by the two enemies, which ably aid and abet each other, 
one by preventing proper preparations of the food by the 
teeth, and the other by converting much of it into rank 
poison. 



36 Pkactical Oral Hygiene. 

"If this trouble is attended to in its early stages, it 
may be removed and the loose teeth tightened and re- 
stored to perfect usefulness; but if neglected, the teeth 
finally will fall out, ending the chapter in disaster. 

"Here, again absolute cleanliness is the great pre- 
ventive. Teeth that are kept clean cannot possibly get 
into this distressing and often fatal condition. Here 
again, dirt, decay, degeneracy and death go hand in hand 
together. 

"This disease, in common with most of those to which 
human flesh is heir, is much more easily prevented than 
cured. Those who are threatened with it or suspect that 
they are, should lose no time in putting themselves under 
the care of a competent dentist, and then follow re- 
ligiously and rigorously the instructions given. 

"The expression, 'My teeth are naturally so poor 
that I am going to let them go and have artificial ones,' 
is very often heard from the lips of even comparatively 
3^oung people ; and, while it implies a compliment to the 
skill of the modern plate-maker, the thought back of it 
is usually a very unwise one to entertain, and the course 
a most foolish and unsatisfactory one to pursue. It is 
hard to imagine a set of natural teeth that are not or 
cannot be made much more useful, satisfactory, sanitary 
and comfortable than the best plate ever turned out of 
a dental laboratory. This attitude has been responsible 
for the heedless loss of millions upon millions of per- 
fectly sound teeth. It has come down to us from the 
days of our grandmothers; and while, in those days it 
may have been justifiable, in these days of advancement 
in dental science and practice, it is so no longer, except 
in very rare and exceptional cases. 

"If the teeth really are too far gone to be saved, the 
sooner they are out and replaced the better ; for, as stated 
a mouth full of decayed and decaying teeth and roots is 
a menace not only to health, but to life itself. But let no 
one needlessly sacrifice his own teeth for artificial sub- 
stitutes. Good as they are now, most necessary in their 



PopuLAK Lectures on Dental Subjects. 37 

place, and much as many of us owe to the advancement 
in dentistry during these last few years, they are but 
poor substitutes at best. 

^'You will be perfectly safe in trusting the judgment 
of a good dentist in such cases. The time has gone for- 
ever when a dentist would extract a tooth that might be 
saved, merely to satisfy the whim of a patient. Preser- 
vation and restoration of the natural teeth is the proper 
field for the exercise of dental skill ; and few indeed, and 
daily growing beautifully fewer, are the dentists who do 
not recognize this fact, and conduct their practice 
accordingl3\ 

''Another cause of poor teeth, crowded teeth, mal- 
formed jaws and unbalanced faces, with ill health and 
all the attendant train of suffering and inefficiency, is 
mouth breathing, due to a growth in the nose called 
adenoids. This is quite common in childhood, and is very 
easily remedied; but, if neglected, means a weakened, 
impoverished body, subject to coughs and colds, throat 
and lung troubles leading on to tuberculosis. Time will 
not permit going into this important topic' in detail, l)ut 
it is the duty of parents to watch their children, partic^^ 
larly while sleeping; and, if mouth-breathing is found to 
prevail, to consult a physician at once. 

"Sucking thumbs and fingers in early childhood, the 
use of 'baby comforters,' rubber nipples or other objects 
held between the teeth, often produces serious deformi- 
ties of the growing jaws, and should be avoided with 
far greater assiduity than contagion from the simple dis- 
eases of childhood. (****) 

"Just a few words in conclusion: 

"Don't forget that the first teeth are just as impor- 
tant while they last, as the second teeth, if not more so, 
for the position, soundness and value of the permanent 
teeth depend, very largely, upon the care that the first 
teeth receive. 

"Don't forget the number of the first teeth; twenty 



38 ' Peactical Oral HrGiEisrE. 

in all, ten in the upper jaw, ten in the lower jaw, five on 
either side in both jaws. 

"Don't forget that the sixth tooth, the six-year molar, 
is a permanent tooth, and is the largest and most im- 
portant tooth in the entire set. 

"Don't forget that clean teeth do not decay; that a 
clean tooth cannot decay; and therefore, always remem- 
her to make ever^^ effort to keep the teeth clean — all 
of them, on all their surfaces, all the time. 

"Don't forget that clean teeth, well cared for, and 
food well chewed, are essential to good health, a sound 
hocl}^ and a strong mind. 

"And do not forget that you are quite welcome to 
ask any questions on the subjects mentioned, if every- 
thing that has been said it not perfectly plain, simple 
and clear to you." 

Stars (**) indicate the advisability of introducing 
slides at points where they appear ; or the slides may be 
left until after the lecture is concluded. 

outlijste lectures. 

Dr. A. H. Stevenson published in Oral Hygiene, this 
outline lecture, used by the Committee on Public Health 
and Education of the Second District Dental Society 
of New York. 

"In order to obtain uniform results, we prepared 
lecture outline forms to cover our most common tyjDes 
of audiences. Three of these I append. They are merely 
guides for the lecturer, and give him ample opportunity 
for originality, as may be seen. 

FORM 1. LECTURE OUTLINE FOR MOTHERS' CLUBS. 

"The following points seem to be the ones that need 
the most emphasis : 

"1. Show that the responsibility for the general 
healtli of tlio child depends mainly upon the mother, and 



Popular Lectures on Dental Subjects. 39 

that she should have somid ideas of how to conserve the 
child's health. 

''2. Bring out the influence that sound, clean teeth 
have upon the general health of the child. 

''(a) Show how diseased and unclean teeth play a 
large part in the causation of disease. That the main 
method of infection in the following diseases is the dis- 
charges of the mouth: Tuberculosis, pneumonia, influ- 
enza, la grii^pe, diphtheria, measles, scarlet fever, 
mumps, etc. 

''(b) Show that lack of or decay of the teeth cause 
mal-nutrition, mouth-breathing, adenoids. 

''(c) Show how the pain of diseased teeth may be 
reflected and cause disturbances in the eye, ear, face, 
neck, head and other parts of the body. 

"3. Show how the temporary teeth develop and then 
the permanent ones. (Use charts.) 

"4. Show the importance of preserving both. 

"5. Lay particular emphasis on the six-year molar. 

"6. Conclude with general mouth hygiene as follows: 

''Articles required: Brush — Size, shape and bristles. 
Floss — How to use. Dentifrice — Warning and advice. 

"Method of brushing. Time — Every time the teeth 
are unclean. Tell something about the removal of tartar. 

"X. B. — Use simple language and avoid technical 
terms. At the close of the talk invite the mothers to ask 
questions. Eemember as many of the questions as pos- 
sible and mail them with any suggestions to the 
committee. 

"form 2. OUTLINE OF TWENTY-FIVE MINUTE 
TALK TO CHILDREN. 

"1. (For boys.) Show how success in sports and life 
depends upon good health. 

"(For girls.) Show how success in singing, reciting 
or any public appearance depends upon good health. 

"Show that good health is impossible without clean 
mouths and good teeth. 



40 Peactical Oeal Hygiene. 

"2. Explain the relation of sound, clean, temporary 
teetli to health. Explain the relation of sound, clean, 
permanent teeth to strength, endurance, grace, beauty 
and class-standing. 

"3. State briefly how decay is produced and it ex- 
tends, using illustrations if possible. 

^'4. Emphasize the importance of ]3reserving the 
temporary teeth, and the six year molar. 

"Introduce the phrase 'A clean tooth never decays.' 

"Have children repeat it in unison. 

"5. Conclude with general mouth hygiene as follows: 

"Articles required: Brush — Size and shape, bristles. 
Floss — How to use. Dentifrice — Warning and advice. 

"Method of brushing. Time — Every time the teeth 
are unclean. Tell something about the removal of tartar. 
jST. B. — ^As above. 

"rOEM 3. LECTUEE OUTLINE FOE NUESES (aND PHYSICIANS.) 

"Preface with remarks showing the sphere of pre- 
ventative medicine, and as a part of same the impor- 
tance of the oral hygiene crusade; indicating its scope 
value and application. Emphasize the necessity of the 
co-operation of the nurses (and physicians) to bring 
about its aim. 

"The following points seem to be the ones that need 
the most emphasis : 

"1. Show how unclean mouths are ideal mediums for 
the proliferation of bacteria. Indicate the following as 
diseases whose main means of infection is the discharges 
of the mouth: Tuberculosis, pneumonia, influenza, la 
grippe, diphtheria, measles, mumps, etc. (Quote authori- 
ties, as per Form 3a.) 

"Show how lack of or impairment of the teeth cause 
malnutrition, mouth breathing, adenoids. 

"2. Give brief histology and development of the 
teeth, temporary and permanent, showing how calcifica- 
tion proceeds and dietetic influences. (Use charts.) 



PopuLAE Lectures ox Dental Subjects. 41 

"3. Show prevalence and nature of dental caries as a 
disease itself, and conditions favorable for its inception 
and increase. Show how reflexly disorders of the eye, 
ear and brain may result. 

''4. Give general mouth hygiene for normal condi- 
tions indicating: 

''Articles required: Brush — Size and shape. Floss — 
How to use. Dentifrice — Warning and advice. 

"Method of brushing. Time — Every time the teeth 
are unclean. Mention the formation and removal of 
tartar. 

"d. Give the application of the hygiene by nurses, 
emphasizing : 

"(a) The preparation of patients for operations. 

" (b) The care of the mouth during pregnancy. (Eead 
article in Vol. I, No. 2, Oral Hygiene.) 

" (c) The care of the mouths of children. 

"(d) The care of the mouths of invalids and con- 
valescents. 

"6. Conclude with the importance of strict oral clean- 
liness on the part of the nurses, as a safegiiard against 
infection for themselves and for those for whom they 
care. 

"N.B.— As above. 

"form 3a. lecture OUTLIiSTE FOE XUESES AXD PHYSICLAXS. 

NOTES. 

" 'From a hygienic standpoint the secretions of the 
mouth constitute the chief, if not the only, source of 
respiratory infection.' — Dr. TVadsworth of the ]\[edical 
Commission for the investigation of Acute Eespiratory 
Diseases, N. Y. Dept. Health. 

" 'Each patient should be furnished with a new tooth- 
brush and a bottle of antiseptic mouth wash, and the 
nurse instructed to cleanse the mouth every 2 or 3 hours, 
prior to a surgical operation.' — ^Foynahan. 



42 Peactic.\l Oeal Hygiexe. 

a 'Three patients (two men, one woman) died from 
tuberculosis. In eacli of these three cases the contribu- 
ting cause was a decayed or impacted third molar tooth. ' 
— M. Dubois, Chief of Clinics at the Ecole Odonto, Tech- 
nique. Paris, France, from Mevnue Generale de L'Art 
Dentaire. 

" 'Several cases of tonsilar inflammation are caused 
by the focus of infection in the mucous membrane near 
a decayed third molar tooth. Also persistent throat 
inflammation and tonsilitis is caused by the infection 
from decayed or diseased teeth.' — F. Le Maire, Paris, 
France, in the Odontologue. 

'• 'Many cases of chronic lacuna tonsilitis have arisen 
from, and are continued because of neglected teeth and 
gums. Chronic laryngeal catarrhs ma}- be continued by, 
if not originated by, diseased conditions of the teeth and 
gTims.' — Wyatt Wingrave, M. D., Durham, Eng., in the 
London Lancet. 

" 'Measles, German measles, chicken-pox, whooping 
cough, mumps, scarlet fever, or scarletina, diphtheria, 
influenza and small-pox, all have for their method of in- 
fection either the discharges of the mouth, nose, or par- 
ticles of the skin, and the most fertile soil and the most 
prolific breeding ground; and the best harbor and the 
never failing spring for the germs of all these diseases 
are filthy and decayed teeth.' — A Brown Ritchie, medi- 
cal officer to the Education Committee of the City of 
Manchester, Eng., in Allen's Civics and Health. 

" 'Out of 684 sarcomas in different regions of the 
body, 309 of these were either on the lower lip, upper 
lip, tongue, mucus membrane of the soft and hard palate. 
One very frequent cause of these maligTiant tumors is 
the constant irritation of a sharp edge of a decayed 
tooth.'— Woods Hutchinson, A.M., M. D. 

" 'Ninety per cent, of all the destructive diseases of 
the upper and lower jaw bones have for their chief and 
almost their sole cause, dental alveola abscesses (and 90 
per cent, of the dental alveola abscesses are caused by 



PopuLAK Lectures ox Dextal Subjects. 43 

decayed teeth). Persistent lieadaclies and general reduc- 
tion in health are frequently caused by insiduous aveola 
abscesses.' — Stewart L. McCurdy, M. D. (Section of 
Stomatology, A.M. A.). The value of our most recent 
efforts in the training schools for nurses is self-evident. 
These nurses, heretofore uninstructed on the subject, be- 
come active agents of the campaign. 

''OUTLIISrE OF SHORT TALK TO KINDERGARTEIsr CHILDREN. 

"Open talk with either story or demonstration to 
attract attention, and then proceed with the following: 

"1. Describe graphically the doorway and vestibule 
of a house, and the effect on the interior of that house, 
be it ever so neat and clean, of a dirty entrance with 
children passing in. 

"2. Show the analogy of the mouth as the doorway 
and vestibule of the body, and the effect on the interior 
of the body of an unclean mouth with food passing 
through and carr^dng filth into the stomach. 

"Eesults: Disease and illness; loss of play and 
school. 

"3. Ask how many children washed their faces before 
coming to school. (Usually unanimous.) Then show the 
importance of cleaning the 'inside of the face,' in order 
to be clean and well. 

"4:. Very briefly, with a large model, if possible, show 
the alignment of the teeth. Tell the necessity of keeping 
them clean to prevent 'holes' and pain. 

"5. Conclude with simple mouth hygiene, demonstrat- 
ing with giant tooth-brush on model, and emphasize the 
frequency of this operation and the use of a dentifrice." 



CHAPTER IV. 

POPULAR LECTURES— CONTINUED. 

ax illusteated lectuee, zaeboxjgh. lectuee eoe school 

childeek: eeom foueth to eighth geade, coeley. 
lectuee eoe school childeen", hunt. 

If it is convenient to obtain the lantern and proper 
slides, the following lecture hy Dr. L. L. Zarbongh, can be 
used to advantage. The cuts suggested are easily made 
and show to good advantage. While the article was 
written on the subject of "Moving Pictures in Dentistry," 
I have moved it around a little so that it will fit the 
subject of "Outline Lectures in Dentistry." 

"Open with a home scene, showing family group, 
children playing or reading, mother sewing or darning, 
father reading the evening paper. He reads an article, 
^The time to begin to care for teeth is in childhood,' etc. 
Father calls mother's attention to the article, which is 
then shown on the screen. They then look at the child- 
ren's teeth, and decide then and there to instruct the 
children in the care of their teeth, 

"Next is shown a dental nurse or dentist instructing 
the children in the proper manner of caring for the teeth, 
the use of dental floss, the folly of blunt wood tooth-picks,, 
etc., the correct method of brushing the teeth, etc. 

"Then follow with a short, 'cute' picture of 'ihe baby'' 
brushing his teeth, as the dentist has directed. 

"Other subjects will be the interior of a school-room,, 
showing the examination of school children's teeth, show- 
ing that the instruments are sterilized after each child — a 
near view of just how it is done; also showing a near 
view of 20 boys and girls, showing only the mouth and 
teeth, and pointing out the decayed teeth in each mouth 
and other defects as they exist. 

"Show the number of percentage of 20 children need- 
ing dental services. It should be vivid and convincing, 



Popular Lectures oi^ Dental, Subjects. 45 

and will go a loug way towards removing the prejudice 
existing in tlie minds of many members of school boards 
and teachers against it. This part of the lecture will 
awaken such an interest on the part of the public* that 
they will demand the examination of school children's 
teeth— the very thing we are striving for; and the best 
way to get into the schools is to create an interest in the 
public mind, which will soon grow into a demand. 

"Then show a near view of an unhealthy mouth, loose 
teeth, tartar, pus, etc. Move the loose teeth with an 
instrument; show the ruin that neglect will cause in a 
mouth; then show this same mouth as it will appear a 
short time later, unless cared for, as barren of teeth as 
the mouth of a new baby. 

"Next show the progress of decay, by picture or black- 
board illustration, in a tooth from the ver}' start until 
the death of the dental pulp, the breaking down of the 
enamel, etc. This will be done mechanically; the decay 
will be seen moving towards the pulp; the period or time 
at which the tooth begins to ache will be pointed out, 
etc. Some of the text, no doubt, will be along the follow- 
ing lines : 

"Fig. 1. Uncared for teeth, showing food particles, 
which, fermenting, form acid. 

"Fig. 2. Showing the acid attacking the lime in the 
enamel rods. 

"Fig. 3. Showing decay attacking dentine. 

"Fig. 4. Showing further progress of decay; tootli 
begins to ache. 

"Fig. 5. Showing undermining and breaking down of 
enamel walls, exposing largo cavity whicli has been form- 
ing, unsuspected, for months. 

"Fig. 6. Showing death of dental pulp, formation of 
gas, pus, etc., in jDulp chamber; escape of gas at apex, 
swelling, abscess, etc. 

"It has been suggested that inasmuch as we show tlie 
death of the pulp, for a change, and to give the people 
a chance to relax a little, we show the funeral of a dental 



46 



Peactical Oeal Hygiene. 





SHOW/NO FOOD PARTICLES, WHICH FERMENT/NGMMAUO Jao /imcH/NC THE LIME IN THE ENAMEL rods 





SHOWING DEC A YATTA CK/NG DENTINE /i/rflierPro^rej^of Decay - Tooth de£ms ToAc/?e_ 



UNDERMINING AND BREAKING DOWN "^^ EMMEl MllS OEATNOEDE/mL Pl/LP OR NERVT 





Exposing Lar^eCdnl/ which hai been forminjiUnsuspeckd, lor Months, fbrmafion oT PUS snd G^S in Pu/pLhdmber 

Fig. 4. Showing the Various Steps in Tooth Decay. 



PopuLAK Lectures on Dental Subjects. 47 

pulp, witli the owner of tlie tootli as chief mourner. 
Worked up properly it would be very funny and make 
the people in the theatre wonder just how long they will 
dare to wait before they, too, will have a funeral of their 
own. 





Showing' growth and multiplicafion of 

Fig. 5. Showing the Steps in Tooth Decay. 

^ ' Fig. 7. A badly decayed molar, showing the growth 
of bacteria in such a tootli in 24 hours. The multiplica- 
tion of germs also will be shown in motion and will teach 
such a lesson that anyone seeing it, who has a deeayed 
tooth, will not go to bed without making some elTort to 
clean it up. When we consider the appalling rapidity 
Avitli which bacteria multiply we can realize how inter- 
esting this picture is sure to be. According to Conn, 
professor of biology at Wesleyan University, *^it is the 
power of multiplication by division tliat manes bacteria 
so significant. This power of growth is almost incredible. 
Some species divide every 30 minutes, or even less. At 
this rate each bacterium would produce, in a single day, 
more than 16,500,000 descendants; in two davs about 
281,500,000,000, or about one solid pint. At tlie end of 
the third day, unless checked, the product of one original 
bacterium would weigh about 16,000,000 pounds. Of 



48 Peactical Oeal Hygiejste. 

course, this growtli is on\j theoretical, as iiucler no con- 
ceivable bodily conditions could it go on unchecked." 

"Tell about a boy ivho ivoulcl not clean Ms teeth; show 
him going to bed with the toothache (making a striking- 
example of him), show the usual fuss, hot water bottles, 
etc.; then show a dream that he has while in bed; he 
dreams of a trip to the dentist, as he supposed it would 
be. Very funny, of course, yet so arranged as not to 
bring criticism on the profession or detract from the real 
purpose of the lecture. Then after the night-mare, a 
trip to the dentist as it really ivas; show him treated 
kindly and relieved of his suffering, etc. State that fear 
and ignorance cause more pain and keep more people 
from visiting the dentist than any other one thing. 

"Next tell the good resulting from care of the teeth; 
show a healthy mouth from childhood to old age; show 
teeth without a blemish, every one sound, without even 
a filling. This, too, will teach a great lesson and make 
a lasting impression," 

LECTUKE FOR SCHOOL CHILDREjST FEOM FOURTH TO , 
EIGHTH GRADE. 

Compiled by J. P. Corley, M. D., D. D. S., Sewaiiee, Tenn. 
Star (■■■■) indicates the advisability of introducing slides at points 
Avhere they ajipear; or the slides may be left until after the lecture is 
concluded. 

We have a great many good things in this life, but 
the greatest possession of all is good health. Health is 
more important to children than to grown up people, be- 
cause if one is not well while he is growing, he will not 
have a strong vigorous body when he becomes grown up, 
and he will be more apt to have all kinds of diseases 
during the rest of his life. 

Clean, wholesome, well-prepared food has more to do 
with the health of a child than any other one thing. If 
food is clean and wholesome, but is taken through a 
mouth which is unclean and unwholesome, it will not be 
clean and wholesome when it gees into the stomach. 



PopiTLAE Lectures ox Dextal Subjects. 49 

(*) This first picture shows a man with his front cut 
away, sliowing the canal through which the food passes 
into and out of the body. The large hole which we see 
at the top of the canal is the mouth. If the food is clean 
and the mouth is clean our stomachs will get clean food, 
but if the mouth is filthy, the food will surely be made 
filthy before it is swallowed. A great many germs, such 
as diphtheria, scarlet fever, typhoid fever, and tubercu- 
losis, are frequently found in mouths which are habitually 
unclean and full of decayed teeth. 

Some times, after a person gets well of a disease, he 
will carry the germs of this disease in his decayed teeth, 
and by spitting, and various other ways, give the disease 
to other people. 

(*) This is a toothless pair. Old ''Mammy" has lost 
all her teeth and the "baby child" has not gotten hers; 
at least, we can't see them, but if she should scald her 
little mouth bad enough for the gums to come off, we 
would see a row of sacks just under where the teeth will 
peep through when they come into the mouth. 

(*) Just inside of this row of sacks there is another 
row of smaller sacks. If we should slit open one of these 
sacks what do you think we would find? The top of a 
beautiful little tooth like a bulb, which in the spring time 
peeps up through the ground and opens into a beautiful 
flower. This tooth is pretty and clean and hasn't a de- 
cayed spot about it, and if it is kept clean as long as it 
remains in the mouth, it will never decay. The baby 
ought not to suck her thumb or keep a pacifier in her 
mouth all day, because this will mash these little sacks 
out of place and will make her teeth crooked. (*) It will 
also change the shape of the soft bones of the front of 
the face and make her little nose turn up like this.(*). 
So, if you don't want the baby's nose to turn up, you had 
better tell your mother not to let her suck her thumb. 

(*) The picture on the left shows the upper part of 
the mouth of a child two and a half or three years old, 
with all the first set of teetli in jilace. You see that they 



50 Peactical Oral Hygiene. 

are all sound and regularlj' arranged. Tliere is never a 
crooked or misplaced tooth in the first set, but there are 
frequently mis-placed teeth in the second set. The most 
common cause is that the mouth and jaws have not grown 
large enough for the second set. Chewing is w^hat makes 
the jaws grow, so if your teeth are crowded and crooked, 
it is because you didn't chew with your first set. Some- 
times, as we will see in a moment, other things keep the 
jaws from growing and mis-place the tooth, but the lack 
of chewing is the main cause. The picture on the right 
shows the same case at about six years old. It has 
another group of teeth. They belong to the second or 
permanent set. If you lose these you will never get 
others to take their places. They are called the sixth- 
year molars, and are the largest and most useful teeth 
in the mouth. They are more frequently decayed than 
any others for the reason that boys and girls at six to 
nine years don't usuall}" keep their teeth clean. The 
mother usually thinks these teeth are part of the first 
set, and thinks it does not make much difference if they 
are lost, but we will have more to say about these teeth 
in a moment. You will notice that one of the front teeth 
is missing. Do you suppose the dentist had to pull this 
tooth because it ached? No. 

(*) It just dropped out and ''didn't hurt a bit." I 
am going to show you why it dropped out. 

(*) In this picture the bone has been cut away from 
the roots of the temporary teeth and we find that just 
above each little temporary tooth there is a big perma- 
nent one. The permanent tooth comes down upon the 
end of the temporary tooth and nibbles it off as a mouse 
nibbles cheese, so that by the time the permanent tooth 
gets ready to come into the mouth the temporary tooth 
has lost its root and drops out. But I am going to tell 
you something which I want 3^ou to tell your mothers. If 
the temporary tooth is allowed to decay until it aches, 
the permanent one will stop nibbling and you will have 
to 0:0 to i]\o dentist and have him grind it down to the 



PopuLAK Lectures ox Dental Subjects. 51 

gums so that the new tooth can pnsh it like yon would 
drive one nail out with another. This is one reason why 
the temporary teeth should be kept clean and free from 
decay. Another reason is that you can't chew so well 
if your temporary teeth are decayed. Your jaws will not 
grow and be large enough for the permanent teeth, and 
you will suffer from indigestion and its consequences. 
It will also be impossible to keep 3^our mouth free from 
germs and the new teeth will decay as soon as they 
come in. 

(*) When one is four years old the teeth are close 
together, but if the jaws are properly used in chewing, 
they begin to separate as the jaws grow, so that by the 
time one is six years old, the teeth do not stand apart 
as they do in this picture. 

(*) The dentist should put in a little appliance to 
spread the arch, otherwise the |)ermanent teeth will be 
crowded. 

(*) This man didn't chew his food when he was a boy. 
I guess he just gobbled it up with both hands like this — 
(Illustration), so his mouth didn't grow and his teeth 
were all awry. His mouth and face didn't grow either, 
so he had a big head and a little pinched face. 

(*) This man chewed his food when he was a boy, 
and when he grew to be sevent^^-five years old, he had all 
his teeth and was a good-looking, hearty old man. I 
guess he just chewed and chewed and chewed, until the 
food just swallowed itself. You needn't bother about 
swallowing your food. After it has been sufficiently 
ground, it will slip down without any effort. 

(*) This is the lower set, and they are just as fine 
as the upper. Those dark lines which you see marking 
the tops of the back tooth are grooves, which divide the 
top or grinding surface of the tooth into points and de- 
pressions. By this arrangement the free surface of the 
tooth is increased and its unevenliness makes it a much 
more efficient grinder, 

(*') This is the same case with the teeth brought to- 



52 Peagtical Oeal, Hygiene. 

getlier, Xotice liow beautifully they fit, and also that each 
upper tooth touches two lower ones. Which one of these 
teeth could one atford to lose? 

If you should saw through a front tooth and through 
the gum and bone to the end of the root, you would find 
that the tooth is made up of four different substances. 
The one which covers the top is enamel, and it is the 
hardest organic substance in the world except diamond. 
The next substance which makes up the bulk of the tooth 
is dentine, which is not so hard and wears and decays 
more rapidly. Encasing the root is a still softer sub- 
stance called cementum. Occupying a canal in the center 
of the tooth is the pulp, which is composed of blood ves- 
sels and nerves. When decay makes a hole through the 
enamel and dentine into this pulp, the tooth begins to 
ache. Surrounding the root and attaching it to the gum 
and bone, is a thin membrane — the peri-cementum. If 
you allow tartar to accumulate on the teeth and remain 
for a long time, it will destroy this membrane and the 
tooth will loosen and drop out. Teeth are lost mainly 
in two ways — by decay, which destroys their crowns, and 
by disease of the gums and destruction of the peri- 
cementum. Both of these causes can be prevented by 
yourself, and I am going to tell you how you may do it. 
We will first tell you how to avoid diseases of the gums. 

(*) If you will examine your teeth when you first get 
up in the morning, you will find them covered with a 
thin, soft, yellowish deposit, which you can scrape off 
with a tooth pick and examine. It looks like cream, but 
it doesn't taste like cream and it doesn't smell like cream. 
It is composed of epithelial cells, which shed from the 
lining of the mouth, mucus and microscopic granules of 
lime from the saliva, and if the mouth has not been 
cleansed of food before retiring it will contain decayed 
]>articles of food. If you do not brush this deposit off 
carefully before eating, the food will strij^ it down over 
the tooth and pack a little ring of it under the free mar- 
gin of the gum. If it is allowed to remain there for a 



Popular Lectuees on Dextal Subjects. 53 

very long time, it becomes so hard that only the dentist 
can remove it, and it will cause the gums to inflame. A 
little is added to it every day, and by and by the entire 
root will be covered and the gum destroyed. 

(*) This is practically the same thing which causes 
disease of the gums. 

(*') See this deposit on the side of the tooth on the 
right. In the picture on the left, this deposit has been 
removed, showing how much of the membrane has been 
destroyed. 

(*) The tongue side of the lower front teeth is the 
most favorite place in the mouth for the accumulation 
of this deposit, partly for the reason that a great quan- 
tity of saliva is poured out at this point, but principally 
because these surfaces are not properly brushed. 

(*) This shows a deposit on the cheek side of the 
upper back teeth, which is also a surface not usually 
reached with the brush. 

(*) After the gums have gotten as bad as this, there 
is no way to save the teeth, and they will soon be drop- 
ping out. Eemember that this disease of the gums can 
be prevented b}'^ thoroughly brushing the teeth twice a 
day. We will show 3^ou in a moment how to brush them 
thoroughly. Let us now take up decay, which is the other 
great disease of the teeth, and we will then show you 
how both may be prevented. 

(*) If you will examine the tojis of the l^ack teeth 
immediately after eating you will see that the little 
grooves which mark their surfaces, are filled with food. 
At first the food is granular and may be removed easily. 
Usually a vigorous rinsing of the mouth is all that is 
necessary, but if it is not removed at once it begins to 
ferment and develops a muculaginous condition, which 
makes its removal much more difficult. During the pro- 
cess of fermentation, an acid is produced which dis- 
solves the enamel. This is about the only thing which 
causes teeth to decay. Hence, if no food be allowed to 



54 ^ Practical Oral Hygieate. 

remain in tlie mouth mitil fermentation occnrs, there will 
be no tooth decay. 

(*) In tooth No. 1, the decay is very small. The point 
where it made its way through the enamel is scarcely 
larger than the head of a pin, but 3'on can see that it is. 
much larger in the dentine than it is in the enamel. This 
is because the dentine decays more rapidly than the 
enamel. A cavity can be prepared for filling at this stage 
with little time, joain and expense, as shown in fig. No. 2, 
but if you wait until the cavity becomes large, as is shown 
in No. 3, it requires much more time, hurts much worse, 
costs a great deal more and does not last so long. Hence, 
the teeth should be examined several times a year by a 
dentist, and every decayed spot which is too deep to 
dress out, filled while it is small. Tooth deca}^ never gets 
well, but always gets worse, so the sooner the cavity is 
filled, the better. 

(*) These pictures show the historj^ of a tooth from 
the beginning of decay until the development of an 
abscess and the establishment of a fistula, commonly 
called a gum boil. (Go more or less into the details of 
the ditferent steps of the process and the changes which 
take place in the pulp, giving a few facts pertaining to 
the proper treatment of such cases with special emphasis 
on the importance of retaining the tooth.) 

If the residue of food is not removed after each meal 
and the last thing eaten something soft and sticky, as is 
too frequently the case, the mouth will sooner or later 
present the appearance of this one with cavities between 
the teeth and in the depressions in the tops of the back 
teeth, and unless dental attention is given this case, the 
teeth will soon be aching and breaking down like the 
ones in the next slide. 

(*) Some of these teeth have broken so badly that 
they are worthless as grinders, they are liable to ache at 
any time and develop abscesses, they are so many gar- 
bage cans infesting the saliva which is constantly being 
swalloAved and contaminating all food and drink. A 



Popular Lectures ox Dextau Subjects. 55 

month in the condition of this cannot he othAvvrise than 
filthy and a great menace to the health of its possessor 
and its neighbors. 

(*) This is a side view of the same case with the teetli 
bronght together as in chewing. It shows what an enor- 
mons amount of grinding surface is lost. But even 
though your teeth are as badly broken down as these, 
you should not pull them out. Their tops can be restored 
by fillings, inlays, and crowns, so long as the roots are 
strong, which is immensely better than artificial substi- 
tutes. Some grown up people may tell you that it makes 
little difference if you lose this first permanent jaw tooth 
before you are fifteen years old, because the space will 
soon be filled up by the next tooth coming forwai'd. AVell, 
the space does fill up. More's the pity. It would be 
better for you if the space didn't close up. Let me show 
you how the space closes up. 

(*) The teeth behind the space lean forward, and 
lean forward, and lean forward, and the tooth in front 
of the space leans backward and leans backward, until 
their top corners almost or quite touch, thus closing the 
space at the top, but not at the bottom. 

In thus leaning toward each other, their touching 
surfaces are so turned that they fail to touch the upper 
teeth in chewing and their fit in is entirely sjioiled. The 
bone buckles as the teeth lean, so instead of losing the 
use merely of the tooth extracted, you also lose one-half 
to two-thirds of the grinding efficiency of all the grind- 
ing teeth on that side of the mouth. But this is only 
one of the many consequences of losing this tooth in 
early life. It causes a general warping of the bones of 
the nose and front face, which often helps to produce 
catarrh and a number of other diseases which we have 
not time to mention. It is safe to say that the loss of 
this tooth in early life shortens a man's days on an aver- 
age of four or five years. 

If the tooth is so badly decayed that only the roots 
are good, those roots ought to be treated and filled and 



56 Peactical Oeal Hygiene. 

kept in place until one is at least twenty years old. Yon 
may do am^tliing that your dentist tells you to do except 
have this tooth pulled. If he insists on pulling it, then 
you should tell your mother that you have a poor den- 
tist, and ask her to let 3^ou go to another. It is very 
seldom that even a temporar}^ tooth should be pulled with 
forceps, and no permanent teeth, except the wisdom 
tooth, and seldom that should ever lie pulled. If you 
forget everything else in this lecture, don't forget what 
I have said about this first permanent back tooth. Re- 
member that it is yours at six years of age and does 
not replace a baby tooth, but comes behind the last baby 
back tooth. 

(*) This picture shows how much better a man who 
has not lost this tooth can chew than one who has. One 
has at least one-fourth more grinding efficiency than the 
other. 

(*) When this fellow was a boy, he didn't chew his 
food or brush his teeth, so they soon decayed and ached. 
He had two of his upper teeth pulled. His upper jaw 
stopped growing, but his lower jaw kept on growing, so 
w^hen he got to be a man his teeth didn't fit each other 
and his jaws were not the same size. His chin pro- 
truded like this (Illustration), and he looked like this. 

(*) Do you want to look like thatf Well, you had 
better not have your teeth pulled out. 

(*) This is the kind of dentist who pulls teeth! If 
your dentist looks like this you had better change your 
dentist. 

(*) This picture shows how the adenoid tissue in the 
naso-pliarynx sometimes becomes enlarged and stops up- 
the air passages, so that you cannot breathe freely 
through your nose. This makes you more susceptible 
to nose, throat, and lung trouble. It should be removed 
as soon as discovered. If 3^ou are accustomed to sleep 
with your mouth open and breathe through your mouth 
while awake, you had better have your physician ex- 
amine you and see if you have adenoids, and if you have,, 



Popular Lectuees ok Dental Subjects. 57 

they should be removed. They frequently spoil the 
shape of the mouth and make the teeth crooked. 

(*) This is the way the teeth frequently look when 
one has had adenoids. If your teeth are irregular like 
these, you should go to the orthodontist (the dentist who 
straightens teeth) and have them straightened. It can 
be easily done while one is young, but if you wait until 
you are old, it is very difficult. 

(*) These pictures show how the face looked before 
and after straightening the teeth. The teeth are much 
more easily and thoroughly cleansed, and are therefore 
much less liable to decay if they are regular and straight 
and fit each other properly. They are also much more 
efficient grinders. The first thing for you to do is to see 
a dentist and have him remove all deposits which you 
cannot brush off, fill all cavities and put your mouth in 
perfect order and show you how you may keep it so. 

In making the dental toilet, the first thing to consider 
is the brush. Any kind of brush is better than no brush, 
but the one at the bottom of this picture is too large. 
Well, it is not too large to brush the cow's teeth with, 
but if you don't weigh more than two hundred pounds, 
it is too large for you. If you have a new brush as long 
as this one, you can improve it by shaving the bristles 
off for about the length of the brush. You will then 
have all the brush that you will be able to use. The 
brush at the top is excellent. It has a long tuft of bristles 
on the end which enable you to reach the back sides of 
the last back tooth. The narrow nose, broad base and 
short body makes it adaptible to the various situations 
and the curve of the handle is an advantage. Brushes 
are made in soft, medium and stiff bristles. You should 
use a soft brush. 

The next consideration is a tooth powder. ]\[ost all 
tooth powders are made of the same thing — Precipitated 
Chalk. They vary mainly in the perfumes and aromatic 
and antiseptic which they contain. If you get your 
mouth clean you don't need a perfume. Perfume in a 



58 Peactical Oeal Hygiene. 

dentifrice is a disadvantage, because it deodorizes the 
mouth and deceives you. A pungent aromatic does the 
same thing and interferes with the exquisite sense of 
touch and taste in the tongue, which is the sanitary 
officer of the mouth, and you may think your mouth is 
clean when it is really only deodorized. If 5^ou can get 
your mouth perfectly clean, you do not need an antisep- 
tic, whereas, if you fail to cleanse it thoroughly, an 
antiseptic is of slight and transient value. 

Pass the brush as far back in right bu.ccal pouch as 
possible, place high up on the gums above last upper 
back tooth and bring downward with a rotary sweep. 

You will see that as the bristles slide off the gums 
onto the teeth, they separate and sweep out the triangu- 
lar spaces about the necks of the teeth. Now let me ask 
the girls a question. "If you were going to sweep the 
floor of a street car, would you sweep it across the car 
or down towards the end of the car? When you are 
sweeping the teeth to get them clean, will you sweep 
across the teeth or down towards the end of the teeth?" 
You may think that hard to do, but just to show you that 
it is not, I will brush mine and let you see. (Illustrate). 

Place bristles of brush on cheek side of upper right 
molar gums and sweep downward five strokes. Move 
forward to bicuspid region and repeat. Go back to cheek 
side of lower molar gums and sweep upward five times. 
Move forward to bicuspid region and repeat. 

Place brush high up on tongue side of left upper molar 
gums and sweep downward with a rotary stroke five 
times. Move forward to region of bicuspids and repeat. 
Place brush on tongue side of lower molar gums and 
move upward five times. Move forward to bicuspids 
and repeat. 

Take brush in left band, place brush bigli up on 
cheek side of upper left molar gums and sweep down- 
ward with rotary stroke five times. Move forward to 
bicuspids and repeat. Place brush low down on cheek 



Popular Lectures o^r Dek-tal Subjects. 59 

side of lower molar gums and sweep upward. Repeat 
for bicuspids. 

Place brush on tongue side of right upper molar 
gums and rotate downward. Same for bicuspids. Same 
for lower molars and bicuspids. Change brush to right 
hand. 

Place brush high up on lip side of right upper canine 
gums and sweep downward working around to left 
canine. Pass to lip side of lower left canine gums and 
sweep upward working around to right canine. 

Place brush high up in roof of mouth and sweep for- 
ward and downward over right canine. Work around 
to left canine. 

Place brush well under tongue and sweep forward 
and upward over left canine. Work around to right 
canine. 

Place brush back on grinding surface of right upper 
molars and sweep back and forth to bicuspids. Same on 
left upper molars and bicuspids. 

Place brush far back on chewing surface of left lower 
molars and sweep back and forth to bicuspids. Same on 
right molars and bicuspids. 

Wash brush and hang up to dry. Einse mouth vigor- 
ously with tepid water. Use tooth pick or dental floss 
between all teeth and behind last teeth. Einse mouth 
again. 

The dental toilet should be performed in this way 
before retiring and before breakfast. Immediately after 
eating the mouth should be vigorously rinsed and a tooth 
pick or floss used. If gums are soft or sore they should 
be vigorously massaged with the pad of the finger once 
or twice daily. 

If a tooth should be knocked out accidentally, it 
should be washed and replaced immediately and a den- 
tist consulted at once. 

In case of illness the mouth should be kept as clean 
as possible both mechanically and by the use of lime 



60 Practical Oeal Hygiene. 

water and other antiseptics. The tongue shonld also he 
frequently cleansed and scraped. 

(*) What is the matter with this little fellow? Did 
yon ever have toothache? Did you cry? If you will fol- 
low the instructions given in this lecture you need never 
have toothache again. 

It is not what we learn that makes us wise and happy, 
it is what we remember and practice. 

LECTUEE FOR SCHOOL CHILDREN", BY GEORGE EDWIN HUNT, 
M. D., D. D. S., DEAN OF THE INDIANA DENTAL COLLEGE. 

"Now, young ladies and gentlemen, I nm here today 
to give you a talk about the mouth and teeth, and since 
it is easier to ask questions than to answer them, I am 
going to begin by asking you a question or two. The 
reason wh}^ your teachers ask you so many questions*, is 
because it is easier to ask them than to answer them. 
The first question I am going to ask is, 'How many of 
you washed your faces before you came to school this 
morning? Hands up.' Well, that's good. I guess every- 
body washed their faces before they came to school this 
morning. There's one boy over there in the corner that 
only put his hand up part way, but I guess he must have 
washed for a high-necked collar. Now, I'm going to ask 
another question, 'How many of you cleaned your 
mouths before you came to school this morning?' Ah! 
that's not quite so good. Quite a number of you did, but 
there's quite a number of you that did not. Now, in my 
opinion, if you are going to make a choice between these 
two things, I think you should clean your mouths and 
not wash your faces, but if I were you I would do both, 
because if you don't wash your faces you won 't look very 
pretty, and if you don't clean your mouths, a lot of other 
tilings are going to happen to you that I'll tell you about. 

"Now for another question, 'How many of you ever 
had toothache?' My goodness! Nearly everyone of you 
has had the toothadie. And those of vou that haven't 



PopuLAE Lectures on Dental Subjects. 61 

had tootli-aclie certainly liave seen people having tooth- 
ache and know what it is like. Suppose I tell you what 
makes your teeth ache. In order to do it, I am going 
to ask you another question. I am a great fellow for 
asking questions. 'Suppose the evening meal was over 
and everybody had left the dining room but mother, and 
mother is clearing up the table. She finds some nice 
boiled potatoes, and here is a nice piece of meat too 
large to be thrown away, and here are some other veg- 
etables that she can keep until to-morrow. Maybe she 
will chop up that meat and put potatoes with it and have 
hash for breakfast. When mother makes hash it is a 
pretty good thing to eat. Now, where does mother put 
that food to keep it until to-morrow, so that it will be 
nice and fresh!' (A pupil — 'In the ice box.') Yes, she 
puts it in the ice box. But why does she put it in the 
ice box! Why not just put it out on the back steps where 
the sun will shine on it and the rain will fall on it? Now, 
we wont say anything about the dog or the cat getting 
it or the birds carrying it away, but just tell me what 
happens to food if she were to do that? (A pupil — 'It 
would rot or decaj-.') That's it. It would rot or decay. 
Well, that's just exactly what happens to food in your 
mouth. That isn't very pleasant to think about, is it? 
Every time jou eat, you leave some particles of the food, 
no matter what kind of food it is, about the necks of the 
teeth and in between the teeth, and if it isn't removed 
that food rots or decays just as the food from the dinner 
table would do if mother put it out in the sun and rain. 
Now, when that food rots in the mouth there are certain 
acids formed, so you are carrying around a sort of acid 
factory in your mouth and nobody wants to feel that they 
are an acid factory. This acid dissolves the tooth just 
as water will dissolve sugar when you pour the sugar in 
the water and stir it up, although it does not dissolve it 
nearly so fast. But it dissolves it just a little at a time 
and the first thing you know that tooth has a cavity in 
it. A little later on that cavity gets deeper and pretty 



62 Peactical Oral Hygiene. 

soon the tooth begins to aclie. And that's the way yon 
have decayed teeth and have toothache. Don't yon think 
it would be better not to leave those particles of food 
aronnd the teeth so that the}' will form acid and give yon 
toothache? 

''There are three reasons why I think yon ought to 
take care of jour teeth. The first reason is that you will 
not have pain. The second reason is that your health 
may be better. The third reason is that yon may be more 
beautiful. Now, when I talk about being more beauti- 
ful, these boys laugh in their sleeves because they think 
they don't care whether they are beautiful or not, but 
we girls know that in a few years from now we will 
wish we were good looking, don't we? 

"Now, in regard to the first of these three reasons. 
You have told me that nearly all of you have had tooth- 
ache and that those who have not had toothache have 
seen people who were having toothache, so that I don't 
think it is necessary to spend any time in telling you that 
toothache is not a good thing to have. Nobody would 
go around hunting for a toothache. So we will just take 
it for granted that you know that you don't want a 
toothache and think that your teeth should be cared for 
on that account. 

"Now for the question of health. You have all heard 
of a certain part of the body which has an awfully long 
name, and which it is difficult for me to remember, but I 
can sometimes recall it— the alimentary canal. It is in 
this alimentary canal where all digestion of food takes 
place, and if it wasnt for the the alimentary canal, we 
would all starve to death. I don't know whether you 
know it or not, but the alimentary canal in grown-u]is is 
over thirty feet long. That would make a person awfully 
tall if the alimentary canal was straight, but it isn't 
straight. Now here's the point I want to make. In that 
whole thirty odd feet of the alimentary canal there are 
only three inches — these three inches from the teeth to 
the back of the mouth — over which you have control of 



PopuLAE Lectures on Dental, Subjects. 63 

your food. Now, since digestion starts here in the month 
and digestion cannot start properly unless this food is 
well chewed, and since yon have no control over the food 
after yon swallow it, don't yon think it's a good plan to 
take care of it while yon have a chance to do so? 

''Now I'm going to tell you how to eat. I expect you 
think you know how to eat but I don't believe you do, 
and I'm going to ask yon to do something for me. A¥hen 
you go to the supper table this evening, I want you to 
take a bite of bread and butter out of the middle of the 
slice. Don't get any of the crust, but just get the soft 
inside of the slice. Then see how long you can chew that. 
Kow you probably think you can chew it just as long as 
you please but you can't. After a while, and it won't 
be very long either, you will find that there is nothing 
in your mouth. You have swallowed that bread and 
butter and didn't know when you did it. That's the way 
you ought to chew most foods. You can chew potatoes 
that way and most cooked vegetables, but not all of them. 
Then there are some foods you can't chew that way at 
all, so they will swallow themselves. Unless you get 
better beefsteak here than we do where I live, you can't 
chew beefsteak that way, and unless you get better celery 
here than I do, 3^ou can't chew celery that way, because 
it is stringy and you can't alwaj^s chew string beans that 
way unless they are very well unstrung. However, those 
foods that you can't chew until they swallow themselves, 
should be chewed until there is no longer any taste to 
them. Then you can swallow them all right. Now if you 
would chew 5^our foods that way, it would be a great 
thing for your teeth and gums, and I am sure you would 
enjoy it more if you would once get in the habit of eat- 
ing in that manner and your health would be very much 
better. 

''Now, girls, I am going to talk to the boys a few 
minutes and you can listen if you want to. How many 
of you boys ever heard of a game called base ball? Well, 
I guess most of von know all about base ball. "Well, if 



64 Peacticajl Oeal Hygiene. 

you boys want to be good base ball players, or good foot 
ball players, or good tennis players, or good in any other 
line of athletics, you have to have good teeth, and you 
have to use them properly. Now maybe you think that 
is a funny thing for me to say. But don't you see, that 
since digestion starts in the mouth, that if you don't have 
good teeth to chew your food with and don't use your 
teeth properly you won't have good digestion. Nobody 
with poor digestion can ever be a good athlete. Did any 
of you boys ever hear of Connie Mack, or John McGraw? 
Why of course you have. Connie Mack is manager of 
the Philadelphia Athletics, the champion base ball team 
of the world, and John McGrraw is manager of the 
New York Giants, which is the second best team in the 
world. Well, when the Athletics and Giants report early 
in the spring for spring practice and to go to the training 
ground, Connie Mack and John McGraw make them go 
to the dentist and have their mouths put in order before 
they can ever begin training. Now, Connie Mack and 
Johnnie McGraw don't care whether those ball players 
of theirs are pretty or not, nor they don't care particu- 
larly whether those ball players have pain or not, but 
they do know that if the ball players mouths are not in 
good condition that they can't play ball as well as they 
could if their mouths were in good condition. Suppose 
there was a World Series on and the Athletics had won 
three games and the Giants had won three games and 
the next game was to decide the world's championship. 
And suppose the next morning Baker, of the Athletics, 
their best batter, were to show up at the ball ground 
with his face swollen out with an abscessed tooth. He 
couldn't play base ball that day. Even if he tried he 
couldn't play well. And his absence from the team might 
cause the Athletics to lose the world's championship. So 
you see that to athletes, bad teeth are a great handicap. 
Connie Mack knows that and that's why he insists that 
Baker's teeth shall be in good condition and that he shall 
keep them in good condition all through the playing 



PopuLAE Lectures on Dental Subjects. f)5 

season. He knows that Baker wouldn't play as good 
base ball if he had a mouth full of bad teeth. 

''And now you girls. You like your roller skates, and 
you like to play tennis, and you like to dance, and you 
like to do a lot of other things that depend a great deal 
uj)on the condition of your health. Then you don't want 
to have indigestion and headaches and all those kind of 
troubles when you are gromng up because they inter- 
fere with your school work just as they interfere with 
the boys school work also. And unless your teeth are in 
good shape and you use your mouth properly, you will 
not be in good health. Nobody in school can do their 
best work and keep up with their studies if they are 
suffering with tooth-ache, or if they are suffering from 
indigestion, because of the condition of their mouths. 
You don't want to fall behind in your classes and have 
to take a part of the work over again, and yet you can't 
keep up with your classes unless your health is good and 
your health can't be good unless your mouth is in good 
condition. So you see, your health depends a good deal 
upon the condition of your mouth. 

''Now to take up the third reason why you should 
care for your mouths. You boys may not think now 
that it makes any difference whether your mouths look 
good or not, but it does. Pretty soon now, you boys will 
have to get out in the world and earn your own living. 
Your fathers and mothers have been pretty good to you 
so far, but they can't take care of you always, and after 
a while you have to earn money for yourselves. Then 
again, later on, perhaps, you will have to be earning 
money to take care of one of these girls, also. Now, 
suppose a wholesale merchant in this town wanted a boy 
to come into his establishment and start way down at 
the foot of the ladder, with a prospect of working up. It 
may be the boy could get to be a general manager of the 
institution after a number of years, or head bookkeeper 
or some good paying job. Suppose two boys apply for 
this job. One of them has a mouth full of dirty teeth, 



66 Peactical Oeal Hygieiste. 

witli green scum on them, cavities sliowing in the front 
teeth, month foul as can be, breath bad on account of his 
decayed teeth, perhaps one or two teeth gone. The other 
boy has a mouth that shows that he has taken care of his 
teeth, that he cleans his mouth, and takes some pride in 
it. Which one of those two bo^^s will the merchant hire, 
other things being equal? He'll hire the bo}' with the 
clean mouth. He will say to himself, 'This boy with the 
clean mouth takes some pride in his appearance and is 
more likely to take pride in his work. This boy with the 
dirty mouth is very likely to be slovenly about his work.' 
And then again, the merchant would argiie to himself, 
the boy with the bad mouth is more likely to lose time and 
neglect his work on account of toothache than the boy 
with the good mouth. So you see that it does pay you 
to have good looking mouths, even in business, and it 
pays you girls, too. Of course, you are more likeh' to 
have pride in your looks than the boys are, but from a 
purely business standpoint 3'ou ought to take care of 
your teeth. If jou grow up and have to earn 3"our own 
livings or want to make a little extra money working 
in an office or store, you will find that you can get work 
a good deal quicker if you have nice looking mouths and 
nice looking teeth, than you can without them. Mer- 
chants don't like to hire a girl in their store to sell goods 
to customers if their mouth is in such shape that their 
breath is bad and their appearance is bad. Everybody 
ought to be as handsome as they can in this world, be- 
cause other people have to look at them and they ought 
to make it as easy for the other people to look at them 
as they can. So those are the three reasons why I think 
you ought to take care of your mouth and teeth, and now 
having told you all of this about what will happen to 
you if you don't take care of them, I think I ought to tell 
you how to take care of them. 

"But, first let me tell you how often you ought to 
clean your mouth. Of course, if you could do it, it would 
be better for you to clean your mouths every time you eat 



Popular Lectures on Dental Subjects. 67 

anything, but that isn't always possible. I think, if I 
were you, I would rinse my mouth out with water the 
first thing when I get up in the morning. Then after 
breakfast, I would use my toothbrush and the floss silk 
in the way that I will describe to you, and then if you 
don't clean them again until just before you go to bed, 
you will have done pretty well, anyhow. Always give 
3"our mouth a good cleaning just before going to bed.. 
Dion't forget that, because it is very important. 

" (Now the lecturer should give a talk on the toilet 
of the mouth. If stereoptican views could be shown, 
they can be begun at any point in the talk that the lec- 
turer desires. Personally, I begin showing my stereopti- 
can views as soon as I have wound up my argument for 
good teeth. That is, just before this talk starts in on 
telling them how to take care of their mouths.) " 



CHAPTEE V. 

DENTAL EXAMINATION AND CLINIC FOR 
PUBLIC SCHOOLS. 

HISTORY. OBJECT OF SCHOOL USTSPECTION. HOW TO START 

SCHOOL INSPECTION. ARGUMENT FOR FREE DENTAL 

CLINICS AND SCHOOL INSPECTION. 

Dental examination in public schools consists of in- 
specting and tabulating- the oral conditions of the stu- 
dents, by some dentist under authority of the local dental 
society or public school authority. 

HISTORY. 

It is of interest to note that in 1879 Eussia started 
this inspection. Chicago, some thirty years ago, was the 
first city in the United States to have this work. Ann 
Arbor, Mich., was one of the first cities to make this in- 
spection under the supervision of the school board. Cam- 
bridge, in 1907, had the first school dental clinic operated 
in this country. Nearly all the foreign countries have 
made great strides in this direction, and x^merica has, at 
last, awakened to the need of this work. Nearly every 
state in the Union is now doing some work along this 
line. 

OBJECT OF SCHOOL INSPECTION. 

The object to be gained by the inspection of the teeth 
of scliool children is : 

First, to show the people and the parents the actual 
existing conditions. To tell, for instance, that in New 
York the examinations show such and such defects, is not 
as interesting as to show them the conditions in their own 
children's mouths. 

Second, to increase the working capacity of the child. 



Dental Ixspectiox ix Schools. fiP 

Third, to accumulate data which will in the future 
force the people to wake up on this subject. 

Fourth, to show, by comparison with schools that 
have established this system, what can be done. 

All statistics of school examinations show that dental 
lesions are in the majority of all defects, ranging from 
80 to 98 per cent. 

One of the objections that will arise in the minds of 
the school board, whether expressed or not, will be that 
thej invariably think that the dentists have some ulterior 
motive, or that they are ambitious to advance themselves. 
This, of course, can be met with the fact that the dentist, 
in many instances, is domg the work free of charge, and, 
in addition, is furnishing material, charts, and stationery 
at his own expense. Medical examiners are generally 
paid a salary or else a fee for some special examinations. 

HOW TO STAKT DEXTAL SCHOOL IXSPECTIOX. 

As nearly all schools have some sort of medical ex- 
amination or supervision, the beginning of deiital atten- 
tion must, of necessity, be done through the medical 
examiner. It is a good start for the dentist of local 
society to secure the medical examiner's sympathy and 
co-operation. Have him visit some dental office and show 
him b}^ pictures and by examination of a patient what to 
look for and how to find defects in children's mouths. 
Mail him reprints from the dental journals on the 
subject. 

In attempting to start dental inspection or clinics in 
a new place, the dentist often finds a lack of interest or 
even opposition on the part of the commissioners of edu- 
cation and the teachers. This is humiliating. On the 
other hand, we have found that physicians do not have 
to beg the schools to accept their services, but are wel- 
comed, and the necessary funds are forthcoming for their 
enterprise. It is even necessary sometimes for dentists 
to beg to put in dental inspection in one school just to 



70 Peactical Oeal Hygiene. 

show these men from "Missouri" wliat can be clone. 
This is the one place where it is better to work first with 
the medical examiner. Go to him, teach him how to ex- 
amine for dental defects, and then get him to state in his 
reports the dental defects which he has foimd. This will 
do the authorities more good than forty dentists going 
before them. After the medical examiner has done this, 
you have the entering wedge. 

When the medical examiner has made his report, the 
next man to see is the superintendent of the schools, for 
he is the man who, unless seen first, is going to make 
objection. Put the facts up to him as given in our chap- 
ter on Oral Hygiene. Explain to him that it is not plac- 
ing a burden on his pupils, but taking a burden off of 
them. If you can win his co-operation, one-half of the 
battle is won. Take him along with you to see the presi- 
dent of the board of ©education, and at a special meeting 
have a committee along with reliable facts on oral sepsis, 
and show literature and statistics from other schools 
which have inaugurated this system. Show them how 
pupils with dental irritation are unfit for study. Offer 
to make a voluntar}^ inspection of one school at the open- 
ing of the term and at the close of the term. Have pre- 
pared blanks somewhat on the order of those shown in 
this book, and then the next year when it goes before the 
board of education, meet them on a plain business basis. 
After you have secured consent for the first examination, 
see that the parents are acquainted with the conditions 
of the children's mouths, and that the child is interested 
through popular lectures in prophylaxis, tooth brushes, 
and dentifrice. It is also well to have some slides with 
pointed paragraphs on them or printed cards. Stop in 
the lecture and write these points on the black-board 
every few minutes. A break in a lecture like this has a 
good impression. Statements like the following should 
be used: 

"A Clean Mouth Prevents Pain and Illness." 
"Food Left Between Teeth Causes Decay." 



Dental Inspection in Schools. 71 

"Dirty Mouths Breed Disease Germs." 

''A Clean Tooth Never Decays." 

' ' Clean Your Teeth After Eating. " 

Sometimes it is necessary to use some other attrac- 
tive schemes to produce results. In "Wilkshurg, Pa., the 
dental society devised a plan by which the children were 
induced to use the tooth brush and dentifrice furnished 
by the society. With each package, a check was given 
to the children. Five of these checks would secure a 
package free. The checks were given out by the teachers 
for keeping the teeth clean and owning a tooth brush. 
The reports from the use of such schemes seem to indi- 
cate that they are proving their worth ; the statistics col- 
lected by the dental examiners have been highly satisfac- 
tory, and the parents of the children have shown a keen 
interest in the work. 

As evidence of further progression in this work. Dr. 
A. C. Fones writes me as follows : 

"If our plans go through here in Bridgeport, we will 
start a preventive and educational dental clinic in our 
public schools in September, and intend to educate dental 
nurses to put them in one school as a demonstration, and 
see that the children have a surface treatment once a 
month." 

Before beginning the school inspection, it is well to 
have printed the proper charts, the best of which are 
shown in this book in the following pages. Several ad- 
justable head rests attached to common chairs, can be 
used for the examination. The examination should be 
made in a room separate from the class room, and three 
or four students called out together. It is well to have a 
trained nurse to attend to the sterilization of the instru- 
ments. The assistance of several young dentists, who 
will generally be glad to give their services, should be 
arranged. The cards should be given to the students be- 
fore they reach the examining room, with name and grade 
filled in. Since we do not have to include in our report 
all the minor defects which are found, the examination 



72 Practical Oral Hygiene. 

of about fifty cliilclren an hour can be counted on as an 
average. Specific information should not be given on the 
card which is sent to the child's parents, as the repu- 
tation of the family dentist must be protected for the 
good of all. The only object of the examination being 
to let the parents know that they should have either their 
family dentist, or the school clinician to make further 
or more extensive examination of the teeth. 

After the examination is complete, the popular lec- 
tures should be begun and the children and their parents 
invited. At these lectures the statistics of the examina- 
tion should be shown, and means of improvement 
stressed. All the while the first point in this move- 
ment is to remove the child's apatlw towards the dentist, 
and to urge the necessity for oral hygiene measures. Get 
the child so interested that he will insist on the repair 
of the defects. The dental colleges should be specially 
instructed to help in this work. In those places where 
there is no dental college, and where there is not time 
to establish a dental clinic, the practitioners must give 
certain hours to this free work for those who cannot pay 
for it, for, the failure to repair these defects found in 
the teeth of the children, would result in upsetting all the 
plans for prophylaxis work in the future. 

reasons for free dental clinic and school inspection. 

It saves money for the county and state, for much of 
the expense of teaching goes to laggards, and a large per 
cent, of the laggards are made so by some physical de- 
fect. The largest number of physical defects lies in the 
teeth. This corrected, the laggards become normal in 
their class rooms. By putting the laggards through 
school each year, the school is saved the expense of hav- 
ing to teach the pupils two years the same subject. It 
has l)een said that schools expend about twenty per cent, 
of their income on this kind of double teaching. Another 
of the greatest drawbacks to successful teaching is from 
absentees. A large per cent, of absences from school, 
is from toothache. This remedied, the pupil is more apt 



Dental Inspection in Schools. 73 

to be regular in attendance, and, consequently, can better 
concentrate liis mind on Ms studies. 




Fig. G. a Rochester School Boy Patient of the Free Dextal 
Dispensaries. 

"Handieapped in his school work, health, appearance and ability to 
secure or hold a position. It is necessary for him to leave school to 
help support the family. Who Avants to employ a boy with a mouth 
such as this? We remove the handicaps and enable this lad to start 
even with his associates. This charitj' does not iDauperize the recip- 
ient." 

Dental inspection in our public schools not only edu- 
cates tbe children along these lines, but it also enables 
us to teach the parents what they can and should do for 
the younger generation in the way of preventing disease. 
The laity, being so ignorant on the subject of oral sepsis, 
shiould be given every opportunity, and should have im- 
pressed on their minds the close relation between these 



74 Peactical Oeal, Hygiene. 

conditions and the general health. I have requested the 
privilege of publishing a personal letter from Dr. Zar- 
baugii. It contains the best argument for our work in 

the public schools : 

Toledo^ Ohio^ Thursday, Oct. 30tb, 1913. 

Dr. Robin Adair, 
Atlanta, Ga. 

My Dear Doctor Adair: Enclosed please find my eti'ort on behalf 
of the school children of America. I could not speak the volume that 
is in my heart on this subject, because ours is an empty home, made 
so by the neglect of someone in alloAving a child to return to school 
who had been ill -with scarlet fever, without thoroughly cleaning! the 
mouth. 

I have looked into the diseases of childhood pretty thoroughly, and 
I find that absolutely nothing has been offered the medical men in the 
way of treatment but serumtherapy, and no progress has been made in 
preventing them, except what we of the Dental profession are able to 
do in the oral hygiene movement. I believe that it is our greatest field 
in which to work for humanity. 

Ours was a bright, fair, blue-eyed boy 9 years old, sick one week, 
bid us goodby after telling us that he was going to heaven, kissed us 
with a smile on his lijos and ijassed on. 

The same tragedy is being enacted in many homes at this veiy 
moment, and the sad thing about it, is, that it could have been and can 
he prevented. 

Yours very truly, 

Lyman L. Zarbaugii. 

importaisrce or dental inspection of school 
children's teeth. 

by lyman l. zarbauc4h, d. d. s., toledo, ohio. 

'^If the annual losses to the parents and guardians of 
the school children of America and to the children them- 
selves were focused into a single line of figures, the re- 
sult would look like an astronomical calculation. 

''According to figures given where inspection of 
school children's teeth have been made in schools, ninety 
to ninety-five jjer cent, have defective teeth. 



J)extal Inspection in Schools. 75 

"Tliousauds upon thousands of dollars are wasted 
each year. Untold suffering, great loss of time in scliool 
from toothache, mental disturbances, etc., result because 
of the ignorance of parents regarding their children's 
teeth. This suffering and loss of time and money can be 
stopped very quickly and effectively by the inspection of 
school children's teeth by a dentist twice a year. 

"To illustrate the loss in dollars, one of the thousands 
of cases is cited. A child at the- age of six years erupts 
the first permanent molar. Because of faulty develop- 
ment, a small opening between the folds of enamel at the 
developmental lines allows decay to progress. No 
amount of brushing or anything else will save that tooth 
except a properly inserted filling. Now it is perfectly 
plain that if that child's teeth are inspected at the be- 
ginning and close of the school year, the cavity or defect 
will be found, and the fault remedied if the parents heed 
the warning. If, on the other hand, no inspection be 
held, the tooth continues to decay for a year or more, 
and the child, after the tooth is nearly ruined, complains 
of toothache. The dentist is visited. He finds the pulp 
exposed or putrescent, necessitating tedious treatment 
and expensive restoration, costing an^ns^here from five to 
eight dollars ; whereas, if the matter had been brought 
to the attention of the parent at the start, the cost would 
not have exceeded one dollar at most, and very likely 
less, to say nothing of the loss of time, and pain and 
suff'ering of the child. 

"Dental inspection can be likened to the watchmen in 
large buildings and factories who make their rounds 
every hour, pulling the boxes. They are looking for fire. 
If they find it, the fire department is called and the dam- 
age is slight. Just so with dental inspection in schools. 
The damage to teeth would be very slight indeed. No 
tooth would decay in six months' time sufficient to cause 
any real trouble or suffering. 

"The coming generation would never experience 



76 Peactical Oral Hygiene, 

tootliache and loss of teeth, if dental inspection in the 
schools were universal and the warnings heeded. People 
wearing artificial teeth would be a curiosity in a singio 
generation. If the fathers and mothers knew what it 
would mean to their children to be free from pain and 
mental disturbances caused by toothache, they would not 
only request, but demand dental inspection of the school 
children's teeth. 

"Seventy-five per cent, of all contagious diseases 
enter the body through the mouth and throat, and untold 
thousands of dangerous death dealing disease germs lurk 
in unclean mouths and decayed hollow teeth. Make it a 
part of the regular school work that the children's teeth 
be inspected twice during the school year, and that they 
be taught the vital importance of a clean mouth and its 
relation to good health and a well-founded education. 

"This program, if followed out, will save human lives. 
It will prevent death from snatching children from their 
mothers' arms for the reason that the infectious diseases 
of childhood lurk and grow in the mouths of children 
many weeks after they have, to all appearances, re- 
covered from a disease. They return to school and play 
with their mates, and spread disease and death by infect- 
ing other children, thus emptying the loving arms of 
thousands of mothers every year, and instead of them 
having the God given privilege of watching their child- 
ren develop into manhood and womanhood, the}^ have now 
the task of visiting a lonely cemetery and placing flowers 
on a little green mound, and return to a house that is not 
a home, but which only contains memories of what might 
have been, and a mass of ruined hopes. 

' ' Thousands of children die every year because some 
child who had been sick with a contagious disease, re- 
turns to school with a dirty mouth. Fathers and mothers 
of America, remember this, that dental inspection in our 
schools, and tooth brushes would be much cheaper than 
funeral expenses and flowers, and children's laughter 



Dental Inspection in Schools. 77 

mueli preferable to empty arms and acliing hearts. 
Wliicli do yon prefer? Won't yon start a campaign in 
your locality for dental inspection in your school? The 
authorities owe it to every child." 



CHAPTER VI. 

FORMS USED IX DENTAL INSPECTION AND 
CLINICS FOR PUBLIC SCHOOLS. 

INSTRUCTIONS TOR MAKING SCHOOL EXAMINATION. 
DISPENSARY. THE FORSYTH DENTAL INFIRMARY. 

Dental inspection and record must preceecl any at- 
tempts towards the establishing of a dental dispensary. 
The literature and forms as used at Cleveland, Ohio, and 
Rochester, N. Y., furnish efficient forms, some of which 
are illustrated. 

INSTRUCTIONS FOR MAKING DENTAL EXAMINATIONS IN THE 
CLEVELAND PUBLIC SCHOOLS. 

Examiner should work in barmonj- with the principal of the school and 
should himself make all arrangements for the examinations 
with the principal. 
Examiner should secure from the principal the use of one table, two 
chairs, Avash basin, hot and cold water, and a suitable place 
in which to keep his outfit from Aveek to week. 
Examiner should see that principal undei-stands the instructions for her 
teachers, viz : The teacher should insert carbon paper between 
the first two blanks and then iDroceed to supply the 

School 

Date (of examination) 

Name (of pupil) 

Address (of pupil) 

Age Grade Room No. 
for each pupil. Always in duplicate; aiTanged as the chil- 
dren sit in rows in their class. The children should be sup- 
plied to you for examination in the same order in which the 
blanks have been prepared. Always keep one or more of 
the children in line but never have to exceed fives waiting; 
one or more dispels fear, too may provoke mirth. The 
teacher should not detach blanks. The blanks should come 
to you in pad form. When you have made your record, 
using same carbon paper as teacher, remove the top sheet 
giving this original to the pupil, fold over the pad the dupli- 
cate and later send same to the secretary of examinations. 



Dental, Inspection in Schools. 



79 



DENTAL EXAMINATION OF SCHOOL CHILDREN, CLEVELAND.^OHIO 
The Cleveland Dental Society, The Ohio State Dental Society and The National Dental'Association 

FRONT OF TEETH. 

I a 8 4 6 7 8 e 10 11 la 13 14 16 10 



PER 

m 



UPPER 



Sa 31 30 29 28 27 28 26 24 23 22 21 20 19 18 17 

RIGHT SIDE LEFT SIDE 

> c 



School 








Date . - 






....191... 






Age Grade.. 




...Room No 




Condition of Mouth 


Good 


Bad 




Condition of Gums 


Good 


Bad 




Use Tooth Brush f 


Yes 


No 




Teeth FHIed ? 


Yes 


No 




Mal-occlusioli ? 


Yes 


No 





FRONT OF TEMPORAIir TECTH 



N n L K 



BACK OF TEETH. 
8 9 





25 24 

EXPUNATION OF MARKS ON DIAGRML 
le through tooth mcani cAvity or CAvitie*. 



TO PARENTS — A sound body and sound mind are Csual and frequent companions. Schools are therefore concerned 
with both. Neglect in care of the teeth is the cause of so much ill health that school authorities everywhere are seeking 
co-operation with competent dentists. Our Board of Education has arranged with the local dentists for a free examination 
of the teeth of all school children. The report on your child is shown above. 

This examination and report (though not complete) is not an attempt to interfere with your private matters. -Titej 
will bring to the majority of tihe parents first knowledge of the fact that their children's teeth need the attention of a 
dentist. It is our belief thaj all parents will be interested in having their regular dentist look after the defects pointed 
out by this report. Very truly yours, 

ov.i) W. H. ELSON, Superintendent o( Schools. 



Fig. 7. 



80 Peactical Oral Hygiene. 

(Back of card for dental examiuation of school children, Cleveland, 0.) 

ABOUT TEETH. 

Good Teeth, Good Health. 
"Without Good Teeth there can not be thorough 

MASTICATION. 
Without thorough mastication there can not he perfect 

DIGESTION. 
AVithout perfect digestion there can not be proper 

ASSIMILATION. 
AVithout proper assimilation there can not be 

NUTRITION. 
AVithout nutrition there can not be 
HEALTH. 
: Without health what is 
LIFE? 

Number of Teeth:. 
There are twenty teeth in the first or temporaiy set — 10 upper and 
10 lower. In the permanent or second set there are 32 teeth — 16 upper 
and 16 lower. 

Their Purpose. 
The teeth are for ornamentation, for grinding the food, (thus pre- 
paring it for proper digestion), and assistance in talking. They should 
last to the end of life. 

How Lost. 
By decay and loosening. Decay is caused by allowing food to remain 
about the teeth and by poor health. Teeth become loose by a deposit on 
thern at the edge of the gum, called tartar. 

How Can Decayed Teeth and Diseased Gums be Prevented*? 
By cleaning the teeth with a tooth brush and water on arising in 
the morning and before going to bed at night. A quill toothpick prop- 
erly sharpened, should be used after each meal. A toothpowder used 
on the brush will assist in cleansing the teeth. 

The essential ingredient in all good tooth powders is precipitated 
chalk. This may be flavored to suite the taste. The following formula 
is considered a good one : 

Precipitated Chalk SVz ounces. 

Pulverized Castile Soap % " 

Garantos 1 grain. 

Flavor with Oil of Peppermint, 

Sassafras, Wintergreen or Cinnamon ... 5 drops. 
The slow and thorough chewing of the food helps to preserve the 
teeth and keep the mouth in a healthy condition. 

Evei'y person should have his leeth examined l)y a competent devitist 
several times a year. 

Cleanliness is the best 2'uard acainst disease. 



Dental iNSPECTioisr iisr Schools. 81 

You will find that one bundi'ed examiuations will be all that 
you can care for in one moniing of thi'ee hours until you 
have had some experience. There will be sent to each school 
with examination blanks, four carbon papers so that four 
teachers may prepare for coming examinations at the same 
time. These carbon papers should be left by the teacher in 
the pad of blanks. You Avill need them for your work. 
When you have finished examining for the day, be sure to 
return the four carbon papers to the principal for future 
use. 

Examiner should be prompt in attendance. 

Examiner should have his person neat (wear office coat) and above all 
his hands and nails should be mechanically clean. He should 
see that his mouth is clean as an example, and his breath 
should be sweet. 

Examiner must not use tobacco w-hen on school jDroperty. 

Examiner should use a pad of blanks for each room. 

Examiner should examine with his back toward a window, that he may 
have good direct light in the pupil's mouth. 

Examiner must keep his hands out of pupil's mouth. 

Examiner must not use any instrument except a mouth mirror. 

Examiner must not use a mirror but once until resterilized. 

Examiner should see that vessels containing carbolic acid and alcohol 
are labeled at all times. 

Examiner should see that sterilizing is properlj- done and that miiTors 
are free from both carbolic acid and alcohol and are at a 
temperature that will be comfortable to the mouth and not 
fog the glass. This will necessitate frequent change of hot 
water in the last glass. Proper sterlization of miiTors for 
this work will consist in : 1st. "Wiashing Avith a brush, in hot 
water and soap. 2d, Immersion in carbolic acid solution (as 
provided which is 1 to 64) for at least five minutes. 3d. 
Immersion in alcohol (95%) (alcohol must be at least one- 
half inch deeper than carbolic solution). 4th, Immersion 
in hot water until used. This water should be changed at 
least once for every thirty mirrors passed thru it. jMiiTors 
should be used wet and not touched with the hand, napkin 
or othei-wise. 

Examiner should always leave his outfit clean and as nearly ready for 
use as possible. Carbolic acid solution and alcohol should 
be thrown into sewer at close of day's work. 

Examiner must proAade: Six (6) miiTors (Ash miiTors may be had for 
50c each or 6 for $2.50, at Ransom and Randolph's.) Three 
large drinking glasses for alcohol, carbolic acid, and water. 
Six (6) pencils. Towels for personal use. Soap. Basin 



82 



Peactical (3ral Hygiene. 



and Inrush for scrubbing uiiri'ors. One tray to receive soiled 
niirrois. An assistant to sterilize the mirrors. 




Fig. S. Proper Arraxgemext of Tap.le for School Ixspectiox 

Work. 

Examiner will be furnished with a card of appointment which he 
should carry on his person. 

Examination blanks, alcohol, carbolic acid, and labels for the 
same will be furnished and ^^'ill be delivered to the principal 
of the school. 

The Oral Hygiene Committee will pay assistants at the rate 
of oOe per half day which means three hours work. 
Should examiner be unable to provide an assistant, one Avill 
be furnished him upon request. 
Do not examine Kindergartens. 

Examine 1st grades first, and 8th grades last. Never force 
a child to submit to examination if parents object. If par- 
ents object, so mark his chart and send original home. 
If child is afraid have him first see you examine another, 
after Avhich you will have no trouble. 

detail of a day^s work. 

Examiner and his assistant should be at the school at S :15 A. M. and 
should at once notify the principal that he will be readj- for 
work at 8:30. 

Examiner and his assistant should prepare his table after the fashion 
shown in the enclosed blue print. Begin work promi3tly and 
continue steadily until recess at which time a few minutes 
relaxation in the fresh air will be found beneficial. After 
recess resume work until close of morning session. 
Have assistant clean and store all utensils properly. Make 
out your report and wrap with pads of examinations. Pay 
your assistant; the society will i^ay you. Have her receipt 



Dextal Inspectioi^ IX Schools. 83 

for it on your report. Inform j-our principal of your next 
appearance and depart. In most convenient manner send 
your report and blanks to the seeretai-y of Examinations. 
Should you need any supplies notify See'y of Exams at once. 
Call Main 517. 
Examiner should not ask ]uipil if he has a family dentist. 

DISPENSAEY. 

In Chicago, it took six months of constant work to 
secure the consent and approval of the Department of 
Health for a Dental Dispensary for children. This, in 
the face of a free offer of equipment, and means of main- 
taining it. 

One of the first requirements in establishing a dispen- 
sary is to eliminate those who are not entitled to free 
dispensary care. This is accomplished by having the 
parents of the ^Datient sign a card authorizing the ser- 
vices which is so worded as to eliminate the well-to-do 
child. 

DISPENSAEY PLAN. 

In the carrying forward of the work, various opera- 
tors may have to handle a case before it is finished. As 
every dentist has some pet way of doing things, it is first 
essential to establish and tabulate on printed card a 
routine series of treatments. Thus the patient can be 
carried through any treatment with several operators 
without any hesitation or embarassment of either 
operator. 

The operation of free clinics for dental service is dis- 
cussed here solely for the reason that they can be made 
the greatest factor for oral hygiene teaching. The ques- 
tion has arisen that this part of the work and the great 
opportunity it affords is often neglected. 

Dr. N. S. Hoff has called our attention to the statistics 
of the various dental clinics criticising the reports be- 
cause they show such a small number of operations under 
the head of "cleaning teeth," as compared with other 
work done. His suggestion is that every patient pre- 



84 



Peactical Oral, Hygiene. 



Rochester Dental Society — Free Dental Dispensaries 

OClIITord, Thomas and \Veeger Streets 
School No. '20 



Scto St. cor. University Ave. 
School No. 14 

IMame .J\A.0LnrA4 . .^ O^A^VS^A . . 
Address .'. X. . VtM/lAAir-l? . .*J . •. 



0~32 S. Washington Street 
Uoehe 



■ enter I'ublle Health Ansu. 



No. In family 



Income 



'^/.0">. 



Employer U^ ; %.. A/M-frV^ 
^2 6-"^ .<r ^(^ 



M. 



.^. 



Rent . O 

School No 

Se 

SlKnsiture of I'arent or Guardian 

ALWAYS BRING THIS CARD WITH YOU 



fnt by .IV"^. .U...^S-r^^Vr. . 



Monday 

Tuesday 

Wednesday 

Thursday 

Friday 

Saturday 


h/7 










¥*^ 


n - 




IH 





0%^,.(l,^..9^rQj^.-^r^.. 



"(over) 



PENALTY FOR FALSE REPRESENTATIONS. 

Section 25, Chapter 368, Laws of 1899. 



Any jDerson who obtains medical or surgical treatment on 
false representations from any dispensary licensed nnder the 
provisions of this act, shall be guilty of a misdemeanor, and 
on conviction thereof shall be punished by a fine of not less 
than ten dollars and not more than two hundred and fifty 
dollars. 

(Imprisonment until fine be joaid may be imj^osed. Code 
Crim. Pro. Section 718.) 

Fig. 11. Rochester Dispensary Card. 

sent should have his teeth cleaned thoroughly, and should 
be instructed in oral hygiene. Says Dr. Hoff, in an edi- 
torial in the Denial Dhpensarij, August, 1912, ''It would 
seem that nine-tenths of the time and energy of the den- 
tists in charge of these clinics had been expended in 
relieving the pain of diseased teeth, and repairing the 
loss of tooth substance. We are justified) in say'mg that 



Feee Dental Disjeis^sary. 



85 



ROCHESTER DENTAL SOCIETY — FREE DENTAL DISPENSARY No. 2 
Card of admission on representation or statement of patient. 



^K.o>.^%.A^ \r^a.n-.>^^^ 



1. C>j^y^n-t->A M' 



Date ^ \ >H I I V- School ts^p.yl^ Grad* S 



Teacher \\]JJL Q.. Siu.'^L>- 



^^H^ 



here Born ^l^.^ . 



Age 13> 



Color UtLJLjw 



No. In Family 



\0' 



H» M 2^^<^L Medical Attendant '^ f. )\\ . V^^.^..^ 



Name of Parent or Guardl, 



her Applicant Mental No. Teeth Defective 



Certificate? 



hu^^ I U. 



.kuu^ 



vW^*fl- ! 2.% 



Zi>f'" 



Dentifrice? I Brush? 



Irregular? 1 Saliva? Mouth Breather? 



Remarks 

(X4jL > > <>-X.dU» 



This Is my _i application to this Dispensary In the year ^^ ^ ^ 

the year V^V t^ (or to the following Dispensaries) *^^^.~*->aA^ ~^ t./^.^^Jt|ftA — ^^ ZJLt 
The foregoing statement Is In all respects trus; 

Signature of applicant /^>r-X . ^^ < ^ A7.-'*^l-VL<^g/ . 



been an applicant to no other Dispensary in 



WXuLy.Qi.'S.^^^ 



3m uaJu: s\'. 



ephone No. (M-qtjf K 



^\t«>\vv (»// li^s^K.]^"-"'"^- y^'///: 



Refused J>(^ 



Fig. 9. Card of Admissiox. 



85821 3M I-IO J 





Fig. 10. Back of Card of Adimissiok. 



86 Peactical, Oeal Hygiene. 

RECORD OF EXAMINATION OF THE MOUTH. 
(Suggested by Dr. Hunt.) 

CUT OP TEETH Scbool 

Date • • 

UPPER TEETH. Name 

Address 



A line drawn . ^, 

■ 1 , J- J.1 Age Orac e 

through a tootn *= , r^-, -, •. 

-, (Cheek one) 

means a cavity or ^^ _^. n^r ^i ^^ -, -r^ ■ -J. -, 

.,. Condition of Mouth Good Fair Bad 

■cavities. ,, _ ,^ . 

Abscesses, How Many 1 

around tooth Teeth Need Cleaning? Yes. No. 

means crown is lost. Use Tooth Brush? "Ycs. No. 

X across tooth ^/^ ^f'*!' ^'^^^ If' ^'°- 

means pea-manent Malocclusion? les. No. 

tooth lost. K^™^^-^^^ 



LOWER TEETH. 

Care op the Mouth. — ^^To keep off tartar aud. have better health, 
chew every bit of food twice as much as you have been. Clean the 
teeth every morning before breakfast and at bedtime. The last is 
very important. If you have no other tooth powder you can get a 
good deal of precipitated chalk at the drug store for five cents. The 
teeth should be brushed by placing them end to end and brushing them 
in an up and down direction, letting the brush go well up on the gums 
in both jaws. This should be done on the outer surfaces of all the 
teeth. Then open the mouth and brush the giinding surfaces hard, 
being careful to go clear back to the last teeth. Then tilt the brush 
and scrub the inner surfaces of all the teeth, letting the brush go up 
■on the gaims. Then stick out your tongue and brush the top of it. You 
cannot injure the gums by brushing them up and down. It does them 



To Parents. — 'In making this examination for your child at no 
cost to you, there was no desire to interfere with your private affairs. 
We are sure you will be glad to knoAv the condition of the moutli. We 
hope you ■will take the child to a dentist and have all necessary repairs 
and cleanings made. It may be the dentist will find ot].ier cavities. 
Our examination was not meant to be thorough as our time was limited. 

A healthy mouth means better chewing of food; better chewing of 
the food means better digestion of it; better digestion means better 
health ; lietter health means a strongr, abler child, greater freedom from 
diseases and better school Avork. Give your ehild all the chance yo ucan 
to oTow up healthy and with a good education. 

Very truly yours, 

Superintendent op Schools. 



88 Peactical Okal Hygiene. 

the amount of real hygiene instruction given in these 
clinics is far short of ivhat it should he, for tlie expense 
of money and sacrifice of time put into it by professional 
men, of course actual repair and relief operations must 
be made, but tlie chief aim of these clinics ought to be 
to impart instruction that will help these children place 
the proper value on their teeth, and compel them to give 
some measure of attention in the way of a systematic 
mouth toilet." 

This view is correct, and it is to be hoped those who 
have such work in charge will realize the facts, and take 
advantage of their great opportunity for spreading the 
gospel of clean teeth. 

THE NEW FOKSYTHE FREE DENTAL INFIRMARY. 

The Dental Infirmary erected in Boston, and dedi- 
cated to the needs of children is now the model insti- 
tution for all the world. 

The site and building cost half a million dollars, and 
is endowed with $1,000,000.00 for its maintenance. It is 
equipped with the latest and best dental equipment, in- 
cluding a lecture hall for the teaching of oral hygiene to 
the public. The institution is doing what the trustees 
started out to accomplish, that is an aid for "A better 
looking, more perfectly developed race." 

Dr. G. W. Clapp, by editorial in the Dental Digest, 
thus discusses the oral conditions in their relation to 
community hygiene, writes : 

"In America we have not yet reached so enlightened 
a condition; our oral hygiene clinics are mostl}^ con- 
ducted as charities by the efforts of a few noble-minded 
practitioners and the aid they solicit. In the light of ex- 
perience here and abroad it is probably safe to say that 
this is neither a just, a wise, or a safe foundation for 
such enterprises, save in instances like the Forsythe In- 
firmary, where a great endowment insures permanency 
and adequate equipment. Community oral hygiene is not 







o 

c 






o 



^ 



90 Peactical Oeal Hygiene. 

the burden of the dental profession. It may be our duty 
to^ prove its merits, to show what it can do for the com- 
munity and to assist in its establishment by all the means 
in our power. But to look forward to its permanent con- 
duct by dentists is to insure that it will fail of its great- 
est usefulness. 

'' Community oral hygiene is of right a community 
enterprise. It has more to do with the health of the per- 
sons comprising the community, with their economic 
efficiency and the return which they shall make to the 
community, than almost any other single measure. In 
the minds of those who have studied it most, it will i3rove 
an economy rather than an expense. It is not impossible 
that within the childhood of those who benefit by it, it will 
save its cash cost to the community in freedom from dis- 
ease, in improved attendance of children at school, in 
greatly improved mental ability, and in reforming juve- 
nile criminals." 



C H A P T E E Yll. 

TUBEECULOSIS AND THE OEAL 
HYGIENE MOVEMENT. 

As lias been pointed out again and again, one of the 
greatest fields of dental' work is that of preventive den- 
tistry; from the present trend of medical science, it ap- 
pears that an important branch of this work in the future 
will be that of aiding in the fight on the "Great White 
Plague." Observations have shown me that the vast. ma- 
jority of patients who have contracted tuberculosis, have 
unclean mouths, and, on the other hand, I believe the 
patient with the well-cared-for mouth is better able to 
resist this infection. 

The only successful treatment so far, depends on the 
use of fresh air, plenty of good food, pure water, and 
rest. The most important of these is proper feeding, and 
jDroper feeding depends on proper mastication. Com- 
plete and proper mastication cannot be accomplished un- 
less the patient's mouth is in a healthy conditioai. 
Ulcerated teeth, flowing pus from pockets, exposed pulps 
in teeth, and two-thirds of the teeth out of the jaw or out 
of service, will not give the proper nutrition even from 
the purest foods obtainable. 

The pure air of a pine forest, passing through a sep- 
tic mouth, is no better than tlie air of a crowded tene- 
ment. 

Statistics show that fully seventy per cent, of school 
children have enlarged glands. This means either a form 
of tuberculosis or else a predisposition towards that dis- 
ease. A large per cent, of these cannot have other than 
dental entrance for these poisons, for most of them have 
open root canals. This has been demonstrated before the 
German Surgical Society by the process of innoculating 
the pulps of children's teeth. 



92 Practical Oeal Hygiej^e. 

In the crusade against the ''Great White Plague," 
there is not enough stress being laid on the question of 
oral sepsis as a causitive factor for this disease, nor is 
importance enough attached to its worth towards a cure 
of these patients. This matter should be brought to the 
attention of the heads of the various institutions which 
treat tubercular conditions, and also the authorities who 
control the charity institutions. It is our duty to con- 
vince these people of the great benefits that dentistry can 
accomplish for those under their care. 

A few years ago, the writer became interested in a 
free dental clinic for the "Anti-Tuberculosis Society" of 
Atlanta, which was operating a free medical clinic. He 
brought the matter before the Medical Society, and 
then the Dental Society, finally securing the equip- 
ment for running the clinic. At first the members 
of the Atlanta Dental Society took up the work 
at stated intervals. At the present time the Society 
has a regular clinician of stated salary to do this 
work. Reports show a great number of filling operations 
with a very small per cent, of oral hygiene treatments. 
This criticism, of course, applies not only to this clinic, 
but to all others of this kind that have come under the 
writer's investigation. Not long ago Dr. Hoff criticised 
a report of a similar case in like manner. I hope that in 
the future, those who have these institutions under man- 
agement, will bear in mind that the stressing of oral 
hygiene is of more joractical value than dental restora- 
tion to the patients. This is not meant to discourage 
dental work, but it should be, undoubtedly, made secon- 
dary, while it is at present primary. Every patient who 
presents for dental attention, should have his mouth 
thoroughly saturated with some solution. The clinician 
should not examine the patient's mouth until this has 
been done. Each one of these patients should have his 
teeth cleaned up and treated with Iodine solutions until 
oral sepsis conditions are cured. Not only this, but every 
one of them sbould be instructed in the use of the tooth 



Tuberculosis and Oral Hygiene. 93 

brush, and made to show improvement in mouth condi- 
tions. The method adopted in reference to tooth brushes 
in Atlanta is to buy seconds from the tooth brush manu- 
facturers, and sell them to the jjatients at cost. 

In clinics, which I have visited, I noticed that in the 
medical room there are always charts and pictures, show- 
ing the patients what and how to eat, and how to take 
care of themselves. In the dental clinic a like method 
should teach them how and why they should keep their 
mouths clean. It is now known that more trouble comes 
from septic mouths than from dental caries. I have fre- 
quently noticed that these septic mouths do not present 
as large an amount of caries as do mouths under normal 
conditions. Cards should be distributed in the dental 
clinic, calling attention to the importance of this fact, 
also cards explaining the proper use of tooth brush, and 
dentifrice cream, should be given to the patient. If this 
take all of the time of the clinician, then the dental col- 
leges and other clinics of like nature would be only too 
glad to get the regular dental work to do. It takes an 
expert to handle the oral hygiene part of the work at this 
kind of clinic. If our dentists could only see the matter 
in this light, and quit paying all their attention to filling 
teeth, I believe that the medical men would soon rally to 
the cause and place in every institution dentists to do this 
kind of work. "\¥h.ile there are medical authorities who 
recog-nize, to the fullest extent, the importance of this 
matter, not until it is generally recognized will the con- 
dition improve as it should. 

Drs. Weidmann and Lubowski say : 

' ' There is no disease in which healthy and clean con- 
ditions of the mouth are of such vital importance as in 
tuberculosis of the lungs. Tubercle bacilli are found in 
carious cavities, and it has been proved that especially 
unclean portions of the mouth constitute a portal of en- 
trance for the tubercular poison. Partsch, of Breslau, 
reports a case of grave tuberculosis caused by a carious 
tooth with such acute inflammation of the lymphatic ves- 



94 Peactical Oeal Hygiene. 

sels that an operation became necessary. Also many 
cases of tuberculous infection by way of the alveoli have 
been reported. These and the authors' own observations 
leave no doubt as to the fact that dental caries is respon- 
sible for many cases of tuberculosis. Tuberculous 
tumors situated opposite carious teeth resist every treat- 
ment until the carious teeth are filled or extracted. Long- 
established lymphatic swellings also will generally not 
yield until the carious teeth are treated. All the gener- 
ous efforts of charitable and public institutions for the 
cure or prevention of tuberculosis are of no avail unless 
the causes of the disease are removed, and among the 
most dangerous causes are beyond doubt defective teeth 
and unhygenic oral conditions which exist especially in 
children. ' ' 

S. Adolph Knoph, Professor of Phthisio-Therapy at 
the New York Post Graduate Medical School and Hos- 
pital, of New York, writes : 

"It must be said to the glory of the American achieve- 
ments that dental science, the art of preserving the teeth 
by truly scientific method, had its birth in this country. 
While we physicians have gone to Europe to complete 
our education, the European dentist comes to America 
to learn the best and latest in his profession. The latest 
and most glorious development of the American dental 
science is dental hygiene, for dental hygiene means pre- 
vention and preservation, and these bear the closest re- 
lation to the prevention of tuberculosis. 

''One of the earliest and very frequnet symptoms of 
tuberculosis is impaired digestion. While I do not wish 
to say that bad teeth constitute the onl}^ cause of diges- 
tive disturbance, if bad teeth are present, they are a fac- 
tor contributing to this pathogenic condition. Ulcerated 
teeth may give entrance into the bone of tubercle bacilli 
that have been accidentally inhaled or have been con- 
tracted by secondary infection." 

Prof. Fisher, of Yale, is authority for the statement 
that, ''Seventy-two Americans die every hour from pre- 



Tuberculosis and Oral Hygiexe, 95 

veritable diseases." Counting this up for a year, we are 
amazed at the glaring fact of this needless mortality 
which "^e have here in our country. Enough people 
might be saved each year to populate a city the size of 
Baltimore, and the further fact is that at any time these 
deaths may come near to our o^vn doors. A large' per 
cent, of these deaths come from dental origin, and makes 
it necessary for the dental profession to "sit up and take 
notice." 

Drs. W. Gr. Ebersole and Marshall have declared that 
decay of the teetli is the most prevalent disease of dvi- 
lization, and that there are thousands of invalids who are 
such because of faulty oral conditions. They also believe 
that all the medical treatment in Christendom could not 
cure them. It is not for the dental profession nor 
the medical profession to claim the whole field for the 
work, and, even together, we can hardly make a success- 
ful fight unless the sympathies of the people are gained, 
and they work with us against the great common foe — the 
"Preventable Diseases." 



CHAP TEE VIII. 
BRUSHING THE TEETH. 

SHAPE OF THE BRUSH. TEACHING THE TECHNIQUE OP BRUSH- 
ING THE TEETH. THE DIRECTION CARD. THE BAD 

BREATH SIGNAL. LIME WATER AS A MOUTH WASH. 

Tooth brush handles at the present tune are made of 
bone, purchased from the Chicago Stock Yards. The 
best grade handles are made from the thigh, and the 
cheaper ones are made from the shin and buttocks bone. 
The back is grooved, holes are drilled, and then wire is 
drawn through, pulling the bristles into place. The 
grooves are then filled with cement. 

The best bristles come from Russia, India, and G-er- 
many. They are washed, bleached, cut into proper size, 
selected, and graded. In one tooth brush factory, I am 
informed, that some of the graders have been employed 
for twenty years at the same work. 

SHAPE OP BRUSH. 

As to the shape of the brush, we have every variety 
described, from the sway-backed brush to its opposite, 
the curved handled brush in the so-called "Prophylactic 
Tooth Brush." In shape they vary from the largest, as 
prescribed by Dr. D. D. Smith, to the smallest one, de- 
scribed by Dr. Jules J. Sarrazin, of New Orleans. In 
"texture, they range from the softest brush, prescribed 
by the author, to the stiifest brush, prescribed by many 
of the leaders of the profession. Each dentist has some 
peculiar idea upon the shape and size of the^ brush, but 
this will have little bearing upon the subject as to clean- 
ing the teeth. 

TEACHING THE TECHNIQUE OP BRUSHING THE TEETH. 

There is, however, one point upon which they will all 
agree, and that is the training of the patient into the 



Bkuseeing the Teeth. 97 

proper brushing of the teeth. It is surprising to note the 
ignorance of our best patients upon the handling of the 
tooth brush. It is even more surprising to note how few 
dentists take any time to train these j)atients. I have 
made it a point to inquire always of new patients whether 
or not their former dentists taught them to use the tooth 
brush properly. Very seldom do they answer in the 
affirmative. However, asking the question, m most cases, 
is superfluous. The appearance of the teeth tells us all 
that we want to know. 

It is a good idea to have brushes in the office for sale 
to our patients, for, if we give them a prescription, they 
go to the drug store, and do not always get the proper 
brush, and we do not have the chance of teaching them 
to brush the teeth properly. It is a good idea to buy the 
best brushes obtainable, by the gross, and allow the office 
assistant to handle the sale of them. Incidentally, there 
might be added all the articles for the proper toilet of 
the mouth, such as floss silk, dentifrice, and mouth wash. 
People do not buy brushes enough. They will use them 
until they are worn almost to the handle. Such a brush 
is not only laden with germs of all kinds, but it is abso- 
lutely worse than nothing with which to brush the teeth. 
Such a brush is always shedding its bristles, which stick 
between the teeth and cause great irritation. 

Dr. C. Eclmund Kells, of New Orleans, was the first 
man to give me the idea of having ' ' Direction Cards ' ' for 
brushing the teeth, for ' ' distribution among the patients 
when the brush is sold to them." A modification of the 
Kells card, as used by myself, is here shown. If we give 
the patient these directions orally, he soon forgets, but if 
we give them to him on a printed card, it is impressed 
on his mind. 

Some years ago, I had a patient, an elderly lady, for 
whom I did a great deal of work. "When the work was 
finished I explained to her that, at her age, she could not 
expect the work to last as it should unless she brushed 
her teeth properly. At this time, I did not keep brushes 



98 Practical Oeal, Hygiene. 

for sale in the office, and told lier to go to the drug store 
and purchase a certain kind of tooth brush and to brush 
her teeth correctly. Some months later, I received a long-^ 
distance telephone message that the work had entireh^ 
given out, and that her mouth was in a terrible and pain- 
ful condition. An engagement was made. On her ar- 
rival, I found that the condition was about as she had 
said. Of course, she had been brushing her teeth, ''just 
as 3^ou told me. Doctor." She was rather wrathy. 
Arrangements were made for the patient to come next 
day, and bring her brush with her. The next day she 
returned, and I had her to brush her teeth for me. She 
brushed the teeth as well as I or anybody else could have 
done it, but, if she had been taught for a month, she could 
not have evaded more skilfully the very places which she 
needed to brush, that is, the gingival margin of the gums. 
This led me to the valuable idea of never saying, "brush 
the teeth," but rather say, ''brush the gums," for if they 
brush the gums in a proper manner, the teeth will get 
a thorough brushing. 

In demonstrating the brushing to the patient, there 
are several methods which may be employed. The one 
advocated and used by Dr. Edmund Kells, and Dr. R. B. 
Adair, is that of having a full artificial denture, and 
demonstrating to the patient by brushing this model. 
However, I find it more efficient to have the patient hold 
a hand mirror, and watch me brush their own teeth in the 
proper manner. A peculiar fact is, however, that, while' 
you are brushing the patient's teeth, and trying to show 
him what you are doing, his eyes are over the edge of the 
glass or off to one side, anywhere except on the mirror. 
You will have to look in the glass as well as at the teeth. 
They will tell you, "Yes, I understand, I see," when they 
are not seeing at all. Be careful about this point, and 
make them see. When you have finished the demonstra- 
tion, give them a brush, and make them go over it them- 
selves. I sometimes have the patient hold the brush. 



Brushing the Teeth. 99' 

while I grasp their fingers in order to make them go 
through the proper manipulations. 

I remember one patient, a prominent physician in an 
adjoining state, who I had remain for a week, visiting my 
office daily, taking some six or seven lessons before he 
had mastered the technique of brushing his teeth. It is 
a lamentable fact that so few people possess enough 
manual dexterity to touch all the surfaces of their teeth. 

Personally, I believe in a soft grade of tooth brush, 
for the reason that the gums are massaged with the sides- 
of the bristles; should this be done with a stiff bristle 
brush, it would do considerable damage, that is, if the 
patient carried out my instructions. Again, I know that 
a soft bristle brush is sufficient to clean and polish the 
surfaces of the teeth. I know, that whenever I want to 
polish anything on my lathe, I use wheels of fine texture, 
and, that whenever I want to grind or cut into the sur- 
face, I use a stiff brush. In the mouth I have but one 
idea, and that is to clean and polish, and not injure any 
structure. 

I demonstrated in m}' office to several dentists — ad- 
vocates of the hard tooth brush — by cleaning the teeth 
of a patient in the following manner: on one side, I 
cleaned with a camel's hair brush, while on the other side 
I used a medium stiff brush. The debris was cleaned off, 
if anything, better on the side where the camel's hair 
brush was used, and, on the side where the stiff brush 
was used, the gums were in a bleeding condition. 

Dr. Arthur Black says, ''I have seen very few cases 
only two of which I have made definite record, in which 
the gum septa have been inflamed by the use of a too 
stiff tooth-brush. In both cases, there was marked im- 
provement promptly following the change to a softer 
brush. ' ' 

Dr. M. L. Fletcher insists that his patients use a hard 
brush, and, in addition, that the teeth be scrubbed, claim- 
ing that in addition to cleansing the teeth, the connective 
tissue is developed to a high degree in tliom. This, he 



100 Peactical Oeal Hygiene. 

says, has the same effect on the teeth and gums as the 
mastication of hay, twigs, and rough food has on the 
gTims of animals. Dr. Fletcher, some time ago, suggested 
that corn meal was as good a cleanser for the teeth as 
was needed, claiming that it has sufficient cleansing 
power without injury to the gums. He also objects to 
dentifrices that contain soap, claiming that they cause the 
tooth brush to slip over the tarter and food without re- 
moving them. On the contrary. Dr. N. S. Jenkins claims 
that this is the most important thing for a properly pre- 
pared dentifrice. 

It is reasonable to believe that before the deposit of 
tarter takes place, there must be some cementing sub- 
stance to hold it in place — some agglutinizing material; 
thus, if we fail to brush our teeth one day, this material 
accumulates on the teeth, and forms the beginning of cal- 
carious deposits, with the result that from this one day's 
lack of brushing a rough surface is left for the beginning 
of an accumulation. We see how important it is to train 
our patients to know that an irregular system of brush- 
ing the teeth fails, and that for brushing the teeth, to be 
successful, it must be regular and systematic, with no 
skips in between. After the material has accumulated 
on the teeth for a few days, it is impossible for the 
patient to remove the deposits, and he must report to the 
dentist. 

Dr. Francis says, ''Some mouths, so far as the tooth 
brush is concerned, are unexplored caverns of miniature 
type, and, others which receive an occasional visit from 
the intrusive explorer, are not in a very much better con- 
dition for the little care bestowed upon them." 

Expressions as the one just cited should urge us to 
the utmost to bring about a change of thought in the 
minds of our patients toward the cleanliness of their 
mouths. This training of patients to brush their teeth 
properly is one of the hardest and most thankless things 
that the dentist has to do. 



Brushing the Teeth. 101 

the dieection" card. 

In former years, before I used the printed ' ' direction 
cards," mucli time was spent in training the patients. 
When at a subsequent sitting, if asked to demonstrate 
how they were brushing their teeth, they would do almost 
the opposite from what had been told them. The patients 
way you told me." 
often replied with the expression, "Now that is just the 

DiRECTIOXS FOR THE PROPER CARE OF THE TEETH. 

Upon Rising the teeth and gums should be most carefully, 
thoroughly, and Correctly Brushed — using a soft grade tooth 
brush and • . 

After Breakfast, Avased floss silk should be passed between the 
teeth (be careful not to snap it down hard upon the gtims, as 
•this would injure them) or a quill tooth pick should be used — 
never use a Avood tooth pick. 

After Dinner or luncheon, when possible, waxed floss silk or a 
quill tooth pick should be used and the mouth most thoroughly 

washed with , if convenient^ — otherwise 

with plain water. 

After Supper repeat the above. 

Just before Retiring, the teeth should be again thoroughly 

and Correctly brushed with ' and the 

mouth thoroughly rinsed with ' — . 

Don't brush across — brush the under teeth up and the upper 
teeth down — brush hard — you cannot injure the teeth or ^ims; 
the gums will soon become hard, firm and healthy. 

For foul breath nothing equals the pleasant odor, taste, and 

antiseptic qualities of « ' . which should 

be used in good, big mouthfuls and retained as long as possible. 
Keep the teeth shut and alternately distend and draw in the 
cheeks, forcing the fluid between the teeth. 

Nothing short of the above constitutes good care of the teeth. 

{Tack this card above tooth brush holder). 

Fig. 14. The Dentist's Favorite Dentifrice and Mouth Wash is 
TO BE Inserted in Blanks. 

Now, after training the patients, a card containing 
condensed directions for the care of their teeth is given. 
They are requested to preserve this card. The patients 



102 Peactical Oral Hygieiste. 

will get a better idea from seeing the suggestion in print. 
Tlien when tliey claim, "just as you showed me," you 
have all the advantage by using another direction card. 
Dr. Kells was the first to suggest to me the advantages 
of this method. All dentists should have printed some 
card giving their directions. It saves time, does good, 
and costs little. 

On the direction card illustrated, note carefully the 
word "Correctly," and the technique which is given; 
if this is carried out it will remove the debris from the 
teeth, and give a better massage effect to the gums than 
any other method with which I have experimented. This 
results in the bristles going into the interstitial spaces. 

The manner in which most people brush their teeth 
resembles the way in which the small boy shines his shoes 
on Sunday morning. He shines the tips all right, but, 
if left to himself, he never touches the heels. People 
will brush their front teeth, but they never get to tha 
back ones. 

In brushing the teeth, we should begin at some defi- 
nite point, such as, for example, the upper right buccal 
surfaces. The brush is placed with the bristles pointing 
straight up, the side of the brush against the gums. A 
rotary tilting motion revolves the bristles, using the 
hands as an axis, and thus forcing the bristles between 
the teeth. The brush is next moved around to the front, 
and then the left buccal surfaces. Then, in order, lirusli 
the palatal and lingual sides of the teeth with the same 
position of the brush, high upon the arch, and turned 
outwards, bringing the bristles down between the teeth. 
Then the occlusal surface of the molar teeth is given care- 
ful attention. For more detailed direction for brushing 
the teeth see Dr. Corley's outline lecture. 

Dr. Pones states that the tooth brush be made to 
travel as fast as the hand can be made to go, and he gives 
another useful point in brushing the inner surfaces of 
tlie lower teeth, which is, to have the patient hold the 
thumb on the top of the handle instead of around it. 



Beushixg the Teeth. 



103 



CLEANING THE 

N5IDE: or 

TNE 10\NLK 
mm TEETh 




Fig. 15. Showing Important Tooth Brush Movements. 



104 Peacticai. Oral HYGiEisrE. 

Tlie brush is now placed in the right side in just the 
reverse manner. On the lower jaw, it is just the reverse 
as on the upper. Here, the bristles point straight down, 
and the long- side of the brush is against the gums. We 
now bring j)ressure, and rotate the brush upwards. The 
same technique is brought out around the circle of the 
teeth, but when we come to the lingual sides of the lower 
jaw teeth, we have to change our technique. Here, the 
brush has to be pressed between the tongue and the molar 
teeth. The molars should be brushed with an in and out 
movement, as the rotary movement would be of no use on 
account of not being able to get the brush below the gum 
margin. The lingual surfaces of the lower incisors is 
brushed by inserting the brush as far down as possible, 
and bringing it out with an upward movement. We must 
caution the patient against brushing across the cuspids 
for fear they will cut grooves. 

We mean when we say, ''A clean tooth will not 
decay," that the pabulum on which germ life will feed 
has been removed, or rendered inert. 

Dr. A. E. Peck gives the following suggestions for 
the patient to use : 

"Impress them with the importance of removing all 
deposits of food or other material which would form a 
good culture ground for dangerous germs. These de- 
posits under the margin of the gums can be removed by 
the patient with a properly shaped stick and an abrasive. 

"The Tongue Scraper, Massage Stick, and Polish 
will assist materially in this work. With this stick 
they can keep the tobacco stains from their teeth, 
and prevent many plaques from forming. The mother 
can use this stick on the teeth of the children who are 
too young to come to the dentist. She can help keep their 
mouths clean and healthy, and at the same time educate 
them to the importance of having their teeth attended 
to. It will familiarize them with having others work 
on their teeth, and when they do come to the dentist they 



The Bad Breath Signal. 



105 



will be mncli more easily liandled, and better results will 
be obtained. 




Fig. 1G. The Care of the Tokgue is Oetek Xeglected. SoiiE 

SniPLE Appliaxce as Above, Properly IJsed^ is a Great 

Aid Towards a Cleax JMouth. 

"The value of the tongue scraper was recognized by 
the Chinese many years ago, and a jeweled tongue spoon 
was a part of their toilet requisites. The removal of the 
([isintegrated mucus from between the papillae of the 
tongue eliminates from the body a fine culture ground 
for all kinds of bacteria. The tongue scraper should be 
used soon after rising each morning." 

TI-IE bad breath SIGXAL. 

How often on the street corner, on the car, in the 
church pew, at the social function, and in the dental chair 
have we been annoyed by having to associate with those 
individuals who suffer from bad breath. As the posses- 
sor of the bad breath is not aware of its odor, he, conse- 



106 Peactical Oral HYGiEisrE. 

queutly, does not know tliat he is so afflicted, and it does 
seem that he always wants to get iip close to yonr face 
to talk. Strange to say, some of these very people carry 
out to the best of their ability and knowledge the ordinary 
rules of mouth hygiene, and yet this condition continues 
to exist. 

This is a very delicate matter to mention, and yet, 
there is no one so well placed as the dentist to help in 
this respect. The subject of foul breath should not be 
discussed with these patients, for they are very sensitive 
on the subject. However, in a tactful manner of speech, 
we can train them into a more accurate system of flossing 
the teeth, and can suggest their taking up a system of 
Prophylaxis. If we do this, we can work out to our satis- 
faction the cure of this defect. 

Dr. Geo. M. Niles, a Gastro-Intestinal specialist, has 
written a valuable paper on the subject of, ''The Bad 
Breath: What it Portends." Some extracts from this 
paper give us valuable information on this subject. 

"When the personal odor is offensive, it is a great misfortune; if 
preventable, it is an inexcusable disgrace. 

"In the ordinary intercourse between individuals, the exhaled breath 
generally constitutes the most noticeable odor, and it is to that phase 
of the subject this study is mainly directed. 

"Every one of my readers can probably call to mind one or more 
acquaintances, who, except for an abominable breath, would be attrac- 
tive; but from the presence of this handicap, are avoided, perhaps dis- 
Uked. 

"A busy dental surgeon, of this city, who has offices in the same 
building with a rectal specialist, recently informed me that, on com- 
paring notes, they both decided that the dentist, in his daily routine, 
encountered more offensive and septic cavities than did the latter in 
his rectal work. 

"The mouth, as the portal of entrj' for food and air, warm and 
moist, with numerous nooks and crannies, where stray particles of food 
and other debiis may furnish an inviting field for countless miero-oi-gan- 
isms, is by far the most fruitful source of bad breath. Among other 
causes in and adjoining the mouth, besides carious teeth, pyon'hea 
alveolaris, tartar, septic gums, glossitis or stomatitis, may be men- 
tionod necrosis of the nasal bones, iiurulont hypertrophic or atrophic 



Lime Water as a Mouth Wash. 107 

rhinitis, ozena, septic tousilitis, or even squamous-eelled carcinoma of 
the mouth or tongaie. 

"After all is said, however, it must be admitted that we occasionally 
see a patient in whom no adequate cause can be found, but who, never- 
theless, labors under this misfortune. Though it is possible that such 
may be due to some lamentable jDcrsonal idiosyncrasy, we should be 
slow to admit such a contingency. In these rare cases a jDersistent 
search ■^dll sometimes disclose a putrefying impaction in some almost 
inaccessible recess in the mouth, where neither toothbrush nor denti- 
frice can penetrate. A dentist of experience of this city, stated to me 
that a breath of surprising foulness could be produced by one small 
impaction of this sort — so small as to be discovered only after patient 
search. 

"Successful management by the physician or dental surgeon will 
afford such relief from embarrassment to the patient and annoyance 
to friends, that well may the emancii^ated sufferers 'rise up and call 
him blessed.' " 

While most cases of foul breath are clue to mouth con- 
ditions of the patient, it may come in some degree from 
constipation or intestinal intoxication. Generally, in un- 
complicated cases, the taking of some purgative medicine, 
as one teaspoonfull of epsom salts, before breakfast, for 
a week or ten days together with larger quantity of 
water, will help this condition. 

LIME WATEE AS A MOUTH WASH. 

The number, kinds, and styles of dentifrice and mouth 
wash formulae are legion. It is not the intention of the 
writer to enter into a discussion of their relative merits, 
except to say that it is not so much which brand is used 
as the ivay in which it is used. 

As many of our prominent dentists have become such 
'strong advocates to the use of lime water for a mouth 
wash, the method of its preparation will be given. 

Dr. Kells, of New Orleans, was one of the first advo- 
cates of lime water as a mouth wash. As the proper 
quality of lime is rather hard for the patients to secure, 
he keeps this put up in two-ounce bottles for supplying 
his patients. His idea is that if the patient uses a pro- 



108 Peactical Oral Hygiene. 

prietary moutli wasli in as large quantities as he pre- 
scribes, it wonld be too expensive for tliem. 

Noticing that Dr. Fones, of Bridgeport, Connecticut, 
also recommends lime water, I asked Mm to give his 
opinion relative to the recent publication of Pickerill, 
who claims that all alkaline mouth washes prevent a free 
flow of saliva, and, as the saliva is the best mouth wash 
possible, the use of lime water does not have the desired 
effect. My personal experience was that it always left 
a furred feeling instead of a cleanly one. 

In answer to these queries, Dr. Fones wrote me, and 
I quote at length: 

' ' The reason why I am such an advocate of lime water 
for a mouth wash is that it is such a powerful, 3'et harm- 
less, solvent for the mucilagenous accumulations around 
the necks of the teeth, as well as their proximal surfaces. 

''Kirk has found by scientific experiments that it is 
one of the best solvents for placques and gummy accre- 
tions of the teeth that has come under his observation. 
Its alkiline reaction does not especially enter into the 
subject in consideration of its merit. If you will secure 
the coarse lime, which is a very light cream color, and 
prepare it in the following manner, I am sure you will 
not have any furry effect in your mouth, but one of ex- 
treme cleanliness. 

"Place a half cup of the unslacked lime in an empt}?- 
quart bottle, and then fill with cold water. Thoroughly 
shake and allow the lime to settle. Pour down the sink 
all the water you can without losing any of the lime, as 
this first mixture contains the washings of the lime. 
Again fill with cold water and shake, and when this has 
settled pour off some of the clear water in a ten or twelve 
ounce bottle for use at the bowl and again fill the quart 
bottle with cold water, shake and set aside for future 
use. This operation may be repeated until five or six 
quarts of the mouth wash has been used. If the lime 
water is a trifle strong at the start, dilute that in the 



JjIme Watek as a Moitth "Wash. 109 

small bottle with water. After rinsing the mouth with 
the lime water (and the rinsing should be of sufficient 
length of time to thoroughly foam it), rinse the mouth 
with clear warm water. I have yet to find anything to 
beat it." 



CHAPTER IX. 
CLEANINd THE TEETH. 

SKILL REQUIEED FOR THE WORK. THE BEST TIME TO CLEAX 

THE patient's TEETH. — THE USE OF A DISCLOSING 

SOLUTION. INSTRUMENTS USED FOR CLEANING 

THE TEETH. ABRASIVE MIXTURES TO BE USED 

IN CLEANING THE TEETH. 

Under the term, ''Cleaning the Teeth," will be de- 
scribed the operative measures employed at the dental 
chair for removing* deposits, bacterial placques, and 
stains from the average mouth. This term does not give 
sufficient dignity to the work, and all investigators who 
work along this line will be glad for a better term. None 
has been forthcoming, and, as all our patients know what 
we mean when we use this term, it is one which we will 
more often be forced to use with them. If our clientele 
understand ''Removing Infection," or "Prophylaxis 
Treatment," then these terms can better be employed. 

It seems rather a strange coincidence that a few years 
ago, the dentist who "cleaned teeth," was in danger of 
losing his club and social standing, but within the last 
few years, the importance of this procedure has so im- 
pressed itself upon the patients that the man who does 
not clean the teeth of his patients, or have it done, is 
looked upon as one either behind the times or failing in 
his legitimate duty to his patients. There was a time 
when our profession would put in beautiful fillings, and 
send the patients away with a clean bill of health, al- 
though the free margin of the gums exhibited rings of 
calcarious deposits. It was not many years ago that the 
patient would not pay, or rather was not required to 
pay, more than from one to three dollars for this opera- 
tive procedure. Many of the laity were accustomed to 
having, as the Indians express it, the cleaning put in as 



Cleaxixg the Teeth. Ill 

*'potlash," that is, where any work was done, the clean- 
ing was added free of charge. In view of this state of 
affairs, it is not to be wondered at that there was so little 
cleaning of the teeth done by the dentists. It was also 
a deplorable fact that onr colleges paid little heed to this 
subject, and many gi'aduates, during their college days, . 
never saw a mouth properly cleaned up by their profes- 
sor or demonstrator. If the college did any of this work, 
it was relegated to the freshmen. 

SKILL EEQUIEED FOR THIS WOEK. 

From the belief that any one can clean k set of teeth, 
we are now learning that this operation requires most 
expert ability, and thorough knowledge of anatomical 
landmarks, as well as medical treatment for pathological 
conditions. Generally, the placing of fillings is mere 
routine work, but the. more teetb we clean, and the more 
mouths we j)ut in a healthy condition, the more we realize 
that greater skill is required here than in any other line 
of work which we do. We have learned that the average 
patient cannot maintain clean teeth, and that they will 
have to have our professional assistance along this line. 
We have also learned that this work is of immense value 
to the patients, and that it is worthy of a reasonable com- 
pensation which will enable us to pay more attention to 
the matter. 

To secure a clean set of teeth — -one that would be so 
considered by a specialist in prophylaxis — is one of the 
most difficult procedures in dentistry. It behooves us to 
put just as much time on this work as practicable, or, in 
the event the patient is one who will appreciate this ser- 
vice, as much time should be given him as would accom- 
plish the proper cleansing of the teeth. 

THE BEST TIME TO CLEAN THE PATIENT 's TEETH. 

A surgeon would not dare perform any operation 
without first making some attempt at cleaning and steri- 



112 Peacticai. Oral Hygiene. 

lizing the field of operation, but the dental surgeons ab- 
solutely ignore these rules of surgical procedure. I do 
not think that any dental operation should be undertaken 
until the teeth have first been properly cleaned. This 
should be done as routine work. There are many ad- 
vantages resultant from this procedure. In the first 
place, it puts the cleaning operation on a higher plane 
than if it were done when the regular dental work is 
finished. In the second place, it enables us to bring for- 
ward the salient points of oral hygiene to the patients. 
In the third place, it protects the dentist from any in- 
fection, should any of these germs be absorbed through 
a break of the skin in his hands. In the fourth place, 
it prevents hini from having the possible infection of hay 
fever, la grippe, and tuberculosis, for, if the mouth be 
properly cleaned out, the danger of infection from this 
source will be reduced to a minimum. In the fifth place, 
there is no doubt in my mind that if the mouth is prop- 
erly cleaned out before the work is done, crowns and 
bridges will stay and last longer. There are many other 
reasons that I could enumerate, but these are enough to 
impress the matter on the mind of the dentist. Again, I 
w^ould like to repeat, '^' Clean or have cleaned every set 
of teeth before you operate." 

Eight here comes the question, ''Who shall do this 
ivork?" Some of us have dental nurses in our offices, 
and to them is intrusted this work. I have seen better 
work done along this line by them than by many dentists. 
If you can train up an assistant to do this work, well and 
good. 

The methods employed in cleaning the teeth are many 
and varied. Whatever method is employed, let us be 
sure that the patient's gums and lips are not torn up with 
the instruments or the floss silk. All of us have seen 
patients with their mouths so sore that they could not 
brush their teeth for a day or two, or even chew their 
food properly, following the simple operation of cleaning 



Cleaning the Teeth, 113 

the teetli. There is no need for any great physical force 
to be exerted in the operation. 

THE USE OF A DISCLOSING SOLUTION. 

In beginning, it is well to spray the mouth with a 
solution containing aromatic spirits of ammonia, diluted 
three times with water. This removes the viscosity of 
the saliva, and removes all decomposed particles of food. 
It is a strong cleanser, and has a pleasant effect. We 
now paint the teeth with some staining solution, the best 
of which is Skinners' Disclosing Solution. 

FORMULA FOR 1 OZ. DISCLOSING SOLUTION. 

Iodine (ei-ystals) grs. 50 

Potassium Iodide grs. 15 

Zinc Iodide grs. 15 

Glj^cerin drs. 4 

Aqna drs. 4 

Mix. Sig. paint teeth (one or 
'two at a time) and rinse immediate- 
ly with water. 

Put Tip in dass stojipev hottle. 

In making it, put the iodine, zinc, and potassium 
iodide into a, mortar with five or ten drops of glycerin. 
Grind to a thick syrup, and then pour all you can into 
the bottle. Pour the remaining glycerin into the mortar, 
and stir with a pestle. Pour out again, then add water, 
and stir again. In this way you can get all the solids out 
of the mortar, whereas, if the solids and liquids were all 
put in at once, some of the iodine would stick to the 
morter, and an inferior staining solution would be the 
result. This solution shows up the bacterial placques, 
and aids in removing them. 

INSTKUMENTS USED FOR CLEANING TEETH. 

There are many and varied instruments in the market 
for removing calculus, and with most of them you can 
obtain good results. It is a question of personal equa- 



114 Peactical Okal Hygiene. 

tion. I would caution yoii to select, and use the smaller 
instruments. Many colleges have on their required in- 
strument list, scalers which suggest plows, rather than 
dental instruments. The writer has for years been an 
advocate of the Good- Younger instruments for this work, 
for the reason that they can be used either "push" or 
"pull," and, being small and roimded on the back, do not 
injure the tissue; they are rights and lefts and can be 
used in a double ended handle, simplifying operating a 
great deal. 

The students should be taught that pyorrhea work is 
on the same principal as cleaning the teeth, and, if they 
hope to operate for pyorrhea, they must become adept 
in cleaning teeth. With this thought in view, let me urge 
that much care be taken in the use of whatever instru- 
ments are selected for this work. 

It takes a separate set of instruments for this work, 
and for the pyorrhea work, for here we do not wish the 
instruments to be sharp. It is advisable to round off 
the sharp edges of the set intended for cleaning the teeth. 
Much injury can be done to the peridental membrane if 
its attachment is separated at the gingival border. Use 
a chip blower, or a strong current from the compressed 
air syringe, and blow at the gingival margin, thus forcing 
the margin of the gums away. This enables the operator 
to see the small patches of infection or deposit which 
have been previously stained by the solution. The assis- 
tant can so manipulate the air syringe as to be of great 
aid to the operating dentist. Now, as in pyorrhea work, 
to be skillful, one must brace his fingers on the teeth, so 
that no slip of the instrument can occur. The number 
15 is used for removing deposits on the anterior teeth, 
while the numbers 3 and 4, right and left, are used 
for removing material from the posterior teeth. The 
small blade of the instrument should be run completely 
around the free margin of the gums, for we have found 
this to be the starting point of many pathological con- 
ditions of the gums. It does no more harm to carefully 



Cle AIDING THE Teeth. 115 

clean out this free margin than it does to clean out the 
finger nails. In fact, one of the tests that I make of new 
instruments is to run them under my thumb nail, and, 
if it cleans the cuticle there without injury, it will do to 
use on the free margin of the g-um. 

After the instrumentation has been done, the next 
procedure is the use of waxed dental floss silk between 
the teeth. The usual round dental floss will not give the 
desired results. You must have a flat floss to do the work 
properly. It must also be as large as can' be forced be- 
tween the teeth. On this floss we use an abrasive con- 
sistent with the amount of infection which is to be re- 
moved. If the spaces between the teeth are large, and 
considerable debris is to be removed, then we may use 
an abrasive containing flour of pumice. On the other 
hand, if the patient's mouth is in fairly good condition, 
we need not use such an abrasive powder, but use a chalk 
mixture or one of the formulas which I am giving at the 
end of this chapter. There is one caution to be borne 
in mind, and that is, in using large size silk, place the 
thread between the teeth, and then place on whatever 
abrasive is to be used. If we placed the abrasive between 
the teeth, and then attempt to pass the silk, we would find 
it almost impossible to do so, and, even if it did go, one 
half of the floss silk would be cut in two. 

It is not necessary to saw the gaims or the cheek with 
the silk, nor is it necessary to fill the mouth with the 
abrasive material. The smallest amount is all that is 
necessary. The silk should be passed thoroughly be- 
tween all the teeth and threaded under whatever bridges 
the patient may wear. "When this is done, the patient's 
mouth must be thoroughly rinsed out with a syringe, or 
sprayed with compressed air, and then some mild anti- 
septic mouth wash used. 

We are now ready to cleanse the bodies or the crowns 
of the teeth. If you have the skill, and the time, there 
is no better method than the orange wood stick and dry 
pumice flour, but, while this is the ideal method in pro- 



116 Practical Oral, Hygiene. 

pliylaxis, for the simple cleansing of the teeth, most of 
ns will use the dental engine. There are many and varied 
devices at our command for use on the engine in our hand 
piece. Possibly, you have adopted the bristle brush as 
being the most efficient; nothing has yet been found equal 
to the brush wheel for polishing. We should have one 
right angle hand piece set aside for this \vork. Surely, 
everybody has an old right angle that can be dedicated to 
this work. I have never been able to do this class of 
work with a straight angle hand piece, and any one who 
has used a right angle for cleaning teeth with a bristle 
brush, will never use a straight one again. Formerly, I 
had a great deal of trouble with my right angle in this 







Fig. Vi 



work, because of the abrasive getting into it, but now T 
use the Consolidated Dental Mfg. Co 's., right angle, which 
completely closes at the back, and by inserting a rubber 
cup on backwards, I can keep the abrasive out of the 
mechanism. Needless to say, a fresh brush is furnished 
to every patient. However, I can see no objection to 
these brushes being saved, and, at the end of the week, 
being cleansed by boiling for fifteen or twenty minutes, 
and used in future operations. 

These inverted bristles can be had in a stitT grade, 
which are black, and in a soft grade, which are white, 
also in camel's hair brushes. The unmounted kind are 
the ones used in right angle hand piece, using the short- 
est right angle mandrel. 

With the sharpened orange wood stick, place around 



Cleaning the Teeth. 117 

the teetli the abrasive, and with the dental engine run at 
a low rate of speed, carefully go over all surfaces of the 
teeth, giving the hand piece a motion from the gum 
toward the cutting or grinding surface of the teeth. The 
mouth is again washed out, and the staining solution ap- 
plied as at first. If there is any debris, bacterial plaques, 
or calculus still remaining, this staining solution will im- 
mediately show them up. 

Now comes one of the most important parts of the 
operation— the careful removal from under the free 
margin of the gums all trace of the abrasive that has been 
used. It takes force to remove this material, and calls 
for the highest pressure which we can put on the air or 
water syringe. We must bear in mind that this abrasive 
has sharp edges, and, if left under the gum margin, ijiaj 
cause irritation or pyorrhea! conditions. The mouth 
should then be rinsed out with cold water, and, as a 
finishing touch, I advise that some lotion as Holmes' 
Fragrant Frostilla be applied to the lips, which have 
necessarily had much unpleasant stretching. "When this 
technique is carried out, and the proper dental toilet ex- 
plained, the patient is delighted and is usually willing- 
to pay liberally for the services rendered. 

abeasive mixtuees to Be used in cleaning the teeth. 

Ordinary powdered pumice can be mixed with either 
tincture iodine, alcohol, or peroxide of hydrogen. The 
iodine stains, the alcohol is the best antiseptic, while the 
peroxide is good to remove green stains. 

To a teaspoonfull of pumice can be added about ten 
drops aromatic sulphuric acid. This is splendid for 
tobacco stains. 

The above should only be used where the teeth are in 
a bad condition. 

Flour of pumice is much finer, and should be substi- 
tuted for the regular pumice, if possible. It can be mixed 
with anv of the above drugs. 



118 Peactical Oral Hygiene. 

If the teeth, are in a fair condition, it is best to make 
a teaspoonfull of any good dentifrice or tooth paste, and 
incorporate with it a small quantity of flour of pumice. 

Any of the above can be used either with dental en- 
gine or hand cleaning with porte polisher. 



PART II. 

PRACTICAL ORAL PROPHYLAXIS 



CHAPTEE X. 
ORAL PROPHYLAXIS. 

DEFINITIOlSr AiSTD VIEWS OF SMITH, SPALDING, FLETCHER, 
FONES, TAYLOR, RHEIJST AND HARPER. 

It was some years ago at a meeting of the National 
Dental Association, in Washington, that I first heard any 
thing definite on oral prophylaxis, and became interested 
in this subject. At this time it was my pleasure to listen 
to a paper read by Dr. D. D. Smith, of Philadelphia, and, 
a few days afterwards, to meet him personally in his 
office. This meeting changed my entire method of con- 
ducting practice, and led me into the channels of prophy- 
laxis. While it is true that this subject of oral hygiene, 
prophylactic treatment and j^rophylaxis has been 
brought up in various meetings, there is no doubt that 
Dr. Smith was the first dentist to advocate a systematic 
treatment along this line. His first paper was read Octo- 
ber 18th, 1898. According to his own statement, this 
paper excited no interest among the dentists themselves. 
Some years later, by inviting dentists to visit his office, 
and exhibiting a large number of patients to whom he 
had been giving this treatment, he convinced many of the 
leaders of the profession that this was really a new de- 
parture. It was interesting to note, that while many 
were interested, and went home to put the idea into prac- 
tice, many criticised him severely. In Washington, it 
was said that they did not need any one from Philadel- 
phia to teach them to clean teeth. Another one, sup- 
posed to be a teacher in a dental college, said that it was 
a great craze. Many said that it would polish away the 
enamel. Some said that a tooth held against a brush 



122 Practical Oeal Hygiene. 

wheel was in time worn away, and that this would be 
the way with teeth under prophylactic treatment. 

Dr. Smith's plan of frequent treatment was based on 
the fact that tooth decay begins at a vulnerable point on 
the outside, and proceeds inward along the tubuli. It 
mattered not to him whether this disease was caused b}^ 
lactic acid. He contended that the decay of teeth de- 
IDendecl upon our care exercised over environmental con- 
ditions. To him the place of decay or the resting place 
of the bacterial plaques was to be forcibly removed. This 
being done, we have changed the tooth conditions from 
bad to good, and have removed the means by which decay 
and disease gain a foothold. 

In answer to the question, "What is Prophylaxis 
Treatment?" there can be no better answer than that 
written by the originator of this systematic treatment. 

"The treatment consists of enforced radical and 
systematic change of environment of the teeth and per- 
fect sanitation for all organs of the mouth. Experience 
having demonstrated that the most careful and painstak- 
ing are unable, with the agents commonly employed — as 
the tooth brush and dentifrice, took pick and dental floss, 
soaps, so-called germicidal washes or other agencies — to 
effect this end, the plan of forcible, frequently renewed 
sanitation by an experienced operator has' been found 
indispensable. In detail, oral prophylaxis consists of 
most careful and complete removal of all concretions, 
calcic deposits, semisolids, bacterial placques and inspis- 
sated secretions and excretions which gather on the sur- 
face of the teeth, between them, or at the gum margins; 
this operation should be followed by thorough polishing 
of all tooth surfaces by hand methods (power polishers 
should never be used), not alone the more exposed labial 
and buccal surfaces, but the lingual, palatal and proximal 
surfaces as well, using for this purpose orange wood 
points in suitable holders, charged with finely-ground 
pumice stone as a polishing material. Treated in this 



Definition. 123 

manner the teetli are placed in tlie most favorable con- 
dition to prevent and repel septic accumulations and 
deposits, and not less to aid all efforts of the patient in 
the direction of cleanliness and sanitation." 

To my idea nothing short of the above meets the 
requirements of prophylaxis. 

Dr. E, B. Spalding in a paper before the Michigan 
Dental Society said : 

''One, two or three treatments does not constitute 
jDrophylaxis. It is the constant watching, guarding and 
maintaining the mouth in a condition of health which con- 
stitutes oral prophylaxis." 

Another definition by Dr. M. H. Fletcher is as fol- 
lows : 

''The name prophylaxis means preventive as you 
know, and is the work that should be done by the patient 
in cleansing the mouth. When a surgeon removes a 
foreign body from the qjq or treats a wound in any man- 
ner he calls it by its proper name, viz., surgical treatment. 
When a dentist treats the disease of the mouth, he is not 
doing preventive work, but surgical work, just as any 
other surgeon does, and I think the dental profession 
should rise to the occasion, and prove to the medical 
world as well as to the laity that they are scientific men. 
This can only be done b}^ using the proper terms to 
describe the locations and pathology. This will indicate 
that they know what they are doing." 

Dr. Fones calls prophylaxis', "the ideal ser^dce to the 
patient." 

In as much as the terms oral hygiene, prophylactic 
treatment, and prophylaxis have caused so much mis- 
understanding, it is not to be wondered at that this work 
has not found its way into the general routine of more 
dental offices. Granting that all we have said about oral 
hygiene, even if this is practiced to the fullest extent, it 
still remains that we must imbibe some of the spirit and 



124: Peactical Oral Hygiene. 

intent of prophylaxis to carry out the treatment as it 
should be carried out. It is a lamentable fact that so 
few dentists in the United States do this work in a 
systematic way. In 1911, I made a tour of most of the 
large cities of the United States, and, after hearing- 
numerous papers, seeing exhibits at societies, and read- 
ing a mass of magazine articles on this subject, I realized 
that little had been done in the carrying out of systematic 
work along this' line, and few had imbibed the true spirit 
of preventive dentistry. On June 21st, 1911, I read a 
paper before the Florida State Dental Society upon the 
subject, ''Introduction of Oral Hygiene into a Dental 
Practice." In this paper I gave some interesting corres- 
pondence contributing to the historical data of the subject 
of oral prophylaxis. This paper was published in the 
Dental Summary in December, 1911. I quote at length: 
''Several years ago the dental profession was con- 
fronted by the fact that one of its mem/bers, a competent 
dentist, a social favorite, a refined and cultured gentle- 
man, had been blacklisted from membership in a swell 
■social club for no other reason that that he "cleaned 
teeth." Nor was this stigma on prophylaxis confined to 
the laity. Dentists seemed to think it beneath their 
dignity to clean teeth, and, if it must be done, it was 
relegated to the assistant. Others tell us that it takes a 
crank to work prophylaxis. Dr. Levi C. Taylor, of Hart- 
ford, wrote me on February 7th, 190-5, 'I find upon inves- 
tigation that it (prophylactic) means a medicine or medi- 
cal treatment, the word being very old in this connection. 
Dr. M. L. Rhein took exception to this, and claimed it to 
be a word taken from the name of a tooth brush in 1882. 
Prophylaxis came into use in the sixties, and was defined 
by Donaldson, in 1874, very much as I defined it at your 
meeting, 'Surgical or manipulative treatment for the 
preservation of teeth. That both are a treatment no one 
will deny, but I do believe that each has a distinct mean- 
ing. Men and women both belong to the human family. 



Definition. 125 

but wlio would think of using the words interchangably 
as meaning one and the same thing?' 

'^Dr. M. L. Ehein wrote me a letter in June, 1905, in 
which he said, *I don't believe it makes any ditference 
whether you use the word as an adjective or a noun ; what 
I said in Washington, was that I was the first person to 
introduce the word into dental nomenclature when I intro- 
duced the prophylactic brush in 1883, and, having first 
made use of the word in that sense, I thought its very use, 
by virtue of priority, entitled it to be used in this way.' 

''Dr. D. D. Smith wrote me on June 10th, 1905, as fol- 
lows, 'Dr. Ehein is entitled to no credit for original work 
in this matter. He never heard of it or thought of it until 
I published m}" paper in 1898. Propliylactic refers to a 
remedy and should be used adjectively. The w^ord 
prophylaxis is never used as an adjective but as a noun, 
the name of a process. Prophylaxis is not a preventive, 
remedy, but a preventive process. You will find these 
terms used interchangably in the dental nurse paper, and 
without any discrimination.' 

"On June 18th, 1905, Dr. Ehein again wrote me; 'Not 
one patient out of five hundred wouhl understand your 
purport, although they may declare they do. I find it 
necessary tc impress these truths upon them again and 
again to make them understand. I don't care a rap about 
what I call this treatment to my patients. I believe that 
what they can understand most plainly is the term to use, 
therefore, I never say prophylactic treatment or prophy- 
laxis to them. Plain English is the best thing to use at all 
times with a layman. Therefore, I tell them that the 
cleaning and polishing of their teeth, and massaging of 
their gums, done frequently, is the best preventive treat- 
ment that we have in dentistry. It is all very well to use 
these words professionally, but plain English is the best 
thing for our patients. ' 

"Dr. Taylor, in discussing the name says, 'Dr. Harper 
suggested that prophylactic was a noun derived from the 



126 Peactical Oeal Hygiene. 

Latin. So far he is right, but he does not go far enough. 
It is both a noun and an adjective, and has been applied 
to medicine for more than two hundred years. What does 
prophylaxis mean? It is of Greek origin, derived from 
a verb that means to stand guard before. There should 
be a distinct meaning to our words, and prophylaxis I 
would define as the surgical and manipulative treatment 
for the preservation of health, and many physicians, with 
Webster, define prophylactic as a noun and an adjective, 
meaning a medicine which preserves or defends against 
disease, and the same definition is given in the Standard 
Dictionary. Prophylaxis is a noun, meaning the art of 
guarding against, preventing disease, observance of the 
rules necessary to preserve health, preventive treatment. 
I believe the essayist intended to convey to us the mean- 
ing of what I would term Prophylaxis, the surgical or 
manipulative treatment for the preservation of health, 
and not the rinsing of the mouth from time to time with 
medicine in the expectation of establishing the health of 
the mouth, I criticised his use of the term, as I believe 
he means prophylaxis when he says prophylactic/ 

''Dr. Harper says, 'Prophylaxis is derived from the 
G-reek; I did not say it came from the Latin, I said dis- 
tinctly that ic, al, and ary are Latin suffixes, and that 
prophylactic is the adjective form which means pertain- 
ing to, belonging to, or consisting or prophylaxis. Take 
the word atmospheric, which means pertaining to the 
atmosphere. You use the adjective form with the ic 
suffix, because you indicate samething that pertains to 
atmosphere; also hy genie, as relating to hygiene. The 
word prophylactic is the adjective form which is used in 
referring to the noun prophylaxis. Prophylaxis is strict- 
ly the adjective form with the ic termination. At most, 
even if used as a noun, as in calling certain medicines or 
washes prophylactics, it is still, strictly speaking, an ad- 
jective qualifying the medicine or wash as' to its uses and 
purposes, and i-ef erring to prophylaxis.' 



Definition. 127 

''Leaving each indhddual to take liis choice between 
these opposite opinions, and omitting any and all special 
methods of treatment, I shall at once introduce my sub- 
ject by the statement which I believe will be generally 
accepted, that nearly all our dental operations are neces- 
sitated by unclean and infected mouths. Then is it not 
strange that we, as dentists, have failed to keep those 
mouths clean? Is it not strange that we have treated this 
abscess, filled this tooth, operated for disease of the 
gums, but still think it beneath us to clean the mouth and 
keep it thus so as to prevent these operations? I know 
there are many here who will say that they have practiced 
cleaning all their professional lives and that these things 
will happen anyway. But the fact remains that a thor- 
ough search has been made of all available dental litera- 
ture, and no mention of systematic prophylactic treat- 
ment was' made up to 1898. About this year two promin- 
ent dentists began to investigate those infected mouths, 
and to publish their views and results. Still few dentists 
took up the work. In public exhibitions the actual re- 
sults were shown by submitting patients who had been 
under prophylactic treatment. Some were enthused and 
wrote of what they saw, but so little progress was made 
that the originators nearly gave up hope, and, as one of 
them expressed it, 'went home tired, despondent, and 
with the feeling that he had done his best, and, that as 
the dental profession had repudiated his work, he would 
make no further effort.' 

"But they kept at it, and evolved a system of prophy- 
laxis founded on correct etiologic iDrinciples. The results 
accomplished have forced us to realize the wonderful 
development there is in store along this line, and we now 
see the dental journals teeming with some new phase in 
every issue. 

"In the past, our work has been the repair of diseased 
tissues ; our studies in etiology yielded no practical re- 
sults. Dentists of the future must study and practice- 



128 Peactical Oeal Hygiene. 

etiology and prevention. Until our present views on 
oral prophylaxis were accepted and understood, etiology 
was the subject about which dental authors wrote volumes 
and spun theories that now seem ridiculous when we 
meet them in reading. 

"Detail would make this paper too long, and I shall 
confine myself to facts which have been well established. 

"1st, That the etiology for the larger per cent, of 
dental operations is traceable to local infection. 

"2d, That tooth decay is from without, and caused by 
constant contact with infectious material. 

"3d, That simple gingivitis, Riggs Disease, and en- 
larged glands, are rarely traceable to constitutional 
causes, as urema, or syphillis, but generally to an in- 
fected mouth, 

"If you accept these well established truths, 1 can 
expect your interest in the remaining part of this discus- 
sion. The medical profession has just emerged from a 
transformation of its methods from all treatment to pre- 
vention and sanitation. For instance, instead of giving 
all their time to the treatment of malaria, medical men 
now turn to the cause, and, by sanitary measures, seek 
the death of mosquitoes. The up-to-date physician now 
watches the surroundings of his patients to prevent 
typhoid fever. He takes all precautions to prevent small 
pox, scarlet fever, and diphtheria. 'To cure is the voice 
of the past, to prevent is the Divine whisper of today. ' 

"Dr. M. L. Rhein, of New York, and Dr. D. D. Smith, 
of Philadelphia, both believe alike that this is the most 
important part of a dentist's work, but they have differed 
decidedly as to how to put the work into execution. Dr. 
Ithein claims that all patients should be given the benefit 
of Prophylaxis, but that if he did the work himself, he 
would have little time for anything else. The charge for 
the treatment would be a burden for the patient to pay 
at the rate of $5.00 to $15.00 per hour for twelve treat- 
ments each vear. He contends that the work is not so 



DKFrxniox. 129 

difficult, but that an assistant can soon learn to do it, and 
he has introduced to us the dental nurse, whose duty it 
is to jDerform this work for patients at a nominal charge. 
Br. Smith, on the other hand, won't agree to any of Dr. 
Rhein's ideas, and contends that prophylaxis is the most 
difficult thing that the dentist can be called upon to per- 
form. Inasmuch as it is the best thing that a dentist can 
do for his patients, and takes a great amount of skill, the 
patients should not go into the hands of an assistant, 
but that he must do the work himself and charge accord- 
ingly. ' ' 



CHAPTEE XI. 
WHY IS PROPHYLAXIS NEiCESSARY? 

WHEEE TO BEGIN PEOPHYLAXIS. FREQUEIstCY OF TEEATMEJJ'T. 

OBJECT OF PROPHYLAXIS. 

One question which will frequently be asked us is, 
"Wliy is prophylaxis necessary today when all these 
years up to the present time cleaning the teeth once a 
year was thought to be all that was necessary T ' 

If you will go back a few generations, you will find 
conditions very different from those of the present day. 
In the first place, even those who lived in the cities lived 
more of an outdoor life. The strenuous life of the mod- 
ern business man was then unknown. The time for a 
meal was of much longer duration. In addition to this, 
the culinary art had not reached its present high state of 
development. Cooks in our time seem to have for their 
chief object the preparation of foods for absorption 
through the intestines, and to dispense, as it were, with 
the duties of the stomach. They seem also to strive to 
prepare the food in as sticky a manner as possible. In 
this day and time, if food were put on the table which 
would require a proper amount of mastication, we would 
think that something was surely wrong, our cook would 
think it an insult to our table, and that such food should 
be run through the meat chopper. It is a rare oppor- 
tunity when one of us makes a meal of such food that the 
teeth get to perform their real duties, that is, tearing, 
rending and grinding. 

The interproximal spaces in our mouths which were 
intended to be closed up, are now wide open to receive 
this sticky food. While we have this sticky mass adher- 
ing to the surfaces of the teeth, it constitutes the best 
pabulum for the growth of the numerous bacteria which 
are always in the mouth. 



Why is Prophylaxis Necessaey? 131 

Disuse of any organ or of any part of the hocly results 
in the atrophy of that part. Take for example the wide 
alveolar process with teeth embedded in thick peridental 
membrane, that our forefathers had. They were capable 
of much greater chewing action than are the teeth of our 
j)resent day with the thin peridental membrane surround- 
ing the teeth. And then we have that modern abnor- 
mality — the narrow arches and irregular teeth — making it 
necessary to carry out the most careful oral hygiene in 
order to keep the teeth free from stick^^, doughy, tenac- 
ious foods. Also the teeth in our present day are sub- 
mitted to various deleterious influences in the way of food 
and drink condiments which are strong enough to etch a 
marble slab, and these are followed by an ice cold drink or 
steaming cup of coffee. Thus we see that cleaning the 
teeth was not so necessary with our forefathers as it is 
with us on account of the high degree of civilization^ 
with its consequent dental degeneracj^, to which we 
have attained. We might say that modern prophylaxis 
is to counteract this self occasioned loss. In other words, 
we have to do by cleaning the teeth, and prophylaxis 
treatment, what used to be done by nature. The great 
number of tooth manufacturing houses throughout the 
land points to the necessity of finding some way by which 
this great loss of such important organs as the teeth can 
be checked. 

The medical profession has for years advanced along 
the lines of preventive or prophylactic treatment. The 
prevention of small pox has been insured by vaccination. 
We have recognized the fact that the best work of our 
medical men is along the lines of sanitation. We have 
welcomed the preventive measures in our army for the 
checking of malaria and typhoid fever, and while all these 
are being constantly brought before our eyes, dentists 
not quick to accept the simple truths which are continual- 
ly in their sight, are still making crowns, fillings, and 
bridges for these broken down teeth, and are not recoo;- 



132 Practical Oral Prophylaxis. 

nizing that the crown of these teeth is not so important 
as the root, and the peridental membrane surrounding it. 
"When we realize the nature and cause of all these dis- 
eased conditions, and when a system of preventing it is 
at our hands, the neglect seems criminal. 

WHERE TO BEGIN PROPHYLAXIS. 

Our patients seem to think that decay in childrens' 
teeth is just a normal condition, for how often will a 
IDarent when told of the decay in a molar tooth say, "0 
that is only a temporary tooth," and seem no more to 
mind it than they would a bump on the face, when we 
know that the decay is serious because of its bearing on 
the future condition of the child's teeth 

In the first part of the book we have learned the start- 
ling facts of what accumulation on the teeth leads to, and 
the logical reason why a systeinatic removel should be 
instituted. Dentists should be willing to give more of 
their time to this work. 






ja- S<3 <^- 



-^ 









Fig. is. 

The necessity for and frequency of prophylaxis 
treatment may be illustrated by what I term the Age 
Curve. "What is meant is, that children at the age of 
six years should be placed upon a regular and systematic 
prophylactic treatment for it is' here that the care of the 
dentist is most needed. In my practice I have been aston- 
ished at the needless loss of sixth year molars. It is for 
this reason that I say the most important time for 



Why is Prophylaxis Necessary? 133 

prophylaxis is with children at the age of six years, for 
at this time we can have better control over the patients, 
and suggest to them habits which will lead them into 
];iroper hygiene rules. We can thus have the opportun- 
ity, at the proper time, of extracting the temporary teeth 
so that the permanent teeth will erupt at the proper 
places. This will save the parents much orthodontic 
expense, and save these teeth from the very start. At 
this' time the children learn the proper oral hygiene, and 
dental toilet habits; later, as they are having to go to 
school or to work, there will not be a good opportunity 
of getting these ideas instilled into their minds. From 
the age of twenty-five to thirty-five, there is a period of 
comparative immunity, and I would not think that such 
frequent prophylaxis treatment should be necessary. 
After this time some of the work that was done in former 
years begins to fail, and the rush of business or social life 
makes great demands on the vitality, so that more fre- 
quent treatments will prol)ably be necessary. From 
tliirty-five to old age, more stress should be laid on 
prophylaxis. 

In children the main thing we have to combat is dental 
caries. I have heard mam'' a dentist tell children that 
meat eating is the cause of these decays. If Prof. Miller's 
experiments are correct, he has proved that meat eating- 
is not the cause of such decays. I believe that we should 
encourage the children to eat meat, and, what is more im- 
portant, to leave off sticky foods. On the other hand, it 
is just as true that as the child grows older, these remains 
of meat left between the teeth become more dangerous 
on account of their tendency to cause pyorrhea. From 
twenty-five on, we are not looking so much to have to 
prevent caries, for as we have said, there seems to be a 
form of immunity to caries at this time, but the greatest 
trouble will come from some infection or disease of the 
peridental membrane, and we must look with all care 
towards savino- this membrane in its intesritv. Meat 



134 Peactical Oral Peophylaxis. 

impactions, and clecompositiou, cause mucli distress 
and disease of the gum margin. The reason for this is 
that as the patient grows older (as in all other parts of 
the body) the alveolar process begins to undergo a senile 
change. In the first place the animal matter becomes less, 
the bone begins .to solidify, and the blood vessels to get 
smaller. The haversian canal can hardly be found. 
These changes give food debris a greater opportunity to 
irritate and infect the gums. 

It was once argued by some of the medical profession 
that the dentists did a great wrong when they tried to 
preserve a man's teeth after he had passed the age of 
fifty, for, said the essayist on the subject, "It is nature's 
jjlan to lessen the amount of food for the senile stomach." 
They claimed that if the dentists kept the teeth of the old 
people up to the standard that this would enable them to 
eat as when young, and that many of the ills to which old 
people were subject were caused solely by their being able 
to carry on active mastication. 

Dentists, and especially those engaged in prophylaxis, 
now stand ready to refute this from every point. Of 
course, if the joatient is one who has a very septic mouth, 
has bridge work which will not be kept clean, and toxin 
is generated around this, the medical man has some justi- 
fication for his belief that the patient named be better off 
without any teeth at all, but we have found that the old 
man on prophylaxis receives just as great benefits as the 
young person. This system will not only maintain oral 
cleanliness, but prevent, to some extent, the atrophy of 
the ligament attachment of the teeth. Old people who are 
on this treatment are very enthusiastic, and as free from 
general constitutional troubles as it is i^ossible for them 
to be. 

FREQUENCY OF TREATMENT. 

In conclusion, children should be treated at least once 
a month, and persons from twenty-five to forty-five, 



Why is Prophylaxis Necessaey? 135 

about once in three months. From forty-five on the treat- 
ment should be given once a month. 

Frequently dentists on viewing the mouths of regular 
prophylaxis patients in my office, have expressed the 
thought that it did not seem necessary for teeth so clean 
and in such good condition to have further treatment. 
This is the key note of the whole situation. It would he 
simply oral hygiene to clean the teeth, but here w^e have 
something deeper. The patients on prophylaxis come to 
us not for cleaning, but for the results in the true meaning 
of prophylaxis — the guarding of the oral cavities from 
the entrance of infection which would in any way get into 
the teeth and mouth. In prophylaxis, we pre-suppose 
that all adhesions have been removed, that the treatment 
will be directed to those places which the patients them- 
selves cannot reach, and all tendency towards any path- 
ological condition has been eradicated. 

OBJECT or PROPHYLAXIS 

The claim of Smith, that the peridental membrane is 
of more importance than the crown of the tooth, has been 
borne out by investigation of the origin of pyorrhea, and 
the quicker this is' recognized, and the quicker we diag- 
nose any inflammation at the gingival margin of tlie 
peridental membrane, the more certain we will be of free- 
ing our patient from any possible danger. There is some 
doubt whether there is ever a reattachment of the perice- 
mental fibres after they have once been detached by dis- 
ease. This emphasized the necessit}'' of prophylaxis as a 
preventive of pyorrhea. 

We have learned that the caries of the teeth are de- 
pendent for the most part upon two formations, the carbo- 
hydrates' and micro-organisms. As neither of these fac- 
tors can be eliminated, all that we can do is to learn as 
much as possible how to hold either or both of these ele- 
ments in check. Unfortunatelv, the vcrv articles of which 



136 Practical Oral Prophylaxis. 

vre eat most freely, that is, pastry, candy, etc., give tlie 
largest percentage of carbohydrate and acid units. 

As it is difficult at the present time to control the mat- 
ter of diet the object of prophylaxis should be to elimi- 
nate as far as possible the effects, and certainly the first 
question to be taken up is that of logihiUtii. Thus we find 
that those substances which are either alkaline or neutral 
in effect are chocolate, biscuit, milk, dates, etc., while 
substances such as potatoes, lemons, pine apples, nuts 
and meats, being originally acid in reaction, are 
beneficial. 

The conclusions which are reached by Pickerill after 
considerable experiments along this line are: 

''That in order to prevent the retention of fermant- 
able carbohydrates on and between the teeth, and so 
eliminate or very considerably reduce the carbohydrate 
factor in the proportion of caries, starches and sugars 
should on no account ever be eaten alone, but should in 
all cases either be combined with a substance having a 
distinctly acid taste, or they should be followed by such 
substances as have been shown to have an 'alkaline potem 
tial,' and the best of these are, undoubtedly, the natural 
organic acids found in fruit and vegetable." 

Those races where comparative immunity from decay 
is found, undoubtedly produce the result by the con- 
stant use of salivary stimulants producing in the salivary 
glands a constant activity Avhich prevents stagnation in 
the oral cavities, and thus preventing pre-disi)osition to 
decay. 

Several references have been made heretofore to the 
softness and stickiness of our foods which, lodging be- 
tween the teeth, give a start towards caries. The child's 
taste is a guide which, instead of giving heed to, we have 
always sought to ignore. The child naturally calls for 
the articles of diet having an acid reaction, fruits, salads, 
candies, etc. The harm does not come to the child's teeth 
from these substjinces, but from the form in which they 



Why is Peophylaxis Necessaky? 137 

are eaten — ^sticky, doughy cake for example, sticks be- 
tween the teeth and stays for future decomposition. I 
have no doubt that candy in the pure state is not only 
non-detrimental, but of great food value, and a preventer 
of decay. Dr. S. A. Visanska, a pediatrist of Atlanta, 
read a paper before the Georgia State Dental Society, 
in which he said : 

"From time immemorial it has been handed down to us as an 
axiomatic decree that the eating of candy or other sweets does have a 
direct eifect on the teeth causing rapid decay and thereby preventing 
the proper grinding of food and eventually causing stomach or intestinal 
troubles Avith all the myriad dangers attendant on malnutrition. 

"I have considered carefully what candy eating really does for 
the teeth, and apart from the hard stick candy which might injure the 
cutting surfaces of the teeth, or the tough chewing candy which might 
have a similar effect by dulling the surfaces exposed to it, it does not 
seem probable to me that further injurj^ could be done to the hard 
enamel hy actual contact with sweets. We have been told, however, 
that often the solution of sugar or glucose of which the average candy 
is made, causes a process of fermentation which results in lactic acid 
and that this acid does attack the enamel and acts directly upon it 
thus causing decay by injuring this hard surface and hence exposing 
the dentine, which is, in turn, similarly attacked until at last the vital 
structure of the tooth is reached. 

"But now let us see what actually happens when glucose or sugar 
does ferment in the mouth. If the sugar or glucose is held in the 
mouth long enough at the normal temperature of the mouth which is 
98. 6 degrees this fermentation will produce C 0, and alcohol, and 
later acetic acid. Now alcohol is really a perservative and therefore 
C Oo must be the dangerous element. But can this be true? As a 
matter of fact there is absolutely no evidence in support of the destruc- 
tive quality of carbon-dioxide and even if this apparently harmless gas 
could effect the teeth there is still another reason why its dangers are 
minimized. We all know that after eating sweets we get very thirsty 
and usually take water immediately, thus diluting the sugar which may 
remain in the mouth. The reason for this thirst is that sugar has so 
great an aflBnity for water that as soon as it reaches the stomach water 
is taken up by a process of dialysis through the walls of the stomach 
and Nature to comi^ensate for this demand and the consequent defi- 
ciency of fluid, demands water through the mouth. The result is that 
the ample washing of the mouth after eating sugar would seem to point 
to yet another reason against the theory of tooth decay from contact. 

''It has also been determined by testing with litmus paper that in 



138 Peactical Oral Peophylaxis. 

from one to six hours after eating sweets the influence of this acid, even 
if it should be harmful, had disappeared for there is no trace of it in 
the mouth within the period of time mentioned. Acetic acid, howevei% 
does not have any effect on the enamel, this I have proven by actual test. 

"Lactic acid in appreciable quantities will attack the enamel of 
the teeth causing a jelly-like substance to form thereon. But the lactic 
acid foods, such as butter-milk as well as many of the present day foods 
which are prepared from lactone ingredients are too weak in lactic 
acid to have any direct effect. 

"The effect of a solution of lactic acid of the proportion of one 
dram to the ounce, when applied to a tooth I have proven hy direct 
experiment. 

"Of course I know there are many stomach troubles which might 
result in acid formation in the mouth which directly injure the teeth 
and such conditions might possibly result from excess of sweets in the 
stomach or from other dietetic indiscretions — ^but that contact in the 
mouth with even the excessive quantities of sweets which the normal 
child craves, does not appeal to me as a logical reason for decayed teeth." 

These facts are borne out by later day experimenta- 
tion in tbe examinations for defects in the child's teeth. 
We may well consider the food, and lunches furnished to 
the children as a probable cause for these defects, in that 
most of the meals are made up of salivary depressants. 
Added to this fact, we must remember that the debris 
stays around the teeth, and between them until the next 
meal. The child's prophylaxis should begin by recom- 
mending to the child or his parents the addition of more 
fruit to his diet, and that this fruit be eaten, not before 
the meal, but after it in order that the salivary glands 
may become excited, and remain so until the debris is 
rendered soluble or washed away by the flow of saliva. 
We, as dentists, formerly thought that salads and condi- 
ments were very detrimental to our patients' teeth. 
However, used in the right way, there can be no detri- 
mental action. 

Tea is one of the salivary depressants, and should 
not be given to children at all; if our grown up patients 
use it, we should insist that they do not end a meal with 
this drink, but use it in the first part of the meal, for, used 
in the later part of the meal or with the desert, it stops 



Why is Peophylaxis Necessaey? 139 

the flow of saliva for some time, allowing the micro-or- 
ganisms of the month to multiply at a great rapidity. 
Some one has said that were lemonade drumk as a unver- 
sal beverage it would be impossible to have typhoid fever. 
This alone is a recommendation for this most excellent 
beverage, but, when we couple to this, the fact that 
fruit acid is one of the greatest salivary stimulants, we 
should not fail to take advantage of its beneficial qualities. 
All this leads us to the fact that the aid we secure 
from nature in the prevention of caries, must be through 
increasing the activity of the nerves leading to, and 
having control of, the salivary glands. These being 
brought to their highest development, we have a prophy- 
lactic fluid far superior to any thing that can be made 
artifically. We can accomplish by mouth washes and 
dentrifices some things (dealt with in a later chapter) 
but let us start off our prophylaxis with the knowledge 
of the fact that nature has this great preparation ready 
to manufacture at our suggestion. 



CHAPTEE XII. 
THE PEOPHYLAXIS CLASS. 

PRELIMHsTARY WORK BEFORE EISTTERIISTG PATIENT ON PROPHY- 
LAXIS. — PROPHYLAXIS TECHNIC. — VIEWS OP KELLY, 
HOWES AND GOBLE. 

When we have finislied our dental work, and have 
taught our patient the importance of oral hygiene, the 
question wMoli will be asked the doctor is, ^'Now doctor, 
what can I do to keep my mouth in this condition, and 
how often must I come back for examination?" If the 
facts and argTimnts, which have been brought forward in 
this book, have been of interest to you, it is hoped that you 
will start what I call the "Prophylaxis Class." This is 
somewhat original with me. I tell my patients, that if 
they are serious in their desires, I will take them at a 
nominal fee for one year, and if they will agree to come 
as often as I think necessary to keep their mouths in 
perfect condition. There is no use to advise patients to 
go on prophylaxis while you have reason to believe that 
they will not carry out your instructions, for it is a waste 
of time and embarrassing at the end of the year to find 
that the patient's mouth is in no better condition in spite 
of all your work. Many times, however, I have seen a 
gawky boy who was a perfect stranger to a tooth brush, 
after six months' of this treatment, acquire oral hygiene 
habits which he would follow all his life. Young girls 
would probably be the best to enter upon this treatment 
in beginning this work. I do not want any one to enter 
the class on the first blush of enthusiasm. I generally 
give them a reprint on the subject to take home and read. 
My policy of educating patients is to select some good 
article appearing in dental journals, and secure from the 
author the necessary reprints. I have always found the 
author glad to supply them. Then, if they are willing to 



The Prophylaxis Class. 141 

fulfil the demands made on them, I gladly place them 
upon the list. One of the worst difficulties in getting 
the joatient ready for prophylaxis is the banded crowns, 
and cement and gutta percha fillings. These necessitate 
considerable dental work. We should have some every- 
day illustration to use in explaining to the patient the 
necessity for having this work done, in order to show 
them that it gives lodgment for debris which would over- 
come all our efforts at prophylaxis'. 

PEELIMINARY WORK BEFORE ENTERING PATIENT ON 
PROPHYLAXIS. 

Before the treatment is begun all dental work must be 
brought up to the standard. All roots of teeth, which 
cannot be saved, must be extracted. All meat holes and 
fillings with bad contours must be corrected. All tarter 
must be removed, and the teeth put in a hygenic condi- 
tion as described under ''Cleaning Teeth." AH this, of 
course, must be paid for at regular fees, for, as I have 
said before, prophylaxis presupjDoses a perfectly clean 
mouth. 

Fones gives the illustration of two pieces of glass each 
five inches square. One of these is ground, and the other 
polished plate glass. Both are smeared over with the 
debris which we would find in the average mouth. With 
one sweep of the tooth brush it is easy to clean the 
polished surface, while it takes several motions to clear 
the ground glass surface. Another illustration is the 
cement slab at our chairs. When this has become scratch- 
ed or rough, we find difficulty in removing the cement left 
over from our operation. On the other hand, when the 
slab is new and free from these defects, it may be cleaned 
by simply placing it in water and wiping off the cement. 
Now the same thing holds true in the mouth. If the 
patient is on prophylaxis and the teeth kept in the proper 
state of polish by the monthly treatments, he can with one 
sweep of the brush remove any deposit Avhich may have 



142 Pkactical, Oe.u. Peophylaxis. 

settled on the teeth, but if this food debris is held by ac- 
cimiulations of tarter, as found in the average mouth, it, 
can only be removed by a dentist. 

PEOPHYLAXIS TECHNIC. 

A few years ago at one of the state societies where I 
was giving a clinic, a countrified looking dentist pushed 
himself to my side and said, "What the devil is a lorophy- 
laxis treatment any how? One of your patients moved 
to my town and insisted that I give her a prophylactic 
treatment. I wrote to you to find out what it was, but 
the answer must not have been correct as I gave her a 
treatment and she never returned." An explanation of 
the conditions which necessitate prophylaxis makes a 
much greater impression than the statement of the simple 
technique necessary to bring about the results. In the 
art gallery, we stand enthralled before some master 
painting, we live with the person or in the scene which it 
depicts, and enter into the vision which caused the picture 
to be painted. Had we been in the studio where this 
work was done, we would probably not have shown any 
interest in the small brushes and palletts of paint with 
which the artist made the picture. Thus I have found 
that I could interest dental students and keep up their 
enthusiasm until I began the description of the technique. 
They expected something big, and when I told them of 
its simplicity, the enthusiasm had a tendency to drop. 
The technique of Prophylaxis is nothing more than the 
technique of cleaning the teeth, only carried out to a 
much greater nicety, and, in addition, the regularity 
with which it is carried out. One prophylactic treatment 
will not amount to much, but the effects of a half dozen 
of these treatments, each one overcoming some defect, 
makes a vast difference between these two operations. 
Dr. Henry A. Kelley of Portland, Me., says: 
"In beginning our spraying and polishing, the first 
condition that confronts us is a viscid coating of saliva. 



Peophylaxis Technic. 143 

and gelatinous plaques that covers tlie teeth and gums. 
First take a tube of rather hot water, of about 150° F., 
to which has been added one dram of aromatic spirits of 
ammonia. The alkalinity of this spray, applied under a 
pressure of from 35 to 50 pounds, will overcome this 
viscidity. After thorough spraying with this first spray, 
alternate with a second spray, composed of three-quar- 
ters of a tube of warm water and one-quarter of a tube 
of some of the forms of hydrogen dioxid. To this' tube 
add a few drops — three or four — of essence of anise to 
disguise the very unpleasant hydrogen dioxid taste. This 
second spray is used on account of its cleaning effect. As 
the doxid comes in contact with the decaying particles of 
animal matter we have the well-known boiling effect, 
which tends to lift out and off all foreign matter accumu- 
lated around the teeth. Then with a hand porte-polisher 
(I use Harrell's) charged with flour of pumice begin the 
polishing. The pumice must be moistened with water to 
make a paste not too thin, to which two or three drops of 
essence of peppermint are added. The peppermint serves 
not alone to take away the sandy taste, but also to exert 
a cooling effect on the gums, and leaves a refreshing and 
clean taste in the patient's mouth after the operation is 
finished. I usually go over all the teeth in a rather 
hurried way in order to first get rid of any matter adher- 
ing to the surfaces, and then after another spraying, 
alternating with both sprays, I pass to the last tooth on 
the upper left side and go over all the buccal and labial 
sides of all the upper teeth, going into the approximal 
spaces as well as pos'sible with the porte-polisher. Use 
flattened orange-wood points for the flat surfaces, apply- 
ing considerable force with a circular movement directed 
from the neck to the cutting edge and just under the gum 
margin. This giim margin is a very important region, 
and it is probable that if this is kept well polished your 
patient will never have pyorrhea, or if he has had it, it 
will never return. Having gone around to the last tooth 



144 Peactical, Oral Prophylaxis. 

on the upper right side, spray again with the second 
spray, and return to the last tooth on the upper left side, 
going over the lingual surfaces and then spraying with 
the second solution. Then polish your grinding surfaces. 
The same process is followed with the lower teeth. Go 
over all exposed surfaces' with your porte-polisher 
charged with tin oxid made into a paste, which will im- 
part a beautiful polish to these surfaces. Tlhen apply a 
thorough spraying with a third solution, which consists 
of one-half a tube of hot water to which has been added 
one-half a tube of some pleasing general mouth-wash (I 
use Alkalyptol, which I find very satisfactory ; not all 
antiseptic mouth-washes leave the same refreshing taste 
in the mouth), and pass waxed floss silk between all the 
teeth and clean out the interproximal spaces, spraying 
with the second solution as necessary. After that finish 
with the third spray, finally allowing a rinsing-out with a 
glass of cool water. If your work has been thorough, 
your patient has the first sensation of what a clean mouth 
means. Patients often tell me that they hate to go home 
and eat and soil the mouth again. 

"It is well to alternate from month to montb, taking 
the upper teeth first in one month and the lower teeth first 
the next month. I find that for some reason which I 
cannot explain, the upper teeth respond to treatment, 
especially in pyorrhea cases, much more readily than the 
lower ones, and I have these two thoughts to offer in this 
connection. I find that when I begin with the upper teeth 
I often spend forty minutes going over them, which 
leaves me but twenty minutes of the hour appointed for 
the lower ones; hence the practice of alternating from 
month to month. The pumice also becomes much thinner 
from the admixture of saliva in polishing the lower teeth. 
I often use the saliva ejector or napkins to offset this lat- 
ter condition, but I cannot as yet say with what result. As 
you first begin to polish with the pumice, your wood point 
will slip over the tooth, and there will be a slimy, greasy 



Peophylaxis Techxic. 145 

sensation. But as yon polish and polisli, you get down 
to the clean tooth-surface, and then you experience that 
squeaky sound that indicates a clean tooth-surface. The 
slimy substance that you are removing is composed of 
the gelatin-forming micro-organisms, which I shall ex- 
plain later in a quotation from Johnson. Hence, if you 
make every filling smooth, allow no shoulder or lodging- 
place for the decay-producing germs to remain, and then 
destroy the gelatinous film under which the micro-organ- 
isms that cause decay are enabled to effect their destruc- 
tive process, you render it extremely hard for decay to 
begin or make progress." — From Dental Cosmos. 

Dr. Kelley suggests the use of a nasal spray tip, made 
b}^ Debilbiss Co., which he uses to spray out the inter- 
proximal space from the buccal side. Place the index 
finger just over it (that is above it, on the upper, towards 
the root end) draw it back just a little and spray. The 
spray thus goes beyond the tooth and out on the palatal 
side. Following this suggestion Dr. Kelley says, "The 
patients realize how you have cleaned the teeth. ' ' 

The difference between my present technique, and Dr. 
Kelley 's is that at each operation the first thing done is 
with a small scaler of the Younger type (which has had 
its sharp edge removed) to gently insert it under the free 
margin of the gum, and to circle the entire gingival por- 
tion, being careful to exert no force on the instrument 
which would in any way tear the attachment at the peri- 
dental margin. I consider this the most important part of 
prophylaxis, for it is this membrane, above everything 
else, which we must protect. It is here that the begin- 
nings of deposits may be detached in their incipiency. 
No porte polisher or pumice will do this; only skilled 
touch and the proper instrument can do it. 

The mouth in which there has once been a pyorrheal 
condition will often call for a fine point of judgment, for 
it is often necessary to enter forcibly into these former 
pyorrhea pockets, and clean them out thoroughly. This, 



146 Pkactical Oral Peophylaxis. 

if riglitly clone, can do no possible harm., and certainly is 
the means of preventing future eruptions from some 
infection forcing its way into these places. If this is 
done, every three or four months, it will in time do more 
to eliminate this scar than any other treatment. It seems 
that with each treatment the pockets get shallower. 

After this, I differ with Dr. Kelly as to the manner of 
using the dental floss silk. He uses it last. I use it im- 
mediately after instrumentation for the reason that at 
this time, the mouth has no accumulation of powdered 
pumice, which would make it most difficult to pass silk 
between the teeth. Do not put the abrasive on the silk, 
and then attempt to pass it between the teeth. Pass the 
silk in first, and then place on a small amount of abrasive. 
The same procedure is repeated at each interdental 
space. The largest and broadest floss silk that can be 
passed between the teeth should be used ; this is the dan- 
ger line at which we make our greatest fight against 
caries, and the simple running of the floss silk between 
the teeth will not accomplish the desired results. Accord- 
ing to later investigations by Pickerill, it might be better 
to substitute for the spray containing aromatic spirits of 
ammonia, to overcome the viscidity of the saliva, some 
vegetable acid spray should be used which will not only 
give an increased flow of saliva, but will furnish the pro- 
tective qualities which it possesses, and will remain for 
some time after the prophylaxis' treatment; this flow of 
saliva is undoubtedly inhibited b}^ an alkaline spray. 

Dr. Gillette Hayden called my attention to the use of 
powdered sodium citrate for the removal of mucus col- 
lections. Dr. Cook, of Chicago, endorsed it, claiming that 
it attacks only organic substances, without detriment to 
the teeth or the soft tissues. It can be used at the chair 
in connection with the abrasive used in the treatment, but 
must not come in contact with any moisture previous to 
the time of using it. Use it with water instead of any 
other fluid as it combines readily with other substances. 



Prophylaxis Techxic. 147 

An admirable adjunct for prophylaxis treatment as 
advised by Dr. Minnie Masters Howes, of Minneapolis, 
is giving much attention to massage and spraying : 

"I massage the gums; showing the patient how it is 
done and instructing him to do this about five minutes 
each day, as long as it is necessary. I use the thumb and 
first finger, catching as high up on the gums as possible, 
the finger on the labial and thumb on the lingual surface 
and pull down over the teeth, gently at first, if the gums 
are sore and more vigorously as they become harder. Re- 
verse the motion for the lower teeth. This will make 
the gums hard and firm and start up a healthy circula- 
tion. It will also check recession of the gums if persisted 
in, and, in many cases, will pull them back to their nor- 
mal position about the teeth. The teeth and soft tissues 
of the entire oral cavity are now sprayed with an antisep- 
tic wash under heavy air pressure, forty or fifty pounds. 
The spray is directed into all pockets, distending them 
and washing out all pumice and debris; the teeth are 
thoroughly washed, especial attention being directed to 
the free gingival gum. margins, the tongue and mucous 
lining of the mouth are cleansed with the greatest care 
and circumspection. This phase of the treatment is the 
one most appreciated hj the patient. The sense of cool 
cleanliness left in the mouth by the spraying is something 
that must be felt to be appreciated. 

''After the first treatment, the gums are apt to be sore, 
so I have the joatient use bicarbonate of soda. Take a 
teaspoonful in a third of a glass of warm water and rinse 
the mouth often until soreness in the gums has disap- 
peared. Give the patient all the instruction you can in 
the proper care of the mouth and teeth, and when they 
return for their next treatment, point out the places, if 
any, they have missed. If it is a very bad case, I have the 
patient return in a week for another treatment. Then 
after that, once a month is usually often enough, although 
there are cases that every two weeks would not be too 
often to see. ' ' 



148 Peactical Oeal Peophylaxis. 

As opposed to this system of monthly prophyhixis, 
is that of Dr. L. S. Groble, of Rochester, N. Y., who writes 
of his technique in a recent number of the ''Dental Dis- 
pensarj^ Record." He prefaces his remarks by saying 
that for twenty years he has been doing prophylaxis work 
in spite of uric-acid and rheumatic diatheses, and found 
that the only way to properly carry out prophylaxis was 
to remove the tarter, and keep the mouth clean. He 
further says that he is not in sympathy with the so 
called "Prophylaxis Movement." 

"Like the cry, 'On to Richmond,' we yell, 'Remove 
the Plaques,' and so the whole mouth is scrubbed and 
the gums are punched and stain is used, all on the basis 
that a micro-organism is the cause of caries, although it 
has not been isolated and the theorj has not been proved. 
Do the plaques stay removed? No, they return in full 
force in six hours and in some peoples mouths in two 
hours, showing that the micro-organisms are always there 
and rightfully there. You may ask, 'What do you say 
then! Let the plaques alone?' No, I say remove them 
in so far that you do not injure the gum tissue and only 
that far. And this putting stain on the teeth and then 
tearing the mouth to pieces getting it off, just to show 
the patient where the plaques are, I consider a mistake 
or worse. And to have all your patients come once a 
month for prophylaxis is rank nonsense, and I have seen 
many evil effects from it. I have, and you. have patients 
whose mouths after three months have no more plaques' 
than other patients have after six hours. The former 
under the monthly rule, you would rob, the latter you 
would 1)6 neglecting. I have patients that come year after 
year and who need no oral prophylaxis and yet I have 
no doubt that I could show plaques. I do not believe that 
plaques cause decay, but as a media for the acid of fer- 
mentation going on in the mouth they may cause one per 
cent., I doubt if it is more." 



CHAPTER XIII. 

INSTRUMENTS AND POLISHING MATERIALS 
USEFUL IN PROPHYLAXIS. 

Autliorities are not agreed as to what constitutes the 
iustrumentation for prophylaxis. Some advise against 
the use of anything like a scaler, while others advise the 
regular use of delicate scaler under the free gum margin, 
and reopening and cleaning out old pyorrhea jDockets at 
frequent intervals. 

The condition before treatment, and present state, 
together with a full understanding of the normal and 
pathological picture presented by each case, must govern 
the operator on this question. 

Instrumentation used with a proper knowledge of the 
demands of true prophylaxis treatment can only be pro- 
ductive of good. Whatever points selected and used 
should have the sharpe edges removed. 

The various shapes of spoon excavators cap. be made 
into most excellent instruments by removing the edge 
with a stone. Many of the instruments hereafter de- 
scribed for pyorrhea work are also useful in prophylaxis. 
Numbers 3, 4 and 15 of the Good set have been of great- 
est use to the writer. 

Smith claims all power polishers are injurious in 
prophylaxis work. R. G. Hutchinson, Jr., says, "Rotary 
brush wheels on the engine are an abomination and do 
infinitely more harm than good when brought in contact 
with the soft tissues, but soft rubber discs and cups, if 
kept wet and not rotated very rapidly or pressed too 
hard, may be used to advantage. ' ' 

INSTRUMENTS FOR HAND POLISHING IN PEOPHYLAXIS. 

There are a great many ^^orte polishers on the market 
which are herewith illustrated. Dr. Harrell. of Gaines- 



150 



Peactical Okal Prophylaxis. 



■ 






I<^ia. 19. The Bkst Forms of Hand Polishers for Prophylaxis 

Work. 



Matekiax,s Used ix Peophylaxis. 151 

ville, Texas, invented the best instrument ever produced 
for the purpose of prophylaxis treatment. The sale of 
this prophylactic polisher is now controlled by the 
Oxylene Company of San Antonio, Texas. 

In the porte polisher various kinds of points can be 
used. Generally, however, they are made of orange-wood, 
and shaped out into a point or into a wedge. In addition to 
the porte polisher, it is well to have about a dozen large 
size orange-wood sticks sharpened into various shapes 
for immediate use. The broad points to be used on the 
broad sides, and the small ones' for use between the teeth 
and in the fissures. 

A new point must be placed in the porte polisher for 
every patient, for as soon as the patients begin to learn 
something about prophylaxis, and the treatment ^and 
technique, they are very particular and watch very care- 
fully to see that everything is as aseptic as it should be. 
If the sticks of orange-wood or bass-wood be used, the 
wood should be washed carefully, a new point cut, and 
the sticks kept in a glass jar filled with antiseptic solu- 
tion. Before I began doing this, I frequently had the 
patients' ask me if I used the same stick on all of the 
patients. 

Dr. H. A. Kelley suggests the use of strips of shoe 
peg wood Avhich can be cut off the exact width required. 
He claims that these have the advantage of orange-wood 
sticks in that thej^ give an expansive flat surface for 
polishing the flat surfaces of the teeth, and that the^^ are 
much superior to the regular orange-wood sticks. They 
can be procured very cheaply at any shoe factory or 
wholesale shoe shop. Dr. F. H. Skinner furnishes, with 
his instruments, a box of prepared orange-wood points 
which are excellent. The S. S. White Dental Manufactur- 
ing Co., and the J. W. Ivory Company, make a specially 
shaped point, for use in porte polishers, which is quite 
an advantage in some places'. The greatest aid as a sub- 
stitute for the orange-wood stick is the contribution of 



152 



Peactioal, Okal Prophylaxis. 



Dr. J. W. Jungman, of Cleveland, whicli consists of round 
bass-wood sticks about six inches long wMcb are placed 
in a 1 in 1000 solution of bichloride with green soap. 
They remain in this until thoroughly saturated. Dr. 
Jungnaan furnishes me with the following prescriptions 
for use with these bass-wood points. 









d^/X^i^i^ OL^^ftry 



Fig. 20. 



No. 1 
Prescribe in cases of pyorrhoea 
where the enamel will permit the 
use of a gritty powder, 

Pulv. Castile Soap Parts % 

Zinc. Sulpho Garb " 1 

Pulv. Pumice (Fine) ... '' 6 
Oxide Tin, (Mercks) ... " 3 

Creata Preseip " 12 

Flavor, Q. S. 



No. 2 
Where it Avill not permit a gritty 
powder. 

Pulv. Castile Soap Parts % 

Saceh. Alba. Pulv " 1 

Oxide Tin, (Mercks) ..." 4 

Zinc. Sulpho Carb " 1 

Creata Preeip " 12 

Flavor, Q. S. 



No. 3 
In well-kept mouths Avhere no 
medicament is required. 

Pulv. Castile Soap Parts % 

Saeeh. Alba Pulv " 1 

Oxide Tin, (Mercks) ..." 3 

Creata Preeip " 12 

Flavor, Q. S. 



No. 4 
In acid mouths. 

Pulv. Castile Soap Parts % 

Sacch. Alba Pulv " 1 

Oxide Tin, (Mercks) . . "' 3 
Sodium Borate (Sqnibbs) " 2 

Creata Preeip " 12 

Flavor, Q. S. 



I secure large mouthed bottles, such as those used for 
barbers' pomade, which hold about one half pint. Into 
these I put the various mixtures which I use in prophy- 
laxis work. 

In beginning this' work, we must be cautious not to use 
the common pumice stone, as it will cause cupping in at 
the cervical margin of the teeth. From the use of this 



Materials Used iist Peophylaxis. 153 

heavy abrasive, I have noticed cups in the teeth of a 
numher of patients. After the patients have been on the 
treatment for several months, it is not necessary to have 
this abrasive used every time. The finer mixtures of 
oxide of tin or prepared chalk, or the preparations made 
by Dr. Carmichael (called Carmi-Lustro) may be used. 
The views of Dr. Carmichael on the subject of the 
abrasive for use in prophylaxis are so interesting that I' 
feel it best to give his views in his own language : 

"The polish or gloss of enamel was put there by 
nature to protect the teeth from diseases. If this liighly 
glossed surface of the tooth enamel was retained, foreign 
matter could not readily adhere and if the surfaces were 
always polished to the gum margin, the teeth would not 
decay, nor would there be dental pyorrhoea. 

''All the substances in general use for cleaning teeth 
are harsh and gritty ; though they be very fine grit, they 
accomplish the purpose only by a scouring process, thus 
gradually destroying the natural gloss of the enamel. 
Although these scratches are not visible to the naked eye, 
they are sufficient to destroy the brilliancy, and leave 
the surface all the more susceptible to receive foreign 
adliesions ; in other words', the more we scour the teeth, 
the more we must scour, to keep them clean; to say noth- 
ing of destroying the life luster; as proof of this, it is 
only necessary to dry the teeth to disclose the fact that 
the enamel gloss has been dulled. 

''It may be necessary, nevertheless, for the dentist to 
apply a very finely powdered abrasive, to remove stains 
in cleaning teeth, and this should not be used over the 
entire surface of the teeth, but confined to the stained 
area, using a preparation of a character that will not 
scratch. 

"Experience has proven that a friction dry rub is 
not only more effective in removing the adhesions, but the 
life luster becomes more intensified. 

"The enamel must be kept so brilliant that the teeth 



154 Peactical Oeal Pkophylaxis. 

will ward off disease. To accomplisli this, we must adopt 
those measures that will restore the teeth to a state of 
nature, which is in line with the highest attainment in 
dentistry. ' ' 

In the use of any polishing instrument bear in mind 
the curvature of the teeth, and do not rub in one place, up 
and down, but follow the curvature of the teeth in a 
circular motion, and at a slow rate of speed. In this 
manner, we are enabled to feel any accumulation which 
we wish to remove. If the point slips over the tooth as 
though it were greased, we know that it is enveloped in a 
secretion which must be removed. We must educate our 
fingers up to this delicate sense of feeling. We soon learn 
that a regular patient's teeth feel entirely different from 
one who has not had this care. There is a peculiar 
squeeh of the patient's teeth, and the minute we hear this, 
we have caught on to the proper manner of handling our 
porte polisher. Just at the free margin of the gums it 
must be polished very carefully. Many operators, 
through too rapid movement of the porte polisher or 
through fear of injuring the gums, lose much of the im- 
portance of this work. I have not found the contact of 
the porte polisher against the gums to be injurious, if 
rightly used. 



CHAPTEE XIV. 

PEOPHYLAXIS TREATMENT OF FISSURES AND 

GROOVES. 

SOFT SPOTS, SENSITIVE AEEA TEEATMENT. 

As previously mentioned, the fissures, grooves, and 
pits in tlie teeth will cause us the greatest amount of 
trouble. The first time that this condition occurs in the 
mouth is following the eruption of the first lower molar. 
It has been my practice for years to attend to these teeth 
as soon as they appear through the gums, whether the 
patient is on prophylaxis or not, but certainly if on 
proj)hylaxis. The tooth should first have the sulci cleaned 
out with a fine pointed instrument. The surface of the 
tooth is then cleaned off with some mild abrasive. The 
tooth is kept as dry as possible, and then sterilized with 
absolute alcohol. When this is done, the whole erupted 
surface of the tooth is covered with some quick setting- 
cement. Many prefer one of the copper cements, but I 
have never seen any advantage in it. The erupting per- 
manent (tooth being behind the temporary molars, at a 
lower level, furnishes a depression which forms an ideal 
catch basin for decaying foods. Again, if the children 
brash their teeth, which they seldom do at this age, it 
is doubtful whether they ever clean this* surface. As the 
tooth grows up into place, the attrition of food soon 
wears all the cement away except that portion in the 
grooves. As soon as the tooth is brought into use for 
mastication, if this cement has not been worn away, it 
can be removed, and in many cases we mil find that no 
further attention is necessary. However, if deep sulci 
have developed, we can, with a real small burr, cut the 
fissue just sufficient for a small gold filling, or, perhaps, 
the little groove can be filled with cement. It will be sur- 
prising to note how this will last in this small line cavity. 



156 Peactical Oral Peophylaxis. 




Fig. 21. Fissure in Lower Bicuspid (Solbrig). 

Such a tooth, unless properly treated, is almost sure to develop a 

serious decay in the fissure. 

Sometimes the simple opening and bevelling of the 
walls that lead to the sulci so that the tooth brnsh can be 
gotten down into it, is all that is necessary. The grooves 
in the buccal surfaces of the teeth had best be ground out 
^\T.th the smallest stone possible, and then the surface 
thoroughly polished. However, if the groove is of such 
depth that the grinding will go through the enamel, or, 
as is' often the case, a small pit shows somewhere along 
this groove it can be filled with a cement filling as this is 
probably the best to put in this position. 

SOFT SPOTS. 

Soft spots at the juncture of the teeth and the enamel 
margin where previous recession of the gums has taken 
place, have proved one of the most disappointing o^Dera- 
tions in prophylaxis', and yet I feel that the percentage 
of successful work along this line is sufficient to warrant 
me in giving the technique; it is certainly worth while 
trying this method, even if the tooth should require a fill- 
ing some years later. 

Small white spots in childrens' teeth can be polished 
away. The method of doing so is by taking the smallest 
size mounted stone, grinding down to hard surface and 



Sensitive Spots on Teeth. 157 

then applying cuttle fish discs, and finally polishing off 
with an old fashioned moose hide polishing point or with 
Darby's Hard Buff Polisher No. 3, used in the dental en- 
gine. On this polisher should be used oxide of tin or 
some preparation such as, " Carmi-Lustro, " provided the 
decay or white decalsification does not extend through the 
depth of the enamel. However, more extensive decays just 
over the juncture of the cementum and the enamel on 
the tooth root often presents a leathery surface which is 
very difficult to handle with this protective technique. 

The surfaces in the anterior part of the mouth might 
be handled with stich substances as nitrate of silver 
hereafter described but, this being a question of position, 
the next best thing is to try the polishing technique. If 
this leathery condition does not extend into the inter- 
spaces, we sometimes get excellent results by the simple 
removal of this condition, and polishing the surface as 
just described after removing this leathery substance. 
If we find a cavity, now is the time to fill it. However, 
if we reach sound tissue, we should have a cup-shaped 
surface. This surface can be maintained in a polished 
condition and it may not require filling for many years. 
Many times' in attempting to operate at this point, we 
find an extra sensitiveness, and the patients will some- 
times say that they would rather have the tooth extracted 
than to have you polish at this spot. Then is the time to 
use the procedure given me many years ago by Dt. 
Taylor, of Hartford, who sprinkled a small amount of 
powdered cocaine over the gum margin allowing the 
moisture to dissolve the crystals. He advises that the 
cocaine be used in about the same manner as when apply- 
ing the rubber dam, but cautions the operator not to 
allow the patient to swallow it. Dr. Taylor used this 
method for many years without the slightest symptom of 
trouble. 

One other point, wliich can be used in the treatment 
of these sensitive spots at the gum border, especially after 



158 Peactical Oeal Peophylaxis. 

tliey have been cleaned out, polished, and are still sensi- 
tive, is the application of a small burnisher. 

The patient's head is held firmly, and the hand hold- 
ing the burnisher is held against the tooth which is to 
be treated. G-reat pressure is applied with up and down 
motion, being careful not to let the instrument wound the 
gum margin. This burnishing should be kept ujd for 
several seconds. It is remarkable what relief this method 
sometimes affords, a considerable length of time elapsing 
before the return of the sensitiveness. I can give no 
better explanation of this than the answer given by the 
student who said that this burnishing ''brads the nerve 
terminals at this point." There are undoubtedly irri- 
tated and exposed nerve ends, and the patient will tell 
you so when you attempt to do the operating. The suc- 
cessful *'br adding" in my own mouth on an upper 
bicuspid, where there has been a slight recession of the 
gums, has' afforded me the greatest relief of any pro- 
cedure which has been suggested or tried. 

In the case of small mouths, I use one of the various 
cheek distenders, which not only enables the operator to 
work with greater ease, but also much to the comfort of 
the patient. 



CHAPTER XV. 
RESULTS OF PROPHYLAXIS TREATMENT. 

The various arg-uments lorouglit forward against the 
monthly system of prophylaxis will not have any weight 
with anyone who has observed a patient who has been 
upon this system for a while. Six months treatment will 
change the whole appearance of the ordinary month, 

1st, The mucous membrane will assume a normal pink 
color, not only around the buccal surfaces of the upper 
teeth but in every part of the mouth. 

2d, Teeth that disfigure the face can be improved in 
appearance, for, if their surfaces be brought to a high 
state of polish, and the surrounding tissues healthy, one 
does not notice so much their ill shape. 

3d, Many defects in the teeth can be worked out, 
white spots' removed, and grooves smoothed out. 

4th, Hypersensitiveness of the cervical margin and 
irregularity of the nerves can be corrected. 

5th, Decay is prevented. 

6th, The vital structures within the tooth, and those 
surrounding it, especially the peridental membrane, are 
maintained in normal condition. 

7th, The mouth is safeguarded against violent infec- 
tions. 

8th, Osseous structures are protected from the irrita- 
tion oT deposits or infection. 

9th, Pyorrhea is positively prevented. 

10th, Last, but not least, the greatest result in prophy- 
laxis is the aid, training, and maintenance, by the patient 
at home, of a perfect dental toilet technique. 

If it were always possible to place the mouth in a per- 
fectly clean condition as to caries and fissures, and the 
patient carried out the instructions for care of the teeth 
at home, we would be able to demonstrate in every case 



160 Pkactical Oral Prophylaxis. 

that "Clean teeth never decay." Unfortunately this is 
seldom the case, and we are often humiliated in our 
prophylaxis by the discovery of a whiteness showing- 
through the enamel, giving evidence of the carious con- 
dition underneath. 

It is' well to explain to the patients, before placing 
them on prophylaxis, in regard to the claim that prophy- 
laxis prevents decay, that some slight carious condition 
may possibly develop during the first six months or year ; 
that in the interproximal surfaces, between the molars 
and incisors, the etching of the enamel may have pro- 
ceeded so far that it will be impossible to prevent further 
decay. It is not always possible to find these at once as 
they sometimes do not develop for six months or a year 
after the patient has been placed on prophylaxis. 

In my experience of about ten years in prophylaxis, 
I do not recall, in any of these reg-ular patients, a decay 
beginning out in the open, that is; on a surface where it 
was |30ssible to maintain a polished surface. Many teeth 
with deep sulci and grooves may decay in spite of all the 
prophylaxis you can give them, because it is impossible 
for the dentist or the patient to keep these depressions 
in a perfectly clean state. It is the best policy to fill these 
-either jDcrmanently or temporarily as explained in the 
chapter on technique of prophylaxis. 

In regard to the prevention of pyorrhea, I can say 
that in my own experience not one has shown the least 
tendency to this disease. Others' who are doing this 
same work have observed the same thing, of course, this 
is not taking into consideration the patients who have had 
pyorrhea at the time they began prophylaxis. 

As evidence for my own satisfaction of the fact that 
prophylaxis really does' prevent disease, I selected pages 
at random from my records, which give the amount of 
dental work required by patients in the five years before 
they began Prophylaxis in comparison with the amount 
of work they have had done since. I included in these 



Results of Peophylaxis Treatment. 161 

statistics such, restorative work as fillings' and abscesses. 
For the sake of comparison with this, another table was 
made of dental work done for patients of about the same 
class and mouth conditions as the patients' who have 
been on prophylaxis. 

These tables show that the patients who have been on 
prophylaxis have had little or no dental work done since 
entering upon this system. The second table suggests, 
that, had these first named patients not entered upon a 
system of prophylaxis, their dental requirements w^ould 
have been like those named in table No. 2, with, their 
constantly recurring dental bills. In addition to this, all 
these prophylaxis iDatients report fewer doctor bills', and 
their illness, if any, has been light in character; also they 
have derived much pleasure from the knowledge that 
their mouths were in a healthy and beautifully polished 
state. Of as much interest as all the above results is' the 
pleasure derived by the operator who sees the accumula- 
tive effects of his work, bringing imkept mouths to a 
healthy state. I have seen prophylaxis patients so that you 
could tell them across the room, when they smile, by tke 
brilliancy of tlieir teeth. Also the satisfaction of having 

people say, "TVTiy, she must be a patient of Dr. , 

for her teeth are so clean looking and pretty." 

The gums of a patient on prophylaxis should become 
hard and pink, and should hug the teeth closely. In other 
words, show a condition of perfect health. The fillings, 
which, ordinarily would show rough margins' and surfaces, 
should present the appearance of having just been inser- 
ted ; and, after the patient has been on the treatment long 
enough, all surfaces should exhibit a luster which reflects 
the lio'ht. 



CHAPTER XVI. 

SOME IMPORTANT OBSERVATIONS ON THE 

TEETH AND SALIVA. 

TOOTH ENAMEL, 

Pickerill, and others, who have studied the histology 
of human teeth, have shown that the enamel, as laid 
down in the formation of the tooth, may contain defects, 
as well as fissures, and unclosed rug£e. This, of course, 
favors decay by the retention of carbo-hydrates in the 
form of food stuifs, with the final development of micro- 
organisms. If we examine any mouth which is subject to 
a large number of caries, we will find that the enamel 
contains some break on its surface, which defect, while 
small, is sufficient to retain food and allow it to decom- 
pose. 

Dr. Head is authority for the statement that the 
enamel of the teeth, which has become decalcified in weak 
solution of lactic acid, or orange juice, even to the point 
of losing their opacity, will be quite restored when sub- 
sequently immersed in saliva for some time. While this 
seems rather hard for us to accept at first, thorough 
chemical investigation seems to bear out this experiment 
and gives us a clue on which to build our future prophy- 
lactic technique, and mouth wash formulas. There is no 
doubt that the enamel of the teeth varies in structure, 
hardness, density, permeability, and solubility, and that 
we must recognize the fact that a large part of this de- 
parture from the normal must be due to developmental 
as well as acquired defects. Taking this view of the mat- 
ter, our prophylaxis treatment must be directed towards 
the enamel in its formative period in order that the 
proper osmosis of the lime salts and phosphates shall 
take place. 



Impoetaxt Obsekvatioxs ox Teeth axd S.\liva. 163 

Eose, Bunge, Malcolm, and Pickerill have made ex- 
haustive experiments in an effort to determine whether 
or not the enamel of the teeth could be influenced by the 
drinking of water heavy with magnesium or calcium 
salts. The result was that the structure of the teeth was 
not influenced to such an extent as' are the other bones of 
the body. Their conclusions were, that the hardness of 
the water was not naturally or essentially a factor for us 
to consider. 

ox saliva. 

Saliva in the normal mouth varies in character from 
a thin watery nature, copiously discharged, to a thick, 
ropy, tenacious nature such as we often see in unclean 
mouths. 

Some writers have endeavored to show that the 
lessening of the quantity of the saliva is responsible for 
an excessive amount of dental caries. So far as I have 
been able to observe clinically, the question of quantity 
is not of so much importance. Recently, I was baffled in 
the case of a young married woman, who, when excited 
or nervous, suffered from temporary stenosis of all the 
salivary ducts, so that the mouth was almost as dry as 
though she had been taking atropin. So great was the 
pain sometimes caused from this condition that the 
patient became very despondent. As the mouth and the 
surrounding structures were in a perfectly normal state, 
I, and my medical associates, were at first unable to find 
any indications for treatment or to afford the patient 
any relief. We began to treat her for a trouble far 
removed, and one which at first we thought had no con- 
nection with the condition of the mouth, for we supposed 
that getting her mind off her mouth conditions would at 
least give her some degree of comfort. She improved for 
a time under a physician's care but later passed out of 
our observation. The point, however, is that while the 
patient's' mouth was dry, she did not exhibit any con- 
siderable amount of carious action of the teeth. 



164 Pkactical, Oral Prophylaxis. 

It lias generally been noticed that where a pyorrheal 
condition is present, we have an increased supply of 
saliva, yet there is often noted a total absence of caries. 
In the mouth of the case described, there was a reduced 
amount of saliva, yet the mouth showed only a small 
amount of care. My observation, while based upon a 
large number of cases, does not allow me to say with any 
positive degree of certainty, that caries are influenced by 
quantity of saliva, still I am of the opinion that the pres- 
ence of some element in the saliva, as well as the quantity 
of the solution, must be loked for as the prohibitive agent. 

Of course, we must realize that stagnation of any 
secretion must result in decomposition or putrefaction, 
and that this will contain some degree of infection, but I 
am forced to believe that it does not have as much in- 
fluence as Pickerill would have us think. 

It is a strange law of nature that the quantity of the 
saliva is' not increased by the drinking of ordinary 
liquids. You can have the patient with thick, ropy saliva 
drink large quantities of water without perceptibly in- 
fluencing this condition. However, stimulants do produce 
vasomotor effects either as a stimulant or al depressant. 
Tea is given as the greatest depressant, while acid fer- 
mented liquor, as port wine, produce the highest alkal- 
inity index. 

The conclusion which I wish to lead up to is this. It 
does not matter what the condition of the saliva is, nor 
the quantity, nor the quality. What we are most interes- 
ted in is to note, that the patient with an abnormalty of 
the saliva has a much better chance for a return to the 
normal or the physiological condition when on regular 
prophylaxis. 

Pickerill has made considerable study of the com- 
position and behavior of the human saliva, and from his 
writings we have the following deductions. On the 
degree of excitability of the various glands which furnish 
the saliva, he has found that the ordinary tasting of 



Obseevations OiSr Sai^iva. 165 

foods does not excite the glands to action and that 
"bread and butter depress the secretion." In his table 
of experiments from bread and butter at 1.73 alkalinity 
per minute, he runs the list of pine-apple, cake, grapes, 
celery, meat, stewed apples and up to lemon juice which 
is 6.24:. Also, it is shown that the alkalinity of the parotid 
saliva is greater than that of the other glands, although 
these glands furnish such a small quantity of secretion. 
It is a most beautiful and wonderful provision of nature 
that, whatever the degree of acidity in the food products, 
the proper alkalinity is furnished by the saliva, although 
the acid food may be so strong that it could etch the 
enamel surface of the teeth, as in the case of the Siles- 
ians, who suck lemons for a pastime. The after flow con- 
tains sufficient alkalinity to neutralize the acid, and the 
question of alkalinit}^ is one of the most important with 
which we have to deal. 

PTYALIN. 

Physiologists teach us that the action of ptyalin in the 
saliva is for the purpose of converting the starch into 
sugar, in order that the sticky or solid material might be 
changed into one soluble and ready for absorption. We 
are led to believe that ptyalin has more to do with mouth 
conditions than this. 

The operation of extirpation of most of the salivary 
glands has not resulted in any difference in undigested 
starch products. In order to prove this, Pickerill selected 
two rabbits', A and B. One was kept as a control while 
the other one had the parotid and submaxillary glands on 
both sides removed. Weeks after the operation feces 
were collected at intervals, and the examination showecf 
no difference or a very small difference of undigested 
starch. Pickerill suggests that the function of iDtyalin 
is not as heretofore supposed, but rather, for acting upon 
the carbohydrates remaining, or debris left around the 
teeth, to be used after the process of digestion in the 
intestines has gone on. 



lG(j Peactical Oeal Prophylaxis. 

SULPHO- CYANIDE OP POTASSIUM. 

Another substance in the saliva which has been the 
subject for much speculation is sulpho-cyanide of potas- 
sium. Some thought that by its quantity increasing we 
would gain some protection against caries, and yet, El- 
lenberger and others have demonstrated that this sub- 
stance is not found in many animals which are immune 
to caries. Some authors, as Neuchael, Lowe, Beech, and 
Greyger, are of the opinion that some salt of this sub- 
stance, administered internally, might in some way pro- 
duce an inhibitory action on dental caries. However, 
Miller and Kirk have exactly the opposite opinion. About 
all we know is that a weak solution of sulphur-cyanide of 
potassium possesses slight antiseptic qualities. Experi- 
ments show that the percentage of this drug in the saliva 
can be increased by the internal administration of one 
fourth of a grain daily, and the suggestion is given to try 
this in those cases where children's teeth are being de- 
stroyed by caries. It is doubtful whether any direct good 
will result but it appears to be worth giving a trial. 

PHOSPHATES AND CHLORIDES. 

Phosphates and chlorides undoubtedly increase our 
desire for a certain class of food and drink. For instance, 
if we rinse our mouths with a mild solution of S'odium 
chloride we are enabled the more readily to taste sweets. 

MUCIN.' 

This substance, so far, seems to have only the function 
of a lubricant or protective covering for the mucus mem- 
brane. Unfortunately, it is also precipitated around the 
teeth and, instead of being a protection, forms various 
kinds' of plaques. Into this precipitation is caught the 
food products which in time cause the development of 
caries. 



Observations on S.ajliva. 167 

possible presence op immune bodies in the saliva, 

Miller suggests that phagocytes or protective bodies 
may be present in the blood. However, the presence of 
phagocytosis has not yet been established. If this is ever 
done, it is possible that opsomins of the saliva and the 
raising of this index will become just as potent a factor 
in dental jDrophjdaxis as it has proven in raising the im- 
munity of certain diseases. 

The result of all this investigation gives us very little 
knowledge which we can use in our work of preventing 
decay. This much we do know, that organic acids in- 
crease the alkalinity of the glands, and, conversely, netual 
salts produce diminution of the protective substances 
which we wish, and that if we remove oral sepsis, by a 
system of prophylaxis, the saliva can be made one of the 
greatest aids in keeping the teeth clean, because, in a 
proper condition, it acts by constantly washing the teeth 
and surrounding parts, giving the patient the most ideal 
mouth wash, nature's own make, which formula has not 
iDeen equalled by anyone. 



CHAPTEE XVII. 

METHODS OF NOTIFICATION AS USED BY 
KELLS, FONES, AND ADAIE. 

Since the whole idea of prophylaxis' is founded on 
regidarity and system, it is well to work out for each 
individual some scheme to carry this out. Dr. 
Smith simply telephones his patients once a month. Dr. 
Kells, of New Orleans, has a list upon which he places 
the names of all patients, at their request for regular 
attention. At stated intervals from this list he mails 
cards as jyer the illustration: 



Dr. Kells Would Remind 



M. 



that the time has now arrived when, to insure 

their best care, teeth should be 

examined. 

1237 Maison Blanche. 
Phone Main 1617. 



Fi(,. J^. 

Dr. Kells' idea is that he wants the patients to know 
that he is interested in them, but does not wish to place 
himself in a position of commanding them to come to Ms 
office, as it might be embarassing sometimes' to call a 
patient who had decided to go to some other dentist. The 
recipient of this card is not commanded to come to him, 
but is just reminded that his teeth need some attention 
and he may go where he pleases for this work. 



Methods of Notification-. 169 

Dr. A. C. Fones mails the patient an engagement card 
when he thinks it time for his teeth to have a treatment. 
In order that he may know whether the patient has 
received this notice or not, he encloses with the engage- 
ment card a self addressed, stamped envelope, which 
contains a second card bearing the same date as the 
notice, which is to be signed and returned by the patient. 



Dr. Alfred C. Foxes: 

Your appointment card for 
June 3d, at 3 P. M. 
has been received and accepted. 
Signed 



Fig. 23. 

If the patient had to telephone his acceptance or 
write a note, Dr. Fones might not be sure as to a definite 
engagement. By this system he makes it so easy that the 
patient readily signs the return card, and mails it in the 
envelope already addressed to Dr. Fones. 

Others doing prophylaxis, simply leave it to the 
patients to come in at regular intervals'. None of these 
plans seemed to fit my ideas of carrying out this work so 
I devised the following scheme : 

At first, I designated certain hours throughout each 

day for this special work. Mrs. 's appointment 

was on the 10th, and she was reminded the day previous. 
So on down the list. This scattered the work all through 
the month and interfered with regular dental operations. 
The next plan was to bunch all this work into whole days, 
and the organization of what I call my ''Prophylaxis 
Class." Certain days in each month were devoted ex- 
clusively to this work and set aside accordingly. For in- 
stance, the second Tuesday, Wednesday, and Thursday in 



170 Peactical Oeal Pkophylaxis. 

each montli. Afterwards I added other days as new pa- 
tients accumnlated. 

The book used was like an ordinary dental engage- 
ment book, only the engagements were permanent, and 
the book had only eight or ten pages, each page rep- 
resenting a day. By referring to the cut of the engage- 
ment book, you will see that we knew Mrs. Smith had a 
permanent engagement. Her time was paid for whether 
she came or not. By adhering closely to these engage- 
ments' of one half hour each, we found that we could treat 
from twelve to fifteen patients in each of these days. Now 
having a list like this of several days, it was out of the 
question to phone all of these patients every month so I 
had printed the card of notification which is mailed the 
day previous to the time for treatment. 

A large number of patients to treat, and this work 
exclusive for the day, make it very interesting, both to 
myself and the patients. These cards are neatly printed 
and only the dates have to be filled in by the secretary. 



8 :30— MRS. WM. SMITH 

419 Piedmont Avenue 
'Phone 490 

9 :00— MR. FRANK JONE'S 

43 Peachtree Street 
'Phone 8960 

10:00— MISS RUBY SIMPSON 

76 Johnson Avenue 
'Phone 2442 

Second Monday in Each Month 



Part of Page from "Permanent Engagement Book.-" 
Prophylaxis Engagements for the Second Monday in Each Month. 

¥i(i. 24. 



Methods of Notification. 



171 



The da}^ before his first engagement he receives a 
postal card with his dates, thus : 



SECOND MONDAY IN EACH MONTH 



DATES rOR PROPHYLAXIS TREATMENT 



PRESERVE THIS CARD 

January Monday 10, at 

February 

March 

April 

May 

June 

July 

August 

September 

October 

November 

December 



10, 


at 9 


o'clock 


14 


u 


11 


14 


a 


li 


11 


li 


it 


9 
13 




it 
it 


11 


li 


it 


8 


11 


ti 


12 


li 


li 


10 


It 


it 


7 


a 


It 


12 


li 


It 



Charge $- 



per year. 

A reminder card will be mailed previous to each date but 
failure to receive such notice does not entitle patient to another 
engagement in the same month without extra charge, unless failure 
to be present is due to unavoidable cause, in which event notice 
must be given several hours in advance. 

The charge for prophylaxis is by the year for twelve regular 
engagements, and is payable semi-annually in advance. If for 
any cause these treatments be discontinued before the expiration 

of contracted time a charge of $ will be made for each date 

nip to the time notice is received to discontinue. 

Appointments are not to be changed more than three times per 
year. 



Fig. 25. 



172 Practical Oral Prophylaxis. 

For each succeeding engagement lie gets a postal card 
very similar, like this : 



rOUR ENGAGEMENT FOR PROPHYLAXIS IS 

AT O'CLOCK 

The charge for this treatment is by the year from date of first 

engagement and is payable in advance. The date and honr is 

fixed, if possible, to conform to convenience of patient 

and is not to be changed oftener than twice a year 

As this time is reser\'ed, failure to meet engagement results in loss 

to patient and can not be made up unless the absence is 

caused by Providential hindrance, in which event notice 

must be given a dav in advance 



Fig. 26. 

The patients shonld not commence our system of 
prophylaxis unless they mean to stay at least a year ; we 
enter the charge in our ledger for one year, and a bill is 
rendered them for one half, or the whole of the amount. 
This must be paid in advance if this time is to be saved 
for them. 

At the first appointment, on the record ledger sheet, 
we make a note of all cavities', including the incipient 
ones, and all defects of the mouth. The jDatient should be 
made acquainted with all these conditions and shown the 
note in the dental ledger. At the first treatment the 
patient must invest in two brushes, floss silk, and dentri- 
fice cream, and he is taught how to use them. One brush 
has the name of the patient engraved on the handle with 
a dental bur and made plain Avith a smear of ink. This 
is kept in the office in the formaldehyde sterilizer to l)e 
used solely for teaching the patient to care for his teetli. 
TJie patient, at first, does not understand all this busi- 



Methods of Notification. 173 

ness of cards and dates but the system keeps up his inter- 
est. After the third visit the benefit is apparent, and the 
patient is yours to command. After years of study and 
practice this system has been evolved as the most efficient 
method of handlina^ the work. 



CHAPTER XVIII. 

XoTincATioisr op Patients. — Recoed of Cases. 

By John Oppie McCall, D. D. S. 
Notification . System. By Heney A. Kelley, D. M. D. 
Notification of Patients. — Technique op Peophytoaxis 
Tkeatment. By Gillette Hayden, D. D. S. 



notification of patients. EECOED OF CASES. 

BY DE. JOHN OPPIE m'CALL^ BUFFALO, N. Y. 

''These two subjects are considered in one chapter, 
because the two things can be very readily and advantage- 
ously combined. This' is done by having the record chart 
printed on a 6x4 card which is kept in a card index system, 
and which thus serves as the basis of the follow-up cam- 
paign, so necessary to secure the best results in this' 
field. 

''We will consider notification and follow up first. The 
back of the record chart shown below may be ruled in 
several ways according to individual ideas. The main 
thing is to have columns for date of appointment, length 
of time consumed, and remarks'. The writer does not 
keep the financial account on this card, and for several 
reasons. The card is to be laid on the bracket table while 
patient is in the chair. It thus serves as a record of past 
appointments with their possible history of delinquency 
on the part of the patient, as' well as a ready reference 
to the pathological conditions in the mouth. A financial 
statement forms no integral part of such a reference card 
and is not one of the things of which we want to remind 
the patient, at least while in the chair. Appointments for 
the next sitting may be noted on these cards in the 
presence of the patient, and then be checked off when 
kept. 

"The filing of these cards is not alphabetical, but hj 
months (or by days of the month, if so desired). An 



Methods of NoTiPiCATiOiSr. 175 

appointment having been kept, the card is filed in the 
month or day of the month when the patient is next to be 
given treatment. As the end of the month is reached, the 
month index card is moved to the back of the file, thus 
bringing forward the cards of those to be seen the fol- 
lowing month, who will then be notified of the impending 
visit. Patients' cards are only moved back in the file 
after the treatment. Hence at the end of the month the 
cards of those patients who have failed to keep their 
appointments' for any reason will be found at the front of 
the index, and will remain there until properly dis- 
posed of. 

"The method of notification of the patient will depend 
partly on the patient, but the initiative in making ap- 
pointments can seldom be left to the patient if good re- 
sults are to be had. A notification and appointment card 
sent by mail is usually the best method, although with 
many patients the telephone accomplishes the same end 
with less friction. The patient should be given to under- 
stand at the time the case is started that the dentist pro- 
poses to send an appointment. If this procedure does not 
meet the approval of the patient, the matter can be talked 
over at the time and the need of such action explained, 
thus settling the method of notification to be followed for 
that patient, and avoiding possible disagreeable incidents 
later on. The following is the text of the card used by 
the writer. 



Dr. John Oppie McCall begs to suggest the advisability 
of making an appointment for a prophylactic treatment. Experi- 
ence has shown that short sittings at regTilar intei-\'als are neces- 
sary, that the improvement secured by previous treatment may 
not be lost. Your ease having been imdertaken, responsibility 
for its success dictates this reminder. 
Time has been reserved for vou at o'clock 



Fig. 27. 



Iv6 Peactical Oral Prophylaxis. 

'^With this is also enclosed a regular appointment 
card, which can be tucked in purse or pocket to refresh 
the patient's memory. 

' ' The method of recording pathological conditions has 
been developed on the basis of the needs of the general 
practitioner, but can be used quite as' readily in a practice 
devoted to this field. 

"The system was suggested by Dr. A. D. Black, but 
has been considerably modified by the writer. The un- 
derlying idea is to have a key of numbers or letters, which 
through their various combinations may serve to indi- 
cate and diagnose various pathological conditions. 

' ' The chart shown here is printed on a 5x3 card, but a 
larger one may be used, if desired, with correspondingly 
larger chart. The diagnoses are recorded on it in the 
spaces indicating the location of the conditions recorded, 
by means of three letters which tell the tissue affected, 
the cause of the trouble, and the result shown at the time 
the examination is made. The three letters refer to the 
three columns of the key, the first letter referring to the 
first column, the second letter to the second column, etc. 

' ' The key letters take up very little room, yet make as 
complete a record as one written in longhand. The key 
is readily memorized and hence records are instantly 
available. The reduction of records to a key system has 
another advantage ; namely, that it is not known to the 
patient, and the dentist is thus' spared the necessity of 
explaining the edges of fillings and crowns, etc., for which 
some colleague is responsible, and which may have caused 
some trouble. 



Methods of Notification, 



177 



KEY TO DIAGNOSIS OF PULPAL AND PERIDENTAL LESIONS. 



Pathological 
Couditiou in 

A. Pulp 

B. Gum Margin 
(J. Pericementum 



Cause 

A. Caries 

B. Lack of insulation 

C. Traumatic injuiy 

D. Denudation of root 

E. Abrasion 

F. Salivary calculus 

G. Serumal calculus 
H. Lack of contact 

of teeth, fillings, 

etc. 
J. Improper contact 

of teeth, fillings, 

etc. 
K. Mal-occlusion 

(other than above) 
L. Improper margin 

of filling or crown 
M. Improper restora- 
tion of occlusal 

surface 
y. Mouth hygiene 
0. Systemic disturb- 

banee 



Result 

A. Active hyperemia 

B. Passive hyperemia 

C. Tubular calcification 

D. Secondan' dentine 

E. Pulp stones 

F. Hypertrophy 

G. Stasis 
H. Infection 

J. Putrescence (pulp 

canal) 
K. Pericementitis 
L. Abscess (incipient) 
M. Abscess (^rith sinus) 
iST. Recession 
0. Denudation without 

recession 
P. PyoiThea 
R. Looseness 
S. Elongation 
T. Bone absorption 

without denudation 
U. Sensation 



•'Thus ABD indicate a pathological condition of the 
pnlp, due to a filling without proper thermal insulation, 
resulting in formation of secondary dentine. BFX indi- 
cates a lesion of the giim margin due to salivary calculus, 
resulting in recession. CKP indicates a peridental affec- 
tion caused by mal-occlusion resulting in pyorrhea. This 
key can be made to serve for quite a complex diagnosis, 
as for instance in the case of pulpal hyperemia due to 
denudation of a root in the course of a progressing pyor- 
rheal affection. The diagnosis of the pyorrhea! condition 
Tvill be noted as above, and the pulp trouble will be re- 
corded thus A.PB. the period indicating that the last two 
letters are taken from the last column, the one indicat- 
ing cause of course preceding the other. In case two 



178 



Pkactical Oeal Prophylaxis. 



causes are found, as is not uncommon, the letters will be 
included between two iDeriods, as C. JN.A. This indicates 
a peridental disorder due to improper contact of teeth 
and improper care by the patient, resulting in hyperemie 
condition. 



M. 







R 
























L 












































































m 


s 


[6] 


[5] 


s 


m 


m 


m 


ai 


a 


m 


SI 


m 


[H 


a 


® 


































































E 


E 


B 


E 


m 


E 


m 


51 


a. 


E 


m 


m 


E 


E 


m 


E) 




































































RE^ 


ARK 


S: 



Fig. 2S. Chart B. McCall. 



' ' On the chart, the teeth are indicated by numbers for 
the ujDper, and letters for the lower, the same number or 
letter indicating the corresponding tooth on either side 
of the median line. The right upper cuspid is 3E, the left 
lower first molar is FL. Again the key is readily memor- 
ized, and is the most compact way of designating the 
teeth in recording various operations. The chart shows 
a series of square and oblong spaces which represent the 
hard and soft tissues. The left-hand teeth are found at 
the right of the mediam line on the chart, this being 
their position in the mouth when the operator faces the 
patient, and vice versa. The little squares containing 
the number or letter represent the occlusal or incisive 
surfaces and are surrounded by a space representing the 
buccal, mesial, lingual and distal surfaces of the teeth. 
In this space are recorded diagnoses of pulp troubles^, 



Methods of Notificatiox. 



179 



and also erosion, cavities, etc., of which a permanent 
record is to be kept. It is not intended for a record of 
operations performed. The horizontal oblong space at 
the top of the diagram represents the labial gum tissue, 
and notations in regard to that tissue or the correspond- 
ing peridental membrane are placed in it. The vertical 
horizontal spaces under it represent the mesial and dis- 
tal soft tissues, and the horizontal oblong just above the 
heavy center line indicates the lingual gum tissue. The 
position of these spaces are reversed for the lower teeth. 
See section of chart enlarged below:" 







- - (^-e-^JilA^^ 



Fin. 29. 



NOTIFICATION SYSTEM OF HENEY A. KELLET, D. M, D., 
POKTLAND, MAINE. 

''My system of notification is very simple. We will 
consider that a patient presents himself for work and 
we wish to get him on to the system of prophylaxis. [ 
give him a talk along the lines of preventive dentistry 
and explain the theory of prophylaxis. Having obtained 
his permission to put him on this system I give him a 
treatment and dismiss him, ha\dng first inquired as to 
what days of the week are best for him for appointments 



180 Peactical Oeal Prophylaxis. 

and what hour in the day is preferred. I tell him I will 
notify him when I want to see him again. After he has 
gone, my secretary first enters him upon the list of my 
patients who are on the prophylactic treatment. I tell 
her how long a time I want to elapse before he has 
another treatment and she turns to my appointment book 
and enters his name as near that time as she can, con- 
sidering his wishes as to day of week and hour. Then a 
few days, say a short week, before the time of his ap- 
pointment my secretary calls him up by telephone and 
says, 'Tou desired Dr. Kelley to send you an appoint- 
ment for your prophylactic treatment about this time. 
Now Dr. Kelley has reserved the time on such a day and 
such an hour for you. Will this day and hour be agree- 
able to you.' If he says yes, the appointment slip is 
mailed to him. This must be done to avoid the un- 
certainty of the telephone and to impress him with the 
importance of the appointment. Should the time re- 
served prove to be one not possible to him, some other 
appointment for prophylaxis made for some other 
patient, not yet notified, can be offered and his time ex- 
changed with that jDatient. This is done, of course, as 
the secretary telephones. You will readily see with many 
prophylactic patients on your book you have great lati- 
tude this way. 

''This is all there is to the system, except, if you have 
to rely upon the mail alone, you must have some system 
in which you get a return answer to your appointment 
when first sent, to know that your patient receives the 
appointment and to prevent loss of time owing to 
failure of patient to receive your appointment when sent. 
It is impossible to fix the blame for this kind of a slip-up 
and you have to assume the loss. One thing you have to 
be careful about, is that you do not in some way break 
this system. Any system is defective in that you may 
think it is working when it is not. So once in a while it 
is well for your secretary to check up the patients that 



Methods of Xotificatiox. 181 

are on the list of those having the prophylactic treatment 
and see that they are all on the appointment hook some- 
ivJiere. 

"I believe that the dentist should always look out for 
the patient and should send for him when he thinks he 
should make a dental call and it should not be left to the 
patient to decide when he will call upon the dentist. This 
system of notification for prophylaxis gives you the 
means of educating your patients along this idea." 

SYSTEM USED AXD DESCRIBED BY DE. GIT;LETTE HAYDEX, OF 
COLUMBUS, OHIO. 

'^ Notification of Patients. — The name, address, and 
telephone number of a patient beginning the regular 
monthly treatment are placed on a card, and the card, 
after having the date of the first treatment entered on 
it, is placed in the file box one month in advance of the 
date of the first treatment. For example: The patient 
has the first treatment January 3d. The notification card 
has this date entered on it, and is then placed in the file 
box back of the month card of February and date card of 
3. On January 31st or February 1st the assistant takes 
all cards bearing date of February 3rd, calls each patient 
by telephone, and arranges the hour for the appointment. 

''In every case this has proven the most satisfactory 
of all methods tried. The patients find it easy to arrange 
hours which do not conflict with other appointments 
which they must make, and I find less disturbance from 
appointments cancelled or changed to other dates. An- 
other feature of this method is that the appointment book 
will have only two or three days in advance filled com- 
pletely. This permits of opportunities to supply time 
not too far removed, to out of town cases, to emergency 
and other cases. 

' ' Out of town patients are notified by mail a week in 
advance that they are due on such date, and that an 
hour (usually that given on the card as the most con- 



182 



Practical, Oeal Prophylaxis. 



T'enient for tliem) is reserved for them on two different 
-days. They make the selection of the day in the reply. 

^^ Charges. — Charges are made for each treatment. 
To those having an account, statements are mailed every 
six months. 

''Technique of Prophylaxis Treatment. — In the usual 
cases presented each month for treatment the buccal, 
lingual and liabial surfaces of the teeth are reached with 
S. S. W. Scaler No. 3, or 6 and 7 (from set of eight). The 
mesial and distil surfaces are reached with Smith files 
Nos. 13 and 14, or Townes Files 33 and 34, or 35 and 36, 
or with Nos. 1 to 8 of the Bates' Scalers, according to the 
size of the inter-proximal space and the extent of the 
recession of the tissues. 




Fig. 30. Bales' Scalers, Ivory. 



"The teeth are then stained, a few at a time, with a 
disclosing solution containing 4 dr. each of water and 
glycerine, 15 gr. potassium iodide, 15 gr. zinc iodide, 5 
gr. iodide crystals. For applying this solution cotton is 
wound around a wooden tooth pick. 

"At present the Carmichael preparations are being 
used with satisfaction as abrasive and polisher. The 
cleansing powder is carried to the tooth to be polished on 



Methods of Notification^. 183 

a Tvedge-shapecl orange-wood stick dipped first in phenol- 
sodique. A straight large sized orange wood stick is used 
where the surfaces of the teeth are accessible to it. A 
wedge shaped point carried in the right angle porte 
polisher is necessarily used on all surfaces not reached 
by the straight stick. Wherever the loss of the tissues 
permits the use of a small wood point on the approximal 
surfaces, these portions of the teeth are polished in the 
same manner as the other surfaces. 

''Ribbon floss, X size, charged with the abrasive then 
passed between the contact points and carried up just 
under the free margin of the gum and with a sliding mo- 
tion of the fingers carrying the floss the aiDproximal sur- 
faces are polished. With an aseptic dental najDhin 
wrapped about the index finger and charged with fine 
polishing material, the final polish is given to the teeth, 
and a light massage to the gums. 

''A spray containing a zinc chloride solution is used 
to complete the treatment. 

"Sticks are prepared by first sharpening them to a 
wedge shape on a very small plane set (plane side up) in 
a vise, then rounding the corners and smoothing off with 
sand paper." 



CHAPTEE XIX. 
TEAINING OF FEMALE ASSISTANT. 

WHEjS^ should such help be installed IlSr A DENTAL OFFICE f 
THE BEST WAY TO SECUEE GOOD HELP. METHODS OP OB- 
TAINING TELEPHONE AND RECEPTION ROOM RECORDS 
TO BE USED BY FEMALE ASSISTANTS.— OFFICE 
TRAINING FOR THE POSITION OF 
DENTAL NURSE. 

When the author first came to Atlanta, some fifteen 
years ago, there was only one white female assistant in 
a dental office ; several dentists had negro girls. Shortly 
after this, some of the dentists began putting white girls 
into their offices, but were criticised for it. Today, such 
a revolution has come about that every office of any 
reputation has from one to three young ladies employed. 
Even the term '^ office girl" has now disappeared, and 
each young lady has her special duties to perform, and 
is entitled to the name either of assistant secretary, book- 
keeper, or dental nurse. 

To the student who is soon to start a practice, to the 
young man already graduated, or to the older practitioner 
who has not availed himself of this great help, these 
pages, I hope will be of assistance. 

The first question which naturally arises when the 
subject is brought up is, "When should such help be 
installed!" In answer to this, I should say that just 
as soon as the office is established, and the patients 
begin to make their appearance, then should the train- 
ing of the assistant begin. In other words, I consider the 
trained female assistant just as necessary to the dental 
office as the chair or the engine^ 

The next question is, "From what source is such a 
girl to be obtained ?" The advice that I give my students 



Training of Female Assistant. 185 

in a rather semi-serious mood is that they insert in the 
daily newspaper exactly the description of the girl they 
desire, withholding, of course, their own name and ad- 
dress; the office will probably be flooded with applica- 
tions. If they meet these pleasantly, they have placed an 
advertisement in just so many homes from which they 
may receive future patronage. 

The scheme, however, which I employ, is to go to 
the floor-walker in some department store, and explain to 
him exactly my needs. My reason for this is that in his 
daily watch over a large number of young ladies, of 
the class from which we must employ the ordinary den- 
tal assistant, he has the chance to pick out the one to suit 
the position. If you explain to him that it is a regular 
position, and one where advancement can be expected, he 
will frequently tell you of some young lady in his em- 
ploy, with whom, for the sake of allowing her to take the 
better position, he is willing to dispense, or, if he is not 
so inclined, he will generally tell you of some one, former- 
ly employed by him, who will come up to the require- 
ments. I have always found the girls endorsed by the 
floor-walker to make better employees than those secured 
from other sources. I have also found that applicants 
from newspaper ads and employment bureaus have often 
not been able to furnish the proper references. 

In making your decision, as to the fitness of an ap- 
plicant investigate her references. If she can give the 
pastor of her church, you may generally put it down that 
this counts. Always prefer one who lives at home, or 
with her relatives, or one who can give good reasons for 
not living at home. Give the preference always to the 
older applicant, other things being equal. The girl under 
nineteen years of age has no place in the dental office. 

One thing that must be guarded against is the good 
looking girl. In my own experience, as well as that of 
others, I find that such a girl is not the proper applicant 
for the position of dental assistant or nurse. Not that 



186 PEACTiCAii Oeal Prophylaxis. 

beauty itself is a detriment, but rather, it is of such charm 
that you will either have your patients talking about the 
good looking girl in your office, or it may soon lead to her 
taking a matrimonial venture and your assistant is lost 
to you as soon as she is trained. 

Explain to the applicant that it will take several years 
of training before she can expect any consider.able ad- 
vance of wages. From the very first, it is best to have 
this understood. I have noticed that the dentist who 
employs a young lady and fails to have this understood 
at first, soon finds that the girl is trying to run the whole 
office. He has made so many promises that her wages 
have to be increased before the dentist's income is suffi- 
cient to warrant it. 

The first duty of the female assistant to the dentist is 
that she, being a good house keeper, keep his office in 
order. This must be understood before she enters the 
office as assistant. No matter what her qualifications are, 
if she is not willing to go into the office, and, if needs be, 
scrub the blood from the floor after an operation, she is 
not the one for you. She must be willing and able to 
keep the office in order and in a clean state for, although 
our buildings have janitors, they do not clean the cabinets 
and wash stands. Many times she will be called on to 
clean the basins and the spittoons after a bloody opera- 
tion. 

The young lady should be given a key to the office, 
and, at least half an hour before you arrive, should open 
up the office, dust it, and turn on the heat. In other 
words, have everything ship-shape on your arrival, so 
that without further delay you may proceed with the 
patients. 

In regard to her dress, I would advise that you make 
some distinction or dilference from the ordinary dress. 
Now this will have to be understood at the time she takes 
the position for, if you wait several months, 3^ou will find 
that she is not willing to change. Many girls of this class 



Teaining of Female Assistant. 187 

wear gaudy jewelry and gay costumes. You will have to 
explain to them that they are in the same position as the 
trained nurse and must wear simple clothing. It is better 
that she wear nurse's costume or some part of a nurse's 
uniform. 

If you have secured the services of the proper young 
lady, and you cannot secure this proper applicant on a 
salary of less than $6.00 per week, this amount will be 
well spent, and she can save the dentist's time, and time 
is money to a dentist. In addition to this, she is in a 
position to add to your reputation, because she will talk 
your business better than you can yourself. 

As the majorit}^ of dentists do not employ but one 
young lady, I will describe some of her probable duties 
which she will have to perform and in which she can be of 
real worth to the operator. 

It will be best not to try to teach her the names of the 
instruments the first week, but try to teach her the use 
of the telephone. I would suggest that the dentist himr 
self not answer the telephone at all. Dr. Kells, for ex- 
ample, will not answer his telephone during office hours. 

There is a good reason for this. These telephone mes- 
sages are often for the purpose of breaking an engage- 
ment, objecting to an account, or complaining about 
work. In making engagements over the phone, you are 
never able to tell just how much time to leave out for 
such and such an operation. It is much better for the 
patient to come to the office for an examination. This 
engagement can be made b}^ the assistant. 

Dr. Conrad Deichmiller, of Los Angeles, has a tele- 
phone record sheet printed and padded. The sheets are 
about 6x8 inches, one sheet being used each day. He has 
all the messages that have come in or gone out over his 
telephone accurately recorded. At the end of the day he 
sits down and attends to each one at his leisure. 

When the assistant makes engagements, I would 
suggest the following line of conversation: 



188 Pkactical Oral Prophylaxis. 

"Yes this is No ■ Dr. 's office. 

What name, please? Yes, he is here, but engaged in an 
operation. It will be a favor if you will give me the 
message as I make engagements for him." The reason 
for this line of talk is that it impresses the patient that 
you are busy. 

If the person at the other end of the line refuses to 
give the message, the following reply should be made, 
''Leave your number and I will have the Doctor call 
you later." If the message is delivered, it should not be 
delivered to you verbally but written on a slip prepared 
for phone messages. 

This gives you time, also, to frame the proper answer. 
If an engagement is to be made, the engagement book is 
taken to the telephone. If a bill is in question, you may 
take the ledger to the telephone with you. 

Have it distinctly understood that your telephone is 
for business, and not for the young lady to talk to her 
gentleman friends, for some day while such a flirting 
conversation is going on, a patient suffering with a tooth- 
ache will call some other dentist, not being willing to wait 
until the conversation is over. 

It is best to have the assistant make all engagements 
which must be recorded in an engagement book. If made 
over the telephone, it should be verified immediately by 
mailing a card to the patient. This will save many lost 
hours. 

She can make all bank deposits. She should be instruc- 
ted how to write a receipt and to receive money from 
patients while you are busy. 

She must be instructed how to handle the patients in 
the parlor, especially the waiting ones. She must be able 
to explain to them that the doctor is engaged in a diffi- 
cult operation, and, in justice to the other patient, they 
must wait patiently. There is one thing which she must 
not talk about, and that is what is going on in tlie operat- 
ing rooms. She must be, so far as talking to the patient 



Training op Female Assistant.' 189 

on tins subject is concerned, a blank. Especially will slie 
be questioned as to the Doctor's fees. She is supposed 
to Jiiwiv nothing along this line. 

As I have said, she must be a good housekeeper. It 
should be her duty to see that the janitor sweeps down 
the walls, that the mirrors are polished each morning, 
that the laundry is not full of holes, and that it goes out 
reg-ularl}^ and comes in on time. She should have the pur- 
chasing^ of the towels, napkins, and linen, as she knows 
more about such things than the dentist. One of the 
hardest things, I find, is to get the assistant to keep an 
accnrate laundry list, and I constantly find myself buying 
a new supply of linen. I find it a good plan to buy ordi- 
nary duplicate order books, and insist that the quantity 
C)f each article be put down, and that a duplicate sheet 
be put with the clothes ready for the laundry, then, that 
this slip be checked before receiving the clean linen. 

If she is to be of value in assisting around the chair, 
she should have the quality of seeing ahead, that is, of 
anticipating the needs of the dentist. In other words, the 
dentist should not have to tell her every thing to be done. 
The minute the patient sits down, she should put a pro- 
tecting napkin around his neck, and place a cup of some 
antiseptic mouth wash near at hand. She should see to 
it that the chair is comfortable. This done, she should 
step "a side. 

I have found it better not to keep up a line of con- 
versation with the assistant. If a code of signals can be 
arranged, yon will find it to an advantage, for, sometimes, 
you will want her to go out, and to tell her to go would 
defeat your purpose. One tap of the insturment could 
mean for her to stay, two for her to retire. 

One of the most valuable adjuncts to my office is the 
use of a card, as shown below. As soon as patients 
arrive they are furnished this card by my female assist- 
ant. She sees that it is properly filled out before bring- 
ing it to operating room where it is i^laced in a special 



190 



Peactical Oeal Peoppiylaxis. 



holder just off from my cabinet, without disturbing me, 
yet where I can see, the full significance of the waiting 
caller at a glance. 



Kindly Weite Name and Addeess and 
Check Youe Call 

Name 

Address 

Wishes to see 

O De. Robin Adaie 

For Examination [Fee $1 to $5] 

To make engagement 

Have engagement 

Business call 

Social call 

Memorandum 



Fig. 31, 



This enables one to know the caller's name and ad- 
dress, saves introduction, and a lot of questions. If the 
check is on second item, then the assistant makes the en- 
gagement without disturbance. I have never yet bad a 
book agent check anything except the business call, and 
all of these checks are requested to call after ofhee hours. 
The numbers at the bottom denote the number of patients 
waiting before the last ono came in. This card enables 
the assistant to handle a large number of callers without 
disturbing the dentist. 



The Deisttal Assistant. 191 

At the eucl of the day those cards are taken and 
all work done for each is figured out. I have their 
correct address which may be new since my last work. 

Other duties for a female assistant are suggested 
under the head of Dental Nurse. Many of these can 
readily be taught to the average female assistant. 

If, perchance, you can emj^loy a young lady who is a 
stenographer and book-keeper, you are indeed fortunate, 
for there is nothing more needed in the modern dental 
office equipment than careful work along this line. While 
you will have to make the original entries of work done 
at your chair, she can afterwards record them in the den- 
tal ledger. At the end of the month, she can save you a 
great amount of time by making out the statements. 

I have always found that a young lady, calling up a 
patient for a delinquent bill, saying that she is book- 
keeper for Dr. , and that it is time for closing 

up the books, and she, iinding that the bill had not been 
paid, would like to send around for it, does more good 
than putting a lawyer after them;. 

Some dentists have their bookkeeper look up the finan- 
cial rating of a new patient when he first presents him- 
self, so that she can hand the dentist, written on a sheet 
of paper, just what to expect in the wa}^ of payment. 
Even the information given by the city or telephone 
directory is most valuable at this time. 

OFFICE TRAINING FOR THE POSITION OF DENTAL NURSE. 

If the dental nurse has been trained up from the 
dental assistant, she probably knows the patients and 
has their confidence and you will have less trouble in 
introducing this line of work into your practice. It is to 
be hoped that by the time this book is published, some 
school will have taken advantage of this opportunity by 
])utting into its curriculum a course of training for 
dental nurses. As the question will be taken up more 
fully ill tlio latter ]Kirt of the chapter, suffice it for the 



192 Practical, Oral Prophylaxis. 

present, to give some suggestions to those wlio wisli to 
train their own assistant for prophylaxis. Some simple 
rules may be of help; in the first place, it will not be 
advisable to call the assistant a dental nurse until she has 
had a degree of training and has become somewhat effi- 
cient. The first qualification is that she have some aim 
in life, and be of settled disposition, for the girl whose 
future is in doubt has no place in this work. 

I would begin the training by placing at her disposal 
some of the simple books on sterilization as given for 
general surgery. 

She should be first aid in minor surgical work, and 
should assist the dentist in administering anesthetics. In 
the first place, it is an absolute necessity that a female 
assistant be present when giving an anesthetic, and that 
she be taught along this line, for many is the time that 
the assistant gets stampeded more than any one else. I 
would let them read the small book of lectures by Dr. de 
Ford. In this way, they will receive the knowledge of 
what is expected of them under such circumstances. 

The anesthetic having been determined upon, if the 
patient is a woman, the dentist steps from the room 
leaving the patient in the hands of the nurse. The nurse 
sees that the corset is either loose or removed, the tight 
collar and the neck band opened. The dental nurse can 
at this stage dispell the fear from the mind of the patient 
better than the dentist. She should put around the 
patient the protecting apron and have a hand spittoon 
within reach and a supply of towels convenient. She 
should be taught how to proceed in the case of an acci- 
dent for, if she is not, she may desert you at a critical 
moment. 



CHAPTER XX. 
THE DENTAL NURSE. 

VIEWS OF FOISTES, MEERITT, HYATT, HART, EBEESOLE, NODINE, 
KIRK AND SKINNER. THE PROPOSED LAW FOR MASSACHU- 
SETTS AS ENDORSED BY THE STATE DENTAL SOCIETY. 

The trend of the times is toward trained dental assis- 
tants for oral hygiene work. Women now employed in 
this occupation have been designated dental nurses. In 
many offices they are successful in the field of prophy- 
laxis, in the schools: they are doing great work in the ex- 
amination of children's mouths, and in the various clinics 
instituted in some countries they have proved superior to 
men for all work. 

In order to show the present demand for dental 
nurses, the author has selected from the published views 
of some of the leading men in our profession, quotations 
on the subject which are given at some length. 

Dr. A. C. Fones, says: ''A busy practitioner cannot 
comfortably do this work alone, unless he limits the num- 
ber of his patients to comparatively few. He must have 
aid, and I believe the ideal assistant for this work to be 
a woman. A man is not content to limit himself to this 
one specialty, while a woman is willing to confine her 
energy and skill to this one form of treatment. A woman 
is apt to be conscientious and painstaking in her work. 
She is honest and reliable and in this one form of prac- 
tice, I think she is better fitted for the position of prophy- 
lactic assistant than is a man." 

This view is also taken by Dr. A. H. Merritt: 

"It is an innovation that has been made necessary 
by the evolution of dentistry. It is in the line of pro- 
gress and will prevail. It may not come this year or 
next, but that is of little consequence, it is enough, just 



194: Peactical, Oeal Prophylaxis. 

now, to know that it is a part of the dentistry of the 
futnre. Like all forward movements it may meet with 
opposition, and that from those most directly benefited, 
but that is to be expected. Progress has always been 
made in the face of opposition. 

"In the very nature of things it must go forward, and 
co-operating with it to the end that the public shall be 
better served, will go to the trained dental nurse." 

Dr. T. P. Hyatt takes up some of the various objec- 
tions which have been raised against this movement : 

"The work of the nurse is to keep all the exposed sur- 
faces of the teeth in a high state of cleanliness and polish. 
Please understand that when I say polish I mean the 
kind that is secured by the methods advocated by Dr. D. 
D. Smith. 

"I shall make no attempt to show the need of dental 
nurses in our dental dispensaries or schools, for the 
reason that once they admit their need in our offices, it 
must follow that the need is great and greater in the 
dental dispensaries and schools. 

"Up to the present I have only heard three objections 
to passing laws permitting dental nurses, which laws 
would regulate the knowledge required, and prescribe the 
rules and regulations under which they should work. 

"1st, If you want a dental nurse take a graduate 
dentist. 

"2d, If this work is so important is should only be 
performed by a college graduate holding the dental 
degree. 

"3d, To allow any one other than a' doctor of dental 
surgery to perform any service in the month is to lessen 
the value and importance of our work. 

"What work is the dental nurse expected to perform? 
To fill teeth? To make crowns or bridges? To cut, or 
remove any of the normal structure, such as tooth struc- 
ture, gum or alveolus? To treat pathological conditions 
and prescribe drugs? If any or all of these are required 



The Dental Nuese. 195 

or expected of the dental nurse, tlieu they should he 
graduated doctors. 

''Those advocating dental nurses do not expect any 
of these things. 

"Does any one question that the work a trained dental 
nurse does is important .' The health, even the life of 
the patient depends upon the performance of these duties 
regardless of who does them. Tlieir importance being- 
admitted, with the realization that the success of an 
operation depends upon their being done, and done right, 
does the medical profession insist that only graduated 
doctors, or women who have secured the degree of M. 
D. be permitted to perform these important services ? 

"Another objection I have heard and with due re- 
spect to those who make it, I am free to confess my sur- 
prise and astonishment that any one for a moment can 
believe that it is really worth considering at all. The 
objection is this : If we allow young women to become 
trained dental nurses, a great many might start dental 
offices of their own. It seems absurd to think that any- 
one could advance such an idea with any seriousness: 

"Dental nurses will be of such inestimable benefit to 
the public, our patients, and to the uplift of our profes- 
sion, that all good men should unite, and think out, and 
work out the best and safest plans for its accomplish- 
ment. ' ' 

Dr. Chas. E. Hart, of San Francisco, says in reference 
to the dental nurse: "I have two with me at present and 
am running two operating rooms. The uniforms that 
costume the nurses are made of white material and of 
similar substance to the ordinary surgical gown, and 
made up in simple form with pattern to suit the person." 

Dr. TV. G. Ebersole, of Cleveland, says: "I find the 
lady graduate for prophylaxis work to be very satisfac- 
tory indeed. This is the beginning of the ninth year in 
which I have employed ladies in this field." 

Dr. A. M. Xodine, of Xew York, suggests that: "It 




K r/' 






1^ a-j 



The Dental, Nuese. 197 

would be a migiity fine thing for the dental profession to 
achieve this accomplishment for the benefit of the millions 
of poor school children. If the public wakes up to the 
realization of the possibilities, importance, economy and 
practicabilit}^ of the idea, it will establish the trained 
nurse in spite of either the apathy or protest of the 
dental profession." 

Along the same line of prophesy, Dr. Kirk, by edi- 
torial in Dental Cosmos, says : 

"Whatever objections may be urged at present 
against the emplo^'ment of the dental nurse in the capac- 
ity here under consideration, the trend of the time ap- 
pears to be inevitably in favor of such a course, and it is 
highly probable that the near future will see the dental 
nurse as firmly intrenched in her field of activity and as 
efficiently serviceable therein as today we find the usual 
lady assistant in our modern dental offices." 

I cannot for the life of me see why the dentist will 
undertake even the operation of filling the teeth without 
first using the precaution of cleaning the field of opera- 
tion, I have made it a rule in my office that before I take 
the patients, I turn them over to my dental nurse, who, 
if nothing more, mops and syringes the mouth out with 
antiseptic solutions. I find that the patient appreciates 
the work more and that it lasts longer, and, surely, it is 
more pleasant to work in a clean mouth than in a dirty 
one. Then too, when I have finished the work for the 
patient, he is again turned over to the nurse, who suggests 
the proper toilet articles such as dentrifice, silk, mouth 
wash, etc. If the patient desires', these are furnished him 
before leaving the office. 

It is a good idea to keep these things for sale in the 
office, as it gives the nurse a chance to earn ]iart of her 
salary. It also gives the nurse the opportunity of in- 
structing the patients in. the manner of brushing their 
teeth. Few patients know this, and the dentist is too 



198 I Peactical Oeal Pkophylaxis. 

busy to sliow them properly, as it takes some fifteen or 
twenty minutes. 

You will find in the case of the younger patients, that 
if they had to be led in to you first, would probably be 
afraid and hard to manage. The dental nurse can take 
these children for a few sittings and, by cleaning up their 
teeth and teaching them something about oral hygiene, 
will be able to turn them over to you, with all fears dis- 
pelled, for the further treatment of their teeth. 

Women are particularly adapted to the work of pro- 
phylaxis in that the sense of touch is more delicate, and, 
just as they are willing to spend hours working on a small 
handl^erchief, so they will be willing to work for a long 
time removing stains from teeth while the dentist devotes 
his time to other work. 

There are many patients who would avail themselves 
of the opportunity for prophylaxis, but who are not will- 
ing to^ pay a dentist for his time. Thus the dental nurse 
enables' these to have this treatment at a smaller fee, as 
the dentist's time is worth from $5.00 to $10.00 per hour, 
the nurse's is worth from $1.00 to $5.00 per hour. She 
can spend more time than if the dentist did all the work 
himself. In the course of time, the patient begins to ap- 
preciate this class of dental work, and will be willing to 
pay regular fees. 

Several years ago when I first determined to train a 
nurse for some of my work I advertised, and talked with 
150 applicants before I accepted a middle-aged trained 
nurse wlio now does the larger part of this work in my 
office. She first helped me at the chair, then took a course 
by reading everything published on the subject ; she also 
brought in her kinsfolk's children and her friends to 
practice on. On regular patients I would do the difficult 
part and have hor finish the treatment. Thus she became 
jiroficient and solf-confidont, while tlio patients are de- 
lighted with the novelty of the idea. 



The Dental Nuese. 



199 



DR. ROBIN ADAIR 

RESPECTFULLY ANNOUNCES TO HIS PATIENTS 
THE SERVICES OF A TRAINED DENTAL NURSE 
TO PRACTICE ORAL PROPHYLAXIS UNDER HIS 
DIRECTION AT A MINIMUM FEE. 

THE TRAINING OF CHILDREN IN THE PROPER 
CARE OF THEIR TEETH HER SPECIALTY. 

Phone Main 2442. 



The above card was sent to all my patients to let them 
know about the dental nnrse. When I saw she was a suc- 
cess I quit the work, except to those who were willing 
to pay well for my service, and sent out, as ' ' per sugges- 
tion by Bro. Bill," a card like this: 



DR. ROBIN ADAIR 

RESPECTFULLY ANNOUNCES THAT ON DECEM- 
BER THE FIRST HIS FEES FOR ORAL PROPHY- 
LAXIS WILL BE ADVANCED. 

November 26, 1909. 



In regard to the dental nurse I can only say that when 
the proper help is secured it not only adds dignity to the 
dental office, but also enlarges the field of the dentist. 

To those who contemplate taking a.stand for the legal 
status of female dental assistants the following sugges- 
tions Avere given by Dr. F. H. Skinner, of Chicago, after 
a lengthy conference with him on this subject. In view of 
the fact that we have no institution where instruction is 
given the nurses he gives a plan whereby they may be 
trained and leo-alized. 



AN" ACT TO EEGULATE THE PRACTICE OF ORAL PROPHYLAXIS BY 

A REGISTERED DENTAL ASSISTANT, BY F. H. SKINNER, D. D. S. 

REQUIREMENTS FOR APPLICATION. 

1. Application for license 'must be made to the State 
Board of Dental Examiners, and signed by a regular 
registered dental practitioner. 



200 Peactical Oeal, Prophylaxis. 

2. Party for whom application is made must be 
twenty-one years old and graduated from an accredited 
high school. 

3. Said party must have had at least three years 
experience as a dental assistant under a licensed dental 
practitioner who vouches for applicant's efficiency and a 
certain knowledge of the few drugs and medicines used 
in oral prophylaxis. 

LICENSE. 

Upon such application being presented to the State 
Board of Dental Examiners, that body, at its' discretion, 
shall issue, or cause to be issued, a license permitting the 
j3arty named to practice oral prophylaxis only in the 
office of the practitioner who signs the application, or 
such place as he may request. (As a call at a home to 
give an oral prophylaxis treatment, in case of sickness.) 

The State Board has a right to satisfy itself as to the 
qualifications of the applicant, as to the education, age 
and character, as well as by examination as to ability, 
and if deemed advisable, require applicant to give a 
clinic to satisfy itself, or it may issue license solely upon 
the reputation of the dental practitioner who signs the 
application. 

FEES. 

The fee for said license shall be $10.00 (ten dollars) 
and shall be subject to the same registration and fees as 
the license of a practicing dentist. 

Should the party to whom license is issued leave the 
employ of the practitioner who signs the application, 
said license becomes: null and void, but a new license may 
be issued without examination should the party enter 
the employ of another dentist. The object of this is to 
have this work done always under the supervision or con- 
trol of a regular dental practitioner. 

A committee from the Massachusetts Dental Society 
drew up and presented a bill for legislative enactment 



The Dental Nuese. 201 

giving a legal standing for the dental nurse and the 
methods of control. The object of this bill was thus urged 
by the committee : 

''The object of the bill is to secure for the dental pro- 
fession the help in practice furnished physicians and 
surgeons. By our present dental law the dentist cannot 
legally have this needed assistance. Even the registered 
nurse while doing work among the poor, cannot examine 
the mouth of a child suffering with toothache and put in 
anything to relieve the child's distress without breaking 
the dental law. So slight an operation as tying a piece of 
silk or putting a piece of tape between teeth for wedg- 
ing, is illegal when not done by a registered dentist. No 
one but a registered dentist may clean or polish teeth. 
This makes it impossible for children's teeth to be prop- 
erly cared for, as the busy dentist cannot devote time 
enough to this operation, and in order to have it done as 
often as needed, it becomes a financial burden for a fam- 
ily of limited income at the price a registered dentist must 
charge for his time. In the public clinic the registered 
dentist can do practically nothing in polishing the chil- 
dren's teeth. 

"The prophylactic care of children's teeth is therefore 
not practicable with our present legal conditions. In 
order that the children may have this proper care, the 
public needs a dental nurse. This nurse need not have 
at present the extended training that is given a register- 
ed nurse. The training that she will receive in the train- 
ing schools will give the dental profession a standard of 
service that we have never had. There are many young- 
women employed in the dental offices of our State who by 
being trained and being registered as dental nurses would 
be of invaluable aid to their employers. No one need, 
however, employ sucli a nurse. The regular office assis- 
tant will be used as formerly, only she may not do the 
things the registered dental nurse may do, and of course 
she will lack the training." 



202 Practical Oeal Prophylaxis. 

HOUSE .... No. 1566 

The Commonwealth of Massachusetts 
111 the Year One Thonsaiid Nine Hundred and Twelve. 

AN ACT 

To amend the law regulating the pactice of dentistry. 

Be it enacted by the Senate and House of Representatives in General 

Court assembled, and by the authority of the same, as follows : 

Section 1. Anj- i^^i'son who is eighteen years of age or over and 
in the opinion of the Board of good moral character, upon payment of 
a fee of five dollars, which shall not be returned to him, may upon 
application be examined by the Board of Registi'ation in Dentistry 
and be licensed by said Board as provided in Section six hereof to per- 
fonn such sen'ice as a dental nurse as shall be si^ecified in his license. 
ExcejDt as provided in Section two in this Act, the person desiring 
such registration shall specify in his application the name and address 
of the registered dentist by whom he is to be employed, and this ap- 
plication shall be approved in writing by such registered dentist. No 
registered dentist shall have at one time more than one registered 
dental nurse in his emplo3"ment, No business firm or private 
incorporated dental company shall employ more than one registered 
dental nurse at one time, in auj office managed or ow^led by it. Such 
license shall be valid for one year from the date thereof unless revoked 
by said Board for the violation of the conditions thereof. Any license 
issued under the provisions of this Section may be renewed without 
further examination in the discretion of the Board, from year to year, 
upon pajTnent of a fee of five dollars. 

Sec. 2. Any person who is eighteen yeai-s of age or over and in 
the opinion of the Board of good moral character may, upon applica- 
tion, be examined by said Board and licensed as aforesaid to serve as 
a dental nurse in any of the public educational or charitable institu- 
tions in the state approved by said Board, which institution shall be 
specified in the license, provided that this application shall be endoi-sed 
by the authorized officers of such institution. Such license shall be 
limited to the performance of service in connection Avith institutions 
of the character specified therein and may be renewed from year to 
year without further examination and without the payment of any 
fee therefor. Any number of dental nurses may be licensed for ser- 
vices in connection with any such institution. Any license issued un- 
der the provisions of this Section shall expire forthwith whenever the 
I'egistcred dental nui-se shall cease to render such services solely for 
institutions of the character sjiecified in the license. 

Sec. .3. A registered dental nui-se shall be licensed to perform only 
such duties as shall be si^eeified in his license and solely in the offica 
and under the direction of a registered dentist. No dental nurse shall 



Peoposed Dental Nukse Law. 203 

be licensed to perform any service other than the examination, wedg- 
ing and cleaning exposed surfaces of teeth, inserting and changing 
dressing's in teeth for the relief of pain and assisting a registered den- 
tist during the jDerformance of his dental operations. 

Sec. 4. Any member of said Board or its agent may at any time 
visit any office or institution in which a licensed dental nurse shall be 
employed and make such examination as he shall see fit in order to 
determine whether the pro\-isious of the laws regulating the practice of 
dentistry and dental nursing have been complied with. 

Sec. 5. Any licensed dental nurse changing employers must notify 
the Board forthwith of such change and also of the name and address 
of the dentist by whom he is to be employed. 

Sec. 6. Whenever by the terms of such license the holder thereof 
shall be authorized to perform all of the ser\-ices specified in Section 
three hereof, and shall have the title of Registered Xurse, such holder 
shall have the right to use the title Registered Dental Nurse. An ap- 
plicant who fails to pass an examination satisfactory to the Board, and 
is therefore refused registration, shall be entitled -within one year after 
such refusal to a re-examination at a meeting of the Board, called for 
the examination of applicants Avithout the payment of an additional 
fee. 

Sec. 7. The Board may, after a hearing, by a vote of a majority 
of its membei's, annul the registration and, without a hearing may 
annul the registration and cancel the license of a dental nurse who 
has been found guilty of a crime or misdemeanor. 

Sec. 8. The Board shall have power to register in like manner, 
without examination, any person who has been registei-ed as a pro- 
fessional dental nui^e in another state under laws which in the opinion 
of the Board maintain a standard substantially equivalent to that of 
this Act. 

Sec. 9. The Board shall investigate all complaints of violation of 
the provisions of this Act. and rei^ort the same to the proper prose- 
cuting officers. 

Sec. 10. "Whoever, not being authorized to practice as a registered 
dental nui-se within this Commonwealth, practices or attempts to prac- 
tice as a registered dental nui"se, or uses the abbreviation R. D. N., or 
any other words, letters or figures to indicate that the pei"son using the 
same is a registered dental nurse, shall for each offense be punished 
by a fine of not more than one hundred dollai-s. Whoever becomes 
registered or attempts to become registered, or whoever practices or 
attempts to practice as a registered dental nurse imder a false or 
assumed name, shall for each offense be punished by a fine of not more 
than one himdred dollai-s, or by imprisonment for tkree months, or 
by both such fine and imprisonment. 

Sec. 11. This Act shall take effect upon its passage. 



CHAPTER XXI. 

TEACHING OF OEAL HYGIENE, PROPHYLAXIS 
AND PYORRHEA IN DENTAL COLLEGES. 

PRACTICAL METHODS EMPLOYED BY THE AUTHOR. THE 

RESULTS OBTAINED. THE NEED OF SUCH INSTRUCTION. 

Tlie subjects of oral hygiene, prophylaxis and 
pyorrhea are receiving more and more attention each 
year in our dental colleges. Having tanght these sub- 
jects for several years, I give some suggestions that may 
prove of value to those just beginning the work. 

If practical, the course should be divided as follows : 
Freshmen receive the course on oral hygiene, the Juniors 
prophylaxis and the Seniors pyorrhea. In order to make 
the lectures of a personal character and to elicit personal 
interest, it is best to make a personal examination of the 
mouths of each class and tabulate the result. Call at- 
tention to any defect or treatment needed. The students 
should be called into a private room, one at a time, for the 
examination. Before final examinations another exami- 
nation should be made and credit mark given for any 
improvement. If the lectures have been interesting, this 
makes the work of practical value. If this is not done, or 
where no lectures have been given on these subjects, wa 
find many Seniors going out with their mouths in a con- 
dition which is a disgrace to the profession, which they 
will represent. 

At the first lecture take into the hall a new tooth-brush, 
floss silk, fjuill tooth pick and dentifrice. Ask for a vol- 
unteer from the class to come to the rostrum. Give him 
the tooth brush with the request that he brush his teeth 
exactly as he practiced at home. He generally will make 
a poor showing. Then take the brush in your own hands 
and brush the teeth correctly. See that the student can 
do this correctly before he leaves the stand. Then ex- 



Teachhstg Hygiene, PbophyijAxis, Pyorrhea. 205 

plain to the class that if a student of dentistry does not 
know how to brush his teeth, they can expect their 
j)atients to know less. The use of the silk and other 
accessories are also shown. The demonstration of the 
proper method of rinsing the mouth is sometimes a reve- 
lation even to a Senior student. 

In teaching prophylaxis, it is well to divide the class 
into sections of twenty each. Take one section into the 
dental infirmary. Seat one-half of them in dental chairs 
and have the other ten get out their prophylaxis instru- 
ments and go to work on those seated. Go from chair to 
chair, showing each individually how to hold their instru- 
ments. At the next clinic the men who did the work be- 
fore are seated in the chairs and the others put to work. 
This may be repeated with each section until every mem- 
ber of the class has his mouth put in good condition. 
Many of their gums will be cut with instruments, tissues 
lacerated and plenty of calculus left on their teeth. How- 
ever, it will be worth all the discomfort they endure, for 
it teaches them the best lesson possible. As you proceed 
with the course induce the boys to take monthly prophy- 
laxis treatments among themselves. 

One of the most convincing arguments for a perma- 
nent interest is for the teacher to exhibit some of his 
private patients who have been on prophylaxis for some 
time, just to show them what can be accomplished. 

In teaching pyorrhea, the cases which were found in 
the examination of the students' mouths should be used 
for clinical material, so that the various treatments can 
be given mider their direct observation. If several cases 
be under treatment they should be turned over to the 
students for dressing and applications and the progress 
closely watched by the professor. No set method of deal- 
ing with this lesion should be given, but demonstrate all 
procedures which seem to have any virtue. 

One session the writer noticed that the students of the 
Senior class were lacking in practical application of his 



206 Practical Oral Prophylaxis. 

efforts to have them carry off the spirit as well as the 
letter of his lectures. This following notice was posted 
in the bulletin : 

"To THE Senior Class:- 

"Without further notice, an examination of the 
mouths of the Senior Class is soon to be made and the 
mark given at this time will count on the final examina- 
tion. Any one presenting an unclean or diseased mouth 
will not receive my name on his diploma." 

The report soon came to me from the demonstrator in 
the Infirmary that he could not get any work out of the 
boys, because they were so busy cleaning up each other's 
mouths. When the graduating exercises took place, it 
was my pleasure to know that the Senior Class presented 
the cleanest mouths of any class that had ever gone out 
of the institution, and-I believed that many of them would 
be future missionaries along this line of work. Later 
results have shown that this supposition was correct, 
for I have heard of the members of the class giving lec- 
tures before the schools in the various towns and leading 
in school inspection work. Most colleges now have some 
lectures on this subject, and a few of them have regular 
chairs, and it is to- be hoped that a greater number will 
see the wisdom of giving this subject the importance 
which it deserves. 

Of interest, showing the trend of the times towards 
teaching this subject in the dental colleges, is the follow- 
ing statement from Dr. G. V. Black, of the Northwestern 
Dental University School, who, in a letter to me, April 4, 
1913, says, "I have been silent on this subject for a num- 
ber of years. In fact, I have not written anything since 
the article for the American System of Dentistry, until 
quite recently, but a couple of years ago I re-arranged 
the curriculum somewhat, and took this subject myself, 
on purpose to have the opportunity of giving my time to 
it, and of finally writing what I might wish to say." 

Dr. N. S. Hoff, of the University of Michigan, in 



Teaching Hygiene, Pkophylaxis, Pyorrhea. 207 

answer to my iuquiiy of his vie\Y.s on tliis subject, wrote 
me March 1, 1913, "The need for this work is tremen- 
dous, and I sometimes feel as though it is a particular 
form of work whicli will have to be done independent 
of the dental college work, as I am eonhdent when it is 
taken into dental college work, it will absorb so much of 
the time that other forms of instruction will suffer, just 
as I have found it to do in private practice. It is imprac- 
tical to do this work in connection with the general 
practice for the reason that it absorbs so much time. The 
dentist becomes so much interested in it that he is not 
willing to allow any patient to go until he has given him 
a complete treatment, and when this is undertaken, neces- 
sarily other lines of work must be set aside." 

Dr. C. M. Gearhart, chairman of the oral hygiene sec- 
tion of the National Dental Association for 1912, writes 
me an interesting letter, from which I quote as follows: 

"I have been struggling for years teaching 'Oral 
Hygiene and Prophylaxis' in Georgetown University 
without a text-book. Oral hygiene covers such a multi- 
tude of sins that I have found it necessary, in a way, to 
have to review, or rather lapse over subjects taught Iw 
other men in Georgetown, in order to make the subject 
worthy of giving it a course. It has always seemed to 
me that the teaching' of oral hygiene is something more 
than merely explaining to students that they should keep 
their own, and advise their patients to keep their mouths 
clean." 

It is hoped that this book will, in some,, degree, meet 
the requirements along this line, and that it may stimu- 
late other teachers of this subject to record their ex])eri- 
ences and methods of teaching. 



PART III. 

A PRACTICAL DESCRIPTION OF PYORRHEA ALVEOLARIS 
AND ITS TREATMENT 



CHAPTER XXII. 
PYORRHEA ALVEiOLARIS. 

SYNONYMS. DEFINITION. CAUSES. 

WHAT IS TARTAR AND ITS FORMATION ! KINDS OF CALCULI, 

AND DEPOSITS. BLACK 's THEORY. 

Authorities in general medicine and surgery have in 
a scientific way decided upon a certain frame work for 
the description of any disease. Failure to adhere to this 
frame work by dentists is one of the reasons why we 
have not come upon any common ground in our writing 
on pyorrhea. Having received reprints by the hundred, 
written by the most prominent men in the profession, 1 
find that they vary greatly in describing pyorrhea and 
do not adhere to the commonly accepted .methods of 
description. The frame work used for the description 
of pyorrhea should be: 1, synonyms; 2, definition; 3, 
causes; 4, pathological anatomy; 5, symptoms; 6, diag- 
nosis ; 7, prognosis ; 8, treatment. 

If we notice the various reprints on pyorrhea, we will 
find that in some of them the prognosis is described first, 
probably the same paper ending with pathological 
anatomy. It would greatly simplify matters if writers 
and teachers of this subject would describe it in a sys- 
tematic manner. 

SYNONYMS. 

Here we have such a large and unfortunate list that 
the student is completely bewildered in his selection : 

Pyorrhea alveolaris, Riggs' disease (Bishop), infec- 
tious alveolitis, cemento periostitis, calcic inflammation 
(Black), blenorrhea alveolaris, hematogenic pericemen- 



212 Peactical Pyoeehea Alveolaeis. 

titis, pliagadenic pericementitis (Black), chronic alveo- 
litis, interstitial gingivitis (Talbot), periostitis dentales 
(Schiff), alveolar pyorrhea (Smith), chronic alveolar 
ostomyelitis (Medalia), oral sepsis (Hunter, of London). 
Edematous perideutitis, hypertrophic peridentitis, 
suppurative peridentitis, gangrenous peridentitis (Hoff). 

Dr. H. M. Fletcher, of Cincinnati, urges the adoption 
of the following classification: 

Initial or simple alveolitis, non-suppurative alveolitis, 
suppurative alveolitis, necrotic alveolitis, acute alveolitis, 
descriptive subdivisions : 

Chronic non-suppurative alveolitis, 

Chronic suppurative alveolitis. 

Necrotic non-suppurative alveolitis (always chronic). 

Necrotic suppurative alveolitis, (nearly always 
chronic but may be acute). 

Zentler, of New York, suggested the name alveolar- 
dental-arthritis, classifying it as the primary, secondary 
and tertiary dental arthritis. 

Dr. M. L. Rhein classifies pyorrhea by the addition 
of adjectives stating the name of the disease which he 
thinks causes the symptoms i. e. "Diabetic Pyorrhea" 
and ''Tubercular Pyorrhea." Prof. W. D. Miller, in 
his text book on pyorrhea, adopted this classification. 

Dr. Eehwinkel first called it pyorrhea alveolaris in 
1877, in the city of Chicago, although the name was used 
in France as far back as 1870. 

Black called it phagadenic pericementitis in 1882, 

The author is not convinced that any one of the above 
should be accepted. Common usage at the present time 
ahnost compels us to use the terim; pyorrhea alveolaris 
until a better term is suggested and adopted. 

Ill llie Soutli many dentists prefer the term ''Riggs' 
Disease," hccanse tlie older practitioners believed that 
the honor for the; beginning of the surgical work should 



Pyoerhea Alveolams. — Definition. 213 

be given to Dr. John M. Riggs, of Hartford, Conn., as he 
was the first man to advocate a treatment or even to say 
that it could be cured. The same sort of sentiment 
IH'ompted this naming as the calling of interstitial neph- 
ritis '' Bright 's Disease." In later-day nomenclature, the 
fault of this method of adopting names has been realized 
and efforts are being made to change many of them. 

DEFINITION. 

The late Chas. B. Atkinson, of New York, defines this 
condition as "a disease following congestion of the 
myxomatous tissue of the oral cavity, affecting with wide 
range of. loss, the gingivae, alveoli, and teeth, from slight 
recession of the gums to entire solution of alveolus, and 
the consequent loss of tooth or teeth involved; therefore, 
perhaps more properly 'pyogenic gingivitis." 

Dr. C. N. Peirce describes' it as follows: ''A chronic 
inflammation of the pericemental membrane, attended by 
a congested, spongy and tumefied condition of the gums 
and mucous membrane, and usually accompanied by a 
persistent flow of pus from the alveolar sockets. In the 
progress of the disease the alveolar process, under the 
influence of engorgement of the periosteal vessels, be- 
comes involved and eventually undergoes atrophy or 
absorption, leading to an exfoliation of practically nor- 
im,al teeth," and ascribes its etiology to the uric acid 
diathesis of the patient. 

Dr. G. V. Black describes it as ''a specific infectious 
inflammation having its beginning in the gingivae, and 
accompanied with the destruction of the peridental mem- 
branes and alveolar walls," and while not committing 
himself, says that probably it is caused by the iDresence 
of some peculiar form of micro-organism and that it is 
infectious. 

Dr. Rhein defines it as folloAvs: "'\^^nle pyorrhea 
alveolaris literally means a discharge of pus' from the 



214 Practical, Pyorrhea Alveolaris. 

alveolus, the simplest definition of its pathogenic condi- 
tion commonly accepted under the term would be that 
it represents a diseased condition of the peridental 
region due to impaired nutrition." 

Dr. D. D. Smith says, "mouth pyorrhea is a disease 
of uncleanliness. " 

Dr. W. J. Younger preferred the name pyorrhea 
alveolaris and gave this definition: "Pyorrhea alveolaris 
is characterized by an inflammation of the gums and a 
deposit of characteristic greenish gray or slate colored 
tartar and the wasting of the alveoli accompanied by the 
formation of pus and pus pockets between the tooth and 
alveolus ; the disease being due, as I believe, to a specific 
bacillus. The disease is chronic in its duration and re- 
sults in the ultimate loss of the teeth. This slate colored 
incrustation of which I have spoken, I consider pathogno- 
monic of the disease." 

Pickerill in his book on "O'ral Sepsis" gives the fol- 
lowing definition: 

"Pyorrhea alveolaris is essentially a suppurative 
process occurring in the joint around the tooth between 
it and the jaw bone; it may be localized or general, but 
usually is found associated with groups of several con- 
tiguous teeth." 

CAUSES. 

The etiology of pyorrhea is given as local and con- 
stitutional. A few years ago the latter was advocated 
by many of the leading men of the profession and many 
valuable papers were published and read upon "Uric 
Acid Diathesis," "Kheumatism," etc., as the etiologic 
factor, but today those who are making the greatest 
success of their treatment are almost unanimous in their 
opinion that local causes would be decided upon as the 
greatest factor. 

It is not denied that the general systemic condition 
of the patient has an influence and must be looked into 



Pyoekhea Alveolaeis— Causes. 215 

and treated, but this should be considered as only a pre- 
disposing factor or complication of the pyorrhea. Per- 
sonally, the author believes that if a mouth is maintained 
in a good condition, with the absence of local causes liere- 
after mentioned, no systemic disorder would ever pro- 
duce a case of alveolar pyorrhea. In other words, there 
are no systemic reasons for the cause of pyorrhea other 
than those which may predispose to any disease. 

Younger claims that temperament has no bearing on 
this disease, while Smith opposes this view with the dec- 
laration that pyorrhea never develops in the puTely 
sanguine but always in the bilious, the lymphatic, and 
the nervous temperament, impaired nutrition, heredity, 
constitutional disorders, excessive lime salt secretion, 
uric acid salts, scurvy, luxury and modern degeneracy, 
sedentary habits, toxic agents introduced into the 
system, chronic infections, and the eruptive fevers have 
also been named as causative agents of pyorrhea 
alveolaris. 

In answer to those who hold the above causes 
Hutchinson says : 

''I have no doubt that in cases where diabetes, 
syphilis or other serious systemic disorders are coinci- 
dent with pyorrhea, the pyorrhea antedates the constitu- 
tional disorder and has been accentuated but not caused 
by such disorder. If such mouths had always been under 
prophylactic treatment I believe there would be no 
pyorrhea. The amount of tissue lost, both hard and soft, 
indicates that the process of destruction has covered a 
period of many years and could not have taken place 
within a comparatively short time. Usually pyorrhea in 
some stage exists long before it becomes manifest to 
either the patient or the dentist, and so the error of be- 
lieving it to be of recent occurrence is often made." 

The initial cause of pyorrhea is sometimes so small 
and simple as to be overlooked. As before stated, the 
object of this book is to be of a practical value and onh^ 



216 Pkacticax. Pyorehea Alveolaeis. 

the causes that we positively know and see every day are 
given : 

1st, Deep interlocking cusps on bridge work, causing 
too great an irritation on the abutments and setting up 
inflammation in the membrane supporting them, finally 
giving rise to pyorrheal conditions. 

2d, Wing bridges. 

3d, Bad bridge work. 

4th, Partial dentures which may have any kind of 
swing on one tooth. 

5th, Ligatures, clamps, wedges in ordinary dental 
operations where the contusion of the gum margin is not 
treated after their removal. 

6th, Mal-occlusions of natural cusps, fillings, or 
crowns. Whether mal-occlusion is a cause or result of 
l^yorrhea, there can be no doubt about its importance, 
no matter what the treatment may be. One of the great- 
est aids is in grinding down markedly prominent cusps 
and in putting out of action those teeth which are weak- 
ened by this disease. The best method of determining 
this is to place the index finger longitudinally across the 
teeth and then let the patient close the mouth, and shake 
the teeth. If this discloses the fact that the affected 
tooth is being moved to a greater extent than the others, 
it is an indication that too much stress is being placed 
thereon. 

Dr. R. G. Hutchinson, Jr., of New York, says: ''Of 
late I have been more impressed with the importance of 
mal-occlusion, either general or localized, as a prime 
factor in the establishment of pyorrhea, and my first at- 
tention is given to this correction by grinding." 

7th, In the disturbance of the contact point of the 
teeth, whether it be from a small separation, or from 
malshaped points, allowing food fibres to pack in and 
gain a point of vantage for future destruction. A large 



Pyorrhea Alveolaris. — Causes. 217 

number of pyorrhea pockets are undoubtedly formed in 
this way, the so-called "meat holes." 

8th, One of the most unbearable forms of pain in the 
mouth is caused by the abuse of wood tooth picks and 
floss silk. Splinters of the picks break off in the mouth 
and, when the patient comes for treatment, we sometimes 
are not able to find the cause of the inflammation. This, 
in time, causes loosening of the point of contact, allow- 
ing further inroads into these inflamed surfaces. 

9th, Any mechanical irritation lodged under the free 
margin of the gums surrounding the tooth will set up 
initial lesions. Shedding bristles from tooth brushes, 
small seeds, grit (possibly left from cleaning the teeth), 
•skin flakes from vegetables or fruit — any one may cause 
this. Tlie gum, being unable to free itself from this 
irritation, inflammation follows, affecting the peridental 
attachment and the alveolus. 

10th, Tartar formation: AYhile it is true some cases 
of pyorrhea do exist where, seemingly there is no 
deposit of tartar present, they are in such minority as 
to be a rare exception. Such cases may at one time have 
had this formation ; furthermore, such minute i^articles 
can start trouble that we cannot say with certainty but 
that all cases have some form of tartar which must be 
removed in our treatment. In fact, the greatest factor 
in the successful treatment of this condition is the finding 
and complete removal of tartar. 

11th, Uncleanliness : Last and probably the most im- 
portant and most frequent cause of pyorrhea is that at 
some period of the patient's life there was a lack of in- 
telligent care of the mouth. A volume might be written 
on the causes of pyorrhea, but we have to admit that the 
greatest factor we have to deal with is uncleanliness of 
the mouth. The first section of this book deals in full 
with this cause. 



218 Practical Pyorehea Alveolaeis. 

what is taetar aitd how does it foem ? 

Tartar is a concreting material, either secreted or 
concreted in the month from the saliva, which is deposited 
on the teeth or artificial dentures. Various hypotheses 
have been advanced in explanation of these deposits. 
We do know that the bulk is composed of calcium phos- 
phate and carbonate, and that certain places are more 
liable than others to the accumulations. One theory is 
that the saliva holds these salts in a very unstable sus- 
pension, and, in the presence of air, carbonic acid gas is 
liberated and the calcium salt precipitated. 

Burchard claimed that the saliva, as manufactured 
by the glands, is of alkaline reaction, holding in solution 
the salts of calcium. His theory was that in most mouths 
the reaction is acid, the coming together of these two 
opposite chemical compositions results in a precipitation 
which is insoluble in the acid medium. 

A third theory is one of crystallization. Younger 
holds the view that some bacteria form a nucleus or 
nidus about which layer after layer of these salts are 
precipitated ; especially . does he believe this to be the 
cause of the formation of serumal calculus, the idea being 
that it was just the same as the crystallization of syrup 
starting around a thread. These theories seem to have 
resulted from the observation that calculus formation in 
other parts of the body generally contains a lump of 
bacteria around which they have been formed. 

The fourth hypothesis is that the calcium salts are 
held in suspension, and when the saliva stagnates, the 
heavier substances collect in favored situations, 

KINDS OF CALCULI AND DEPOSITS, 

There are i)robably many variations in the character 
of the deposits on teeth, but the most important from a 
pyorrhea standpoint are as follows: 



Calculi iisr Pyokrhea Alveolaris. 219 

1st, (Tranular mass, less hard than calcium sulphate. 
This is generally found in large quantities on the lingual 
sides of inferior incisors and on the buccal surfaces of 
the upjjcr molars. 

'2d, Concretions found below the gum margin; color, 
light yellow to dark green. The light concretion is soft 
while the dark one is hard. Some have thought that the 
greeuish scales around the margin of the gums might be 
caused by the disturbance of the gingival glands. Pat- 
terson says, ''These deposits are from purulent matter 
;!iid are the sequence of irritation and inflammation from 
the various local causes referred to. They are not pre- 
cedent to a lesion but invariably are subsequent to irrita- 
tion and exudation." 

3d, Serumal calculus. 

4th, Sorcles is a soft, creamy, pearl gray deposit on 
the surface of the teeth and differs from tartar in that 
it does not concrete, though it is sometimes mixed with a 
form of tartar and partially concreted. 

We think the reason for the salivary calculus deposi- 
ted on the upper molars being softer than in other loca- 
tions is that the parotid gland does not secrete mucin. 

The red or greenish color of the second varietj^ named 
is given by the escape of heamatin of red blood corpuscles 
due to the rupture of small blood vessels by mechanical 
irritation of the deposit. The extreme hardness and 
brittleness which we often find is probably due to the 
absorption of uric acid fi'om the blood. It is supposed 
that this occurs only with those patients whose system 
contains a large amount of uric acid. From this observa- 
tion imany dentists at one time believed that the whole 
cause of jiyorrhea could be explained by the theory of 
the uric acid diathesis; but this theory of its etiology 
has been discarded l)y the majority of the dental and 
medical i)rofession. 

The third variety of calculus was first called serumal 
by Brown, of Georgia. This secretion and concreting 



220 Peactical. Pyokrhea Alveolaeis. 

material is supposed to be formed from some break in 
the peridental membrane and effusion of the serum of 
tlie blood. If this theory is correct the process has never 
been successfully explained. 

At the point of location of the other varieties of tartar 
we have direct contact with the saliva, but with the 
serumal calculus it is claimed that the formation may 
take place in the peridental membrane without any show 
of external communication with the saliva of the mouth. 
The very existence of such a formation has been denied 
by many, who claim that when calculus: is found on a 
tooth there is always some external opening which can 
be found by careful probing with a small instrument 
under the cervical edge of the gum. Nash advanced some 
strong arguments on the impossibility of the formation 
of serumal calculus or tophus in the peridental mem- 
brane. 

black's theoey. 

Dr. G. V. Black has recently reported some interesting 
experiments about the formation of tartar. His theory 
is' that the susceptible mouth contains a material which 
he tenns the ''aglutinating substance." This substance 
is transparent and slightly sticky. This serves to gather 
and hold particles of calcium salts w^hicli are precipitated 
from the saliva. This gradually hardens after a few 
days'. In his personal experiment with a slot cut in his 
artificial set of teeth he advances the idea that salivary 
calculus may be controlled to a certain extent by the 
diet. Eating too much caused him to have a greater de- 
posit, while the use of a saline cathartic would cause a 
cessation of deposits for a week or more. 

Before the advent of prophylaxis, dentists were pay- 
ing most of their respects' to the hard deposits as the 
principal factor in dental lesions but recently we believe 
this to be a inistaken idea, aiid tliat the soft deposits are 
more vicious in their action on the soft tissues. In fact, 



Black's Theory of Calculus. 221 

iipou the removal of largo quantities of tartar from the 
teeth, we frequently find the toofh in a well preserved 
state, and the gums comparatively healthy, but we never 
find this to be the case when the sordes or soft deposits 
are removed, because the latter contain a great amount 
of infection; we sometimes find the tooth in a leathery 
condition and the soft tissues always in a state of inflam- 
im.ation. 



CHAPTEE XXIII. 
PATHOLOGY OF PYORRHEA ALVEOLARIS. 

EECESSION AND CONGESTION OF THE GUMS. — THE CHANGES IN 

THE PERIDENTAL MEMBEANE AND ALVEOLAR PROCESS. 

TOOTH ROOT ABSORPTION. FORMATION OF PUS 

AND POCKETS. ALVEOLAR ABSCESS IN PYORRHEA. 

The pathology of dentistry should be considered in the 
same manner as the pathology of medicine and surgical 
diseases. In dentistry the attempt to bring up a differ- 
ent pathology has been due to a lack of proper knowledge 
and observation. 

In taking up the work of pyorrhea, the dentist must 
have an accurate knowledge of normal conditions in 
order to be able to detect a deviation therefrom. Also, 
a complete knowledge of the histology of the gums, teeth, 
and maxilla is imperative. 

First should be noted the appearance and color of the 
normal gum. We will note that there is no tumefaction 
of the gum margin; also that the gum margin clings to 
the teeth at the enamel margin, completely surrounding 
the tooth at the insertion into the bone. 

The teeth most often affected by pyorrhea seem to 
be the lower incisors. Next in the order of frequency, 
the superior molars and bicuspids ; then the inferior 
molars and bicuspids; the superior incisors; lastly, the 
upper cuspids. 

RECESSION AND CONGESTION OF THE GUMS. 

Recession of the gums is not necessarily a feature of 
the pathology of pyorrhea, although some medical men 
and many of the laity have at times mistaken the reces- 



Pathology of Pyoerhea Alveolaeis. 223 

sion of the gums, especially on the upper cuspids, for 
pyorrhea. This recession is the result of not receiving 
circulation to keep up peridental life and a constant 
diminution of the thickness of the alveolus and the hard- 
ness of the C0m,entum. This structure either moulds into 
the dentine or recedes towards the root when conditions 
are abnormal. 

The recession of the gums at the cervical margin 
brings most patients to the dentist for the treatment of 
pyorrhea. At this stage we find the peridental membrane 
either exposed or destroyed in part, forming a hot bed 
for the culture of bacteria which continue their action in 
destroying the alveolus and inflaming the periosteum. 
This recession is caused by the falling in, as it were, of 
the supporting structures. 

Although the patient worries about the gums, it is 
oftentimes the least affected structure and, if the infec- 
tion be removed, soon resumes its normal appearance 
and function as a protection to the structures which 
underlie it. Just as often do w^e find the opposite picture. 
Instead of recession we find a swelling and congestion. 
On squeezing the gums, pus will generally exude. On the 
other hand, I have seen cases where there seems to be no 
pus ; but there is infection, and pus either has been or will 
be the next step in the progress of the disease. 

Probably one of the most constant diagnostic points 
in pyorrhea is the tumefaction of the gum tissues. The 
extent of this tumefaction may be from a few lines in 
width at the gum margin to a heavy roll of tissue extend- 
ing the full breadth of the roots of the teeth. This tume- 
factory condition may be hard and firm, and when this 
is the case, the color of the tissue will be a light lilac or, 
if the pocket beneath be extensive, of purplish tint. How- 
ever, this tissue may present a very different clinical 
picture in that the tissue may be very soft and fluffy, 
bleeding upon slight irritation, as in brushing the teeth. 



224 Peactical, Pyokkhea Alveolaris. 

In tlie latter condition we find more pus, we also find that 
the teeth are looser than in the former condition de- 
scribed. 

Often the gum is filled with inflammatory exudate, 
giving a rich crimson (chronic state bluish) color, due 
to the accumulation of cells in the connective tissue. 

This gum bleeds at the slightest touch. Inflamma- 
tion may extend only to periosteum or into the alveolus. 
If the condition of swelling continues and the gum con- 
tinues flabby about the tooth, like hypertrophied tissue, 
the best treatment is the surgical trimming with knife 
or scissors. 

When the patients are about to be dismissed after 
treatment, they often call attention to the fact that their 
gums have receded more than they did previous to treat- 
ment. This seems to them a most serious question, and 
the dentist should be very careful to convince the patients 
that such recession always follows a correct treatment, 
because of a reduction of the inflammation and a return 
of the gum to its natural thickness. In addition to this, 
the alveolus surrounding the teeth is now much less than 
before disease, or, having been removed in the surgical 
work, gives the gum covering it the opportunity to fall 
further away from the crown of the tooth. 

This recession, if extensive, may, in the future, cause 
trouble for the reason that the flap of gum tissue which 
normally protected the interproximal space from food 
impactions may be too low to protect this space against 
further inflammation and infection from packing. It 
must be well understood that in these cases the patient 
should present at frequent intervals and have such spaces 
cleaned by their dentist. 

THE PERIDENTAL MEMBRANE. 

The object of the peridental membrane is' to transmit 
nourishment to the teeth and to furnish elacticity and a 
cushion under force, or a sling in which the teeth are 
held. 



Pathology of Pyoeehea Alveolaeis. 225 

Dentists have been taught that the peridental mem- 
brane partook more of the character of a periosteum, but 
later investigators claim this structure to be a true 
alveolar-dental ligament. Microscopical examination 
reveals solid bundles of fibres of Sharpey which extend 
from the tooth out into the alveolar process. The in- 
sertion is' about the same as ligamentous insertion into 
bone in other parts of the body. These fibres of Sharpey, 
according to several authorities, form circular rings 
which suspend the tooth in its socket. 

The peridental membrane has for one of its purposes 
the nutrition of the cementum. This membrane may be 
separated from the tooth or completely absorbed at the 
time of the first injury, be it tartar, bad dentistry or 
infection. 

Healthy strong teeth are often exfoliated from the 
alveolus because of hypernutrition, which results in de- 
posits in the substance of this membrane making it re- 
semble the cementum, or the membrane may be so feeble 
in its function as to shut off nutrition with like result. 
Cases of loose teeth from this cause have frequently been 
diagnosed pyorrhea. 

We must bear in mind that an edentulous jaw never 
presents a pyorrheal condition, and that the extraction 
of the affected tooth or teeth affords relief for that part 
of the bone. This is even so when the process has be- 
come carious in the advanced stages. This leads' us to 
believe that the pathological condition is centered around 
the tooth root and its attachment to the bone. 

Smith has called our attention to the diagnostic points 
in differentiating pericemental abscess and pyorrhea. 

Pericemental abscess is not the result of putrescent 
pulp tissue, but on the contrary, it generality occurs on 
live teeth between the bification or at the end of fused 
roots. The pain is not severe but continuous. There are 
no inflammatory symptoms. The discharge of pus is 
small, oozing to the surface of the gum margin: it never 



226 Peactical Pyokkhea Alveolaeis. 

forms fistulae like a pulp abscess. On extraction these 
teeth present small globules of pus having no confining 
Qiembrane. 

The constitutional symptoms are very severe as com- 
pared with the severity of the pathological condition. 
Nervous oppression, indigestion, malaise or headache 
may result from the absorption of pus from these ab- 
scesses. 

Smith claims that pericemental abscess is' not a state 
of pyorrhea, although they are often associated in the 
same mouth. The abscess' develops in some inaccessible 
depression between bicuspids or molars', while pyorrhea 
is found on straight rooted teeth. Smith further claims 
that teeth affected with abscess cannot be cured except 
by extraction. 

The soreness, looseness and pus discharge from this' 
class of teeth is often mistaken for pyorrhea, and conse- 
quently unsuccessfully treated. 

ALVEOLAR PEOCESS. 

Tolbot in his well defined theory would have us be- 
lieve that the alveolar process is of a diiferent structure 
from the rest of the maxilla, and that it is a transitory 
structure whose only purpose is to mould itself about the 
teeth, and, when they are lost, to be absorbed. His ex- 
periments and arguments have been largely accepted by 
the dental profession. The author is of the opinion that 
tbe alveolar process is in no way different in its charac- 
teristics and structure from the rest of the bone, and that 
the socket is simply a medullary space, situated in an 
extension of the maxilla. 

If the initial infection is not removed, the part fol- 
lows the usual course of infection and inflammation. As 
this condition progresses, the tartar and infection con- 
tinues to collect on the teeth and gums until it results in 
alveolar pyorrhea and we have pus pockets. ISTow in the 
event this infection is not removed, the bone begins to 



Pathology of Pyorehea Alveolaeis. 227 

liquify, constituting alveolar necrosis, and finally tlie 
teeth, lose tlieir attachment and become exfoliated. 

In the true sense of the word necrosis, from a medical 
standpoint, cannot properly be applied to the molecular 
disintegration of the alveolus in pyorrhea. Certainly, we 
do not have any considerable bone dying in masses, thus 
the process is more of the character of carious bone. 
However, necrosis is in common usage among dentists in^ 
describing this condition. 

TOOTH EOOT ABSOEPTION. 

Often on failure to restore a tooth by treatment, we 
extract it and find the end absorbed, leaving a rough 
margin with small sharp projections. 

On Sept. 2, 1913, I wrote to Dr. J. B. Hartzell asking 
him to answer the following questions relative to the 
absorption at the end of the roots of teeth, especially 
with respect to the lower central and lateral incisors : 

1st, Why is it that these teeth are m.ore prone to root 
absorption than other teeth f 

2d, How does it occur and leave the teeth alive ? 

3d, Is it the same x^rocess that occurs with the tem- 
porary teeth? 

4tli, Is there any way of diagnosing probable root 
absorption before it takes place ? 

In answer to these questions Dr. Hartzell wrote me 
as follows : 

"The process of root absorption in teeth that have 
l(xst bony support is largely due to movement, which stim- 
ulates osteoclasis. My experience with those teeth is 
that the more rigid they are held in position, the less 
root absorption. Of course there is a certain amount of 
irritation from bacterial poison in all cases, which added 
to the physical movement, further stimultes bone de- 
struction by making perfect the conditions for absorption. 

"Did you ever see the two ends of a broken bone in 
which you had a false joint finally established ? The ends 



228 Peactical Pyoeehea Alveolaeis. 

of such bones are roiiiided and resorbed back. This is 
the same thing which occurs in the socket about the end 
of a tooth that has movement, and also is the same pro- 
cess which destroys the root end. 

"No, it is not the same process that occurs with the 
temporary teeth. That is a normal physical condition, 
and the process' is stimulated in the case of temporary 
teeth through the irritation by the uplift of the perma- 
nent teeth against the deciduous root end, and happens 
long before any movement can occur in the tooth by 
reason of its shortened. root and without infection. 

''Yes, root absorption is always probable where there 
is considerable movement established or where infections 
are resident in the tissues around the root end." 

Dr. Hartzell did not answer the second question, nor 
has anyone else, to my satisfaction. Tlie answer to the 
fourth can be deducted from his remarks. Stop move- 
ment by treatment and splint. 

FOEMATIOIiT OF PUS AND POCKETS. 

The result of irritation to the gingival tissues pro- 
duces an exudate. This exudate becomes septic through 
the action of the bacteria of the mouth, forming pus ; sup- 
puration destroys the adjacent alveolus, forming the so 
called ''pockets." 

In the early stages, the extent or depth of a pocket 
on the tooth root is indicated by a reddish area. As the 
disease progresses and becomes' chronic the color changes 
to a purplish hue. The color of the pus from the red- 
dish area is yellow; that from the chronic or old standing 
is mixed with stagnant blood and is dark blue, purplish 
or black in color. 

ALVKOTAR ABSCESS IN" PYOEEHEA. 

A narrow constricted pocket may become suddenly 
very active or the exit from any pocket may become 
blocked to Foitn a pyorrheal alveolar abscess. The 



Pathology op Pyoeehea Alveolaeis. 



229 



swelling may have some of the aiDpearances of the ordi- 
nary alveolar abscess from a decomposed pnlp, and is 
often mistaken for such. 

Differential diagnosis between pulp alveolar and 
pyorrheal alveolar abscess : 



PULP ABSCESS. 

Only on dead teeth 
Comes on g-radually 
Severe throbbing pains 
Swelling extends over consider- 
able area 
Color, bright red 
Location, near root ends 



PYOKRHEAL ABSCESS. 

Generally on live teeth 
Appears in a few hoiu's 
Pain not so severe 
Swelling localized on one tooth 

Color, generally purple 
Location, near cervical border of 
glims. 



Other points connected with the pathological anatomy 
are intimately associated with and described under the 
following pages. 



CHAPTER XXIV. 

SYMPTOMS/DURATION, DIAGNOSIS OF 
PYORRHEA. 

SYMPTOMS. 

As we said in the definition of pyorrhea, it is of slow 
onset. So slow is it that a patient may have it for years 
and be unaware of his condition until a dentist tells him 
of it. On the other hand, it is a sleeping volcano, liable 
to break out at any time. Suddenly, some day the gums 
begin to swell and the volcano breaks forth with an 
alveolar abscess. You will find that in the incipient stage 
the patient stops brushing his teeth because the gums are 
painful and bleed. In the latter stages you will find the 
exudation of pus, and the teeth becoming loose. 

The symptoms are sometimes so mild that it is diffi- 
cult to diagnose the condition until you have made a 
thorough examination. A physician once referred a case 
of pyorrhea to me and I reported that I did not think the 
case serious. I failed to make the proper examination. 
When I operated, I found the condition serious in that 
the alveolus was almost disintegrated. 

To know the early signs of the disease one must be 
very familiar with them and always make a careful 
probing examination. The patient may have had 
pyorrhea before he got into the habit of brushing his 
teetli, so that when he comes to you his teeth may be in 
a clean condition, thus somewhat covering up the septic 
picture and deceiving the examiner. 

A rather common syiny)tom of advanced pyorrhea is 
a separation ol' tlie tcctli, destroying the contact points 
and giving entrance for food impaction. The peculiarity 
of this separation is that the affected tooth bears away 
from the point of infection or pocket. At first glance it 



Symptoms of Pyoerhea Alveolaris. 231 

would seem that the tooth would fall over on the weaken- 
ed side. If we imagine the tooth to have rubber bands 
on both sides, each pulling the tooth in" the opposite direc- 
tion, should one be cut, we know that the tendency of 
the tooth would be to move toward the side where the 
rubber remained. Now the peridental membrane or 
ligamentous fibres are the elastic bands which draw the 
tooth away from the side where pyorrhea, has weakened 
the "sling." 

Mal-occlusion is' almost a constant symptom and re- 
sult of oral sepsis. It seems that the teeth are constantly 
changing their position in pyorrhea. One patient had a 
lower cuspid which had turned half way around. An- 
other patient had such a wide separation between the 
two lower centrals that a bridge with two extra teeth 
was required to fill the gap. The result in such cases is 
to destroy the proper occlusion. 

One of the most constant sj^mptoms of pyorrhea is 
the odor coming from the pus, which is similar to that 
from a diseased antrum. You instantly detect this odor 
as soon as the patient opens his mouth, and you will 
soon learn to know it. The odor is characteristic. 

The patients will nearly always tell you that they 
brush their teeth from two to six times per day, and that 
they cannot understand why their gums should give them 
any trouble. 

The slight general symptoms are not nearly what we 
might expect from such an amount of infection; we are 
surprised to have some of the patients state that they 
suffer no other than local mouth symptoms. In other 
eases they have attacks of indigestion and have probably 
been treated by a stomach specialist. 

The patient may exhibit the symptoms of various 
other diseases connected with the eye, throat, heart or 
kidney which may be traced to mouth infection from 
pyorrhea. 



232 Practical Pyorrhea Alveolaris. 

duration. 

The duration of pyorrEea is very uncertain. The 
incipient form, so called gingivitis, may run along many 
years before developing into the more severe types. 
Wlien an infection of long standing does begin to make 
inroads into deeper structure, the progress of the disease 
is very rapid. There are many factors as to health, local 
mouth conditions and character of infection or inflamma- 
tion which affect the duration. 

Individuals who have healthy mouths and who ordi- 
narily give proper regard to dental toilet may for some 
cause, such as sickness or severe grief, entirely omit any 
care of their mouths. This lowering of vital resistance 
together with the omission of cleaning the mouth will 
produce a pyorrheal condition giving a history of rapid 
development. In so short a time as thirty days such a 
case may exhibit bleeding gums', pus, and loosened teeth. 

A recent case was that of a young, healthy girl of 
sixteen years who, inside of six months, developed such 
a severe pyorrhea that one tooth dropped out into the 
spittoon while making the examination. It would have 
been a safe guess to say that in six months more she 
would have lost many of her teeth. This' case yielded 
promptly to treatment with the exception of lower central 
and lateral, which were bridged. 

On the other hand, just the opposite history of dura- 
tion is often met with. Patients often answer that they 
have had diseased gums from ten to twenty years. 

From these observations it will be seen that there is 
no regTilar rule as to the time required for pyorrhea to 
run its course to the stage where there is exfoliation of 
the affected teeth. This much we do know ; it never gets 
better spontaneously without treatment, but always, 
whether gradually or rapidly, is sure to continue to grow 
worse. 



Diagnosis of Pyorrhea Alveolaris. 233 

diagnosis, 

Dr. Youiiger has written that "fully ninety-five per 
cent of the Anglo-Saxon race have pyorrhea in some 
stage of development in one or more of the alveoli. It 
is common among all races in all countries, and among 
all classes. The rich and the poor, the well conditioned 
and the mean, the vegetarian and the meat eater, the 
bibulous and the abstemious, the fat and the lean, the 
robust and the debilitated, the strong and the weak are 
all affected. Neither does temperament seem to produce 
immunity, for the nervous, the sanguine, and the phleg- 
matic suffer from it." 

I am sorry to say that even though the proportion is 
large many dentists who are accustomed to making 
diagnoses of carious conditions' are not able to diagnose 
a pyorrhea case. Patients often complain that the den- 
tist did not tell them that they had pyorrhea. Some den- 
tists may at times recognize the condition but not attend 
to it. In other cases the disease has not received the 
]3roper treatment, meanwhile growing worse, and valu- 
able time is lost before the patient is finally referred to 
a dentist or specialist who can cure pyorrhea. 

The time is passing when a well informed dentist will 
limit his diagnosis of pyorrhea to what he sees in the 
mouth. Dr. Arthur H. Merritt wrote me recently that 
he believes ''still more attention should be paid to the 
general health of ])atients, and very careful histories 
made, such as urinary analysis', blood counts, (including 
a differential), blood pressure, Wasserman test, when 
syphilis is suspected, radiographs, etc. Constipation 
seems to be associated with bad pyorrhea conditions and 
should be looked for and corrected." 

Often grave responsibility is attached to our diag- 
nosis. For instance, xVnglii calls attention to cases of 
ulcerative gingivi-stomatitis due to Vincent's bacteria. 
These cases are said to have a close resemblance to diph- 
theria, wliile the nioutli complication may be pyorrhea. 



234 Peactical Pyokrhea Alveolaris. 

This infection is found between the teeth or in inacces- 
sible places. The interproximal gum tissue and alveolus 
undergo a quick necrotic destruction. The diagnostic 
points are : the gray color which when rubbed otf leaves 
a bleeding surface which will reproduce within two hours, 
much pain and loss of gum, festoon. Positive diagnosis 
must be made by microscopical examination. 

Some other conditions with which we should be famil- 
iar in making a diagnosis are syphilis, leucoplakia and 
tuberculosis. I will not go into a detailed description of 
these diseases; but just a point or two is' given bearing 
on the diagnosis from pyorrhea. The initial lesion of 
syphilis produces a round oval nodule on lip or tongue 
which in color resembles that of boiled ham. The size 
may vary from that of a large pin head to a ten cent 
piece. They are always painless and indurated. In 
syphilis itself the alveolus may come away as a seques- 
trium because the circulation is cut off to such an extent 
that the pulp and surrounding structure may die. In 
diagnosis we must contrast this rapid destruction with 
the slow disintegration of the alveolus from the gingival 
border towards the apex which we find in pyorrhea. 

Leucoplakia is a rare condition, but should be sus- 
pected if gums and cheeks present small, pale colored 
patches which are slightly indurated. 

Tubuculous conditions are likewise of rare occurence 
in the mouth. When present, we have small yellow 
granular nodules which are located mostly in the pos- 
terior part of the mouth and pharynx. 

In making a diagnosis of pyorrhea, we must not only 
know the physical symptoms but go beyond the mere 
mouth conditions. As suggested by Dr. Merritt the gen- 
eral history of the ]jatient must be taken into account 
when a diagnosis is given. By the routine use of a his- 
tory chart many interesting and valuable facts for the 
diagnosis of pyorrheal conditions are brought out which 
will have a bearing- on the treatment. 



Pyoeehea Alveolaeis Histoey Chaet. 



235 




Name Address Date 

Examination 1. No. of teeth involved 2. No. of 

teeth with deposits on enamel and no destruction of peridental fibres 

3. Teeth with pus discharge 4. Teeth 

loose with no pus discharge 5. Condition of teeth 

mucus membrane , bone 

character of deposits Occlusion 

Prothesis worn 

History 6. Age 7. Duration 8. Beginning 

point of inflammation 

9. Most recent point of inflammation 10. Habits 

Tobacco Alcohol 

Oral Hygiene 

11. Parents' teeth 

Systematic Condition Blood pressure 

Urinalysis 



Saliva 12. Have you had any trouble with 

your digestion °i 

13. Have you had any pain in your abdomen 1. 

14. Which did you notice first — trouble in mouth or stomach? 

15. Have you had any he.irt-burn *? 

16. Do you notice any excess of saliva after eating f 

17. Have you any tendency to Diarrhea or Constipation? 

Do you use laxatives'? IS. Do you have Tonsilitis? 

Rheumatism? Gout? Shortness of breath 

or palpitation on exertion? 10. For what other 

diseases have you been treated ? 

20. Are you under care of physician at present time? 

Prognosis 21. Grood Fair Doubtful 

Hopeless To be extracted 

22. Prosthesis indicated 

Treatment and Results. 



Fig. 33. 



CHAPTER XXV. 
PROGNOSIS. 

BLOOD PEESSURE. AETIFICIAL TEETH IN REGARD TO PYORRHEA. 



The question that patients ask the dentist when 
informed that they have pyorrhea are, ' ' Can you cure it, 
Doctor! Will it stay cured! Do you guarantee a cure?" 

To the last named question the dentist should always 
be prepared with an answer and, though he might gain 
a little more business by saying that he could guarantee 
a cure, still the time may come around when he will 
regret having told the patient this. One dissatisfied 
patient can do a dentist a great deal of harm. He should 
be told that to ''guarantee" is only to make use of a catch 
phrase used by dental parlors and shyster physicians. 
Patients would not think of asking a physician to 
guarantee a cure of typhoid fever or grippe or ear 
trouble, before accepting his services. The patient with 
pyorrhea must understand that there are so many con- 
ditions on which our success depends that a cure cannot 
be guaranteed. Then again, we are not in the insurance 
business. Nature could not make teeth with a guarantee 
that they would stand, certainly we should not be ex- 
jjected to. The way to get out of all arguments of this 
question is the method I use in my office. On the exami- 
nation sheet, I have x)i'inted at the bottom the informa- 
tion that "we do not guarantee any operations." The 
patient at once sees this and all questions along this' line 
are generally avoided. 

To the query, ''Will it stay cured!" we can answer a 
little more definitely. If we have diagnosed the case 
])roperly, and have ])romised a cure, we can tell them 
with some degree of certainty that where the proper de- 
gree of oral hygiene is carried out, and where repeated 



Peognosis of Pyorrhea Alveolakis. 237 

visits at stated intervals are made to the dentist, for the 
purpose of having the teeth cleaned and polished (system- 
atic prophylaxis) that thej^ should not only stay cured but 
that the condition of their mouths should improve with 
every visit to the dentist. In other words, if the opera- 
tion is successful, and the patient masters the proper 
technique of keeping the teeth and gums in good con- 
dition, the mouth conditions should improve all the time. 

The question as to the curability of pyorrhea is one 
which has been freely discussed by dentists, and on it lias 
hinged much of the criticism of experts and specialists 
in pj^orrhea. If you mean by "cure" that the bony 
structure will rebuild and will be restored to its normal 
bulk around the teeth; if you mean that the gums will 
grow back to their normal position at the juncture of the 
enamel and root of the teeth and with the same degree of 
firmness as heretofore; if you mean that the patients 
will be able to go as other people with just ordinary 
care of their mouths, then we would have to admit that a 
real case of pyorrhea alveolaris is never cured. Of 
course, in mild and incipient cases of pyorrhea, all this 
does not appl}^, but we are referring to the more advanced 
case. Remember, in giving your prognosis, that the 
patient expects the gum tissue to grow up to its original 
position at the juncture of the enamel and the dentine, 
therefore it should be explained that the gums will prob- 
ably shrink from the teeth even more, for this is one re- 
sult of a successful pyorrhea operation in that tumefac- 
tion is reduced. 

In answer to a question about the cure of alveolar 
pyorrhea Dr. Arthur E. Peck, of Minneapolis, wi'ites : 

"The burden of maintaining a cure after tlie treat- 
ment of pyorrhea rests largely with the dentist. You 
must impress upon your patients the necessity of having 
their teeth looked over at certain intervals, notifying 
them when they should call for a prophylactic treatment. 
This treatment is one of the most important ste]is in 



238 Practical Pyorrhea Alveolaris. 

maintaining a permanent cure of pyorrhea. If the first 
treatment for this disease has been thorough and the 
removal of absolutely every particle of the pyorrheal de- 
posits has' been accomplished the case is then cured. But 
in many cases the return of the disease can only be pre- 
vented by the assistance of the patients and at stipulated 
times a prophylactic treatment which requires as much 
or even more skill than to treat the case originally. The 
instrumentation must be thorough and every particle of 
the returning deposits removed. It requires the touch 
of the skilled operator to detect these slight deposits but 
this is essential to a permanent cure." ^ 

The question as to the curability of a given case is one 
which depends a good deal on the individual skill of the 
dentist. A case may be incurable in the hands of one 
practitioner and easily cured by another, who is more 
skillful in the removal of pyorrheal conditions. 

By proper treatment, pyorrheal conditions can be 
healed, the tumefaction of the gums and soreness of the 
teeth can be made to disappear. The shedding of the 
teeth, flow of pus, elongation of the teeth, recession of the 
gums, carious action in the bone and its resulting odor 
can be obliterated. These are the benefits to be derived 
from the treatment of diseased gums. Not only this, but 
we can also prevent other teeth in the same mouth from 
becoming infected. 

In regard to the curability of pyorrhea Hutchinson 
says: 

''The great majority still believe it to be incurable, 
and progress is being seriously hampered by the influence 
of those who persistently refuse to believe what some of 
us know to be true .... The fact that the majority 
have failed in their efforts to cure pyorrhea has had 
greater weight than the successful effort of the few .... 
I have frequently been told by patients that some friend 
of theirs, at their solicitation, had intended to have treat- 
ment for pyorrhea, but had abandoned the idea because 



Prognosis of Pyorrhea Alveolarts. 239 

tlie dentist had told tlieiii that it was a constitutional 
disease and could not be cured. No man has the right to 
dei^rive the patients of a benefit because he either cannot 
render the service or is ignorant of the fact that it can 
be rendered .... If any practitioner fails in his 
attempts, he must not conclude that a cure cannot be 
effected. If he fails, there is a good reason for it, and 
he may succeed later on." 

The dental profession has been responsible for the 
loss of thousands of teeth just because so many dentists 
have told their patients that there is no cure for pyorrhea. 
If dentists have such large practices that they do not 
care to take time for the treatment of these cases, it is 
well for them to know that other men in the profession 
are making a success' of this work and that from 75 to 
85 per cent, of all cases of pyorrhea are being cured and 
stay cured under the care of these operations. I do not 
make this statement from mere hearsay nor from what 
other men have written. In addition to my own expe- 
rience in treating these cases, I have been in the offices of 
other specialists and have seen numbers of patients' who 
have been cured. This will be discussed again at full 
length; but let no dentist be again guilty of saying that 
pyorrhea operations are failures, for it is up to us and 
up to the dental j^rofession to stop this horrible increase 
of oral sepsis. 

In giving our prognosis to the patient, we should 
bear in mind that the disease in the upper jaw is more 
amenable to treatment than in the lower. In the first 
place the structure of the teeth and jaw favor this and 
they are more easily operated on in the immovable upper 
jaw. In addition to this, they are not subjected to the 
movement of the muscles and are not constantly im- 
mersed in the re-infecting saliva. On the other hand, 
the prognosis should be much more guarded if the 
disease has taken hold of the lower jaw. Here all tlie 
secretions are constantly coming into the pocket that 



240 Peactical Pyoeehea Alveolaeis. 

we are trying to heal, and it is difficult to keep the medica- 
ments that we apply in place for any length of time so as 
to get their full effect. 

]f the patient can be operated on before any destruc- 
lion of the supporting tissues', so much the better, but in 
tliosc cases where this has occurred to au}^ considerable 
extent, even though an operative proceedure might for 
the time being tighten these teeth, it would be better to 
extract them at once. 

On the question of bony support, Smith says: 

' ' The permanent tightening of teeth which have been 
loosened from pyorrhea, is wholly dependent on the 
amount of support remaining in the alveolus and the life 
of the cementum. 

''If the destruction of the pericementum caused by 
the necrotic wasting of the alveolus has not progressed 
too far, the tissues about the loosening teeth may, by 
intelligent treatment, be made to close in upon the roots 
and thus to a greater or less degree, they will tighten in 
their sockets. 

"Terminal alveolar tissue once necrosed and wasted 
can never be restored, this tissue cannot be made to re- 
new or build itself, neither can it be made to build around 
the roots of the teeth, therefore, the cure of pyorrhea is 
not necessarily followed by permanent and satisfactory 
tightening of all the teeth under all conditions." 

Another point in giving the patient a prognosis will 
be the probable condition of vitality of the peridental 
membrane. If the disease is in such an advanced stage 
that this structure has become saturated with infection, 
or its nutrition is to any degree affected, the chances of 
our being able to make a complete cure are correspond- 
ingly lessened. 

In case the teeth are loose, be guarded against prog- 
nosis. In other words, you cannot always give a cor- 
rect prognosis in such a case. If the tooth can be moved 
from side to side, it is not so bad, but if it has that 



Blood Peessuke. 241 

".squashy" souud and you can move it up and down in 
its socket, tlie tooth might as well be extracted^ The ends 
of these ''squashy" teeth often look as if a rat had 
gnawed them. This process is described by Dr. Hartzell 
in the chapter on ''pathology." 

When we find the tooth which can be raised up and 
down in its socket we are led to believe that there is little 
life in the membrane surrounding the tooth, and that the 
terminal end is covered with spicules and burr-like pro- 
jections. When such teeth are extracted, their ends 
resemble a log on which barnacles have collected. Other 
conditions might produce this loosening of the ligament- 
ous attachment, as when the tissues at the apex of tlie 
socket have become so infected that the ends of the root 
undergo a process of absorption similar to the absorp- 
tion of the temporary tooth. If either one of these con- 
ditions can be diagnosed beforehand, we can say with 
absolute certainty that the tooth cannot be saved. 

BLOOD PEESSURE. 

Clinical medicine now demands that the blood pres- 
i-ure test be used in examinations to indicate renal or 
heart troubles. It is required in examinations for life 
insurance, army and police departments. 

Only lately have dentists begun to realize the import- 
ance in regard to the diagnosis, prognosis and treat- 
ment of pyorrhea. 

Blood pressure readings are useful to dentists be- 
cause it gives information about arteriosclerosis, chronic 
nephritis, uremia and plumbism. In these we find the 
l>ressure high while in the following named diseases we 
read a low pressure: anemia, diabetes, starvation and 
exhaustion. 

The average pressure of males should be 1'2(), at the 
age of 20. For each two years above, one millimeter 
sliould be added. Thus at the ao-e of 30 the reading 



242 Pkactical Pyoeehea Alveolaeis. 

should be 125. In women we find all readings about 10 
millimeters less. 

Sim])le inexpensive instruments are now on tlie 
market and have proved their value in pyorrhea work. 

AETIFICIAL TEETH IN EEGAED TO PYOEEHEA. 

Every dentist who treats pyorrhea is frequently met 
with the argument that "it is just as good to have a set 
of artificial teeth and much less trouble than trying to 
save these I have." Such a patient will often bring 
along a friend who has a ' ' perfect set of artificial teeth, ' ' 
and inasmuch as this friend may appear quite healthy, 
it will often take the best argument at our command to 
convince our patient that the restoration and preserva- 
tion of the natural teeth is superior to any artificial sub- 
stitutes. In the first place we will have to admit that 
artificial teeth are better than teeth and gums which are 
diseased and which are not being kept clean. But on 
the other hand, they must consider the mortification that 
they will feel when the teeth are extracted, the incon- 
venience of getting used to the artificial teeth and the 
danger of frequent breakage, and of having to stay 
indoors for days at a time while the teeth are in a vul- 
canizer for repairs. But greater than any other con- 
sideration is the fact that the biting force of artificial 
teeth is only about one fourth of that of natural teeth 
and we know that proper mastication of the food is of 
the greatest importance in maintaining good health. 



CHAPTER XXVI. 

INSTRUMENTS FOR USE IN PROPHYLAXIS AND 
PYORRRHEA WORK. 

Dr. Riggs, of Hartford, is generally credited with 
being the first American to use instruments in the treat- 
ment of pyorrhea. The instruments he used were very 
large and crude. Some of his original shapes are still 
to be found in the supply houses. 

Considerable evolution has taken place in reference 
to size and shape. From a very few we are now offered 
sets of instruments numbering several hundred. 

Beginners should not be discouraged by the fact that 
pyorrhea specialists, though possessing large sets of 
instruments, often wish they had a still greater variety 
of shapes and forms. It is not advisable for the begin- 
ner to buy all instruments in any one set ; he should select 
a small number and add to them as needed and as famil- 
iarity with the work demands. The success of pyorrhea 
operations does not depend so much on the particular 
style of the instruments as on the operator's familiarity 
and dexterity in their use. This is proved by the fact 
that many of the contributors to this book work with 
instruments made on different principles. 

The dentist in beginning this work should select those 
instruments which he thinks will fit into the pockets he 
has seen and should not attempt to use the complicated 
instruments with crooks and turns, the purpose of which 
it takes experience to appreciate. 

In making a selection of instruments we should bear 
in mind the delicate work required. In addition to being 
sharp and delicate the blade must be extra strong. Prob- 
ably more is required from a pyorrhea scaler than any 
other surgical instrument. 

Younger says, ''If but one small speck is left, even 



24A 



Practical Pyoeehea Alveolaeis. 



tlioiigli it could be framed in the point of a pin, the irrita- 
tion and bacterial infection maintained by its presence 
wonld, I think, ])revent the diseased surface frem liealino'. 
It is in the detection and removal of these minute points 
that skill and delicacy of touch are so much required." 

So difficult is the operation, and in order to become 
efficient and expert Dr. Hartzell said that on his infirmary 
patients' he frequently scaled a tooth and pulled it out 
to see what had been done. Often he found tartar which 
had escaped his instruments. 

Probably the best general class of instruments for 
this work will be those which are used with a push and 
those used with a pull motion. 

The Allport and Ivjirk patterns are examples of the 
push motion while those of Tompkins and Hartzell repre- 
sent pull motion. The Younger type has a point that can 
he used either push or pull motion. The file type was popu- 
larized by Smith. Nearl}^ all complete sets now have 
some instruments with file points. The users of each 
variet.y of instruments makes the claim of greatest effi- 
ciency and a minimum amount of pain to the patient in 
their use. 




Fig. 34. Tite Kinic Dental Scalers. 

Tlie dentate edge prevents Interal slipping. After their use smooth- 
edged instruments shnuld he used to make the surfar-e smooth. 



Instruments. 



245 



The Kirk dental scalers are excellent for re- 
moving the large deposits of salivary tartar. The claims 
for their use are a minimum amount of lateral slip- 
ping and wounding of the gums. They are not intended 
for deep pj'orrheal conditions; but for dense masses of 
deposit. The wedge-shaped points on each blade cause 
the mass to break into small fragments which are thus 
loosened from their attachment. When used they must 
be followed by a smooth-edge instrument to remove the 
smaller particles and to smooth the surface. 

At the time when the push motion instruments were 
popular Dr. E. B. Adair revised the Allport type of blade 
and added others. This was the first set having 
the end of the blades concave on the cutting side to 
better adapt them to the contour of the root, while the 
back was rounded to prevent unnecessary irritation or 
wounding of gum tissue. 




Fig. 35. The R. B. 
Adair-Alport Pyor- 
rhea Instruments. 



246 Peactical, Pyoerhea Alveolaeis. 




( 1 


\ 


» s 




f "^ 




(F \ 


\ 


' 1 





Fig. 36. The Younger 
Pyorrhea Instruments. 



Insteuments. 



247 



The curved plane head was patented by Dr. G-eo. 
Winkler. Dr. Gartrell, of Washington, introduced points 
with blades to work on the Japanese plane principal. Dr. 
0. W. Jones, of St. Paul, suggested having the points 
centered with the long axis of the handle. Also a method 
of sharpening the blades to prevent deep cutting. Dr. 
Carr took these ideas and classified the instruments into 
a set. Dr. T. B. Hartzell has modified some points and 
by adding others has produced a most efficient collection. 

This set is probably too expensive for the general 
practitioner but for those who desire to specialize in this 
line of work it is certainly a good investment. 

The W. J. Younger pyorrhea instruments receive 
a well merited large sale. They have been con- 
densed and modified by Dr. Eobt. Good, of Chicago, into 




Fig. 3/. The Good Revision of the Younger Pyorrhea 
Instrument. Cleve-Dent. 



248 



Pkactical Pyorrhea Alveolaris. 



a new set which is in the writer's opinion indispensable 
to any dentist who even "cleans teeth." Dr. Good says: 
''These instruments are made thin, so they will pass 
under the gums easily, and I always use them with the 
'pull' motion, never shoving, because the 'shove' motion 
will cause pain. The entire point is a cutting edge, so 
that it makes no difference at what angle the instrument 
is held, it will cut." 



If 18 




+ . 5 6 7 . 8 9 10 )1 la 13 

Fig. 38. Smith's Prophylaxis Instruments. Ivory. 



The Smith prophylaxis instruments, and the various 
modifications l)y other dentists and manufacturers are 
used to remove deposits from the roots and necks 
of the teeth. The smaller oval forms are for open- 
ing into the diseased pockets'. The large blades are for 
the interdental spaces. The writer has the lilade of No. 
13 of this set made three times longer and finds it most 
excellent to reach deep pockets on the posterior root 
surface of molars. The files are used to finish with after 
using other scalers. 

The M. H. Fletcher set of bone curettes and alveolitis 
burs, are fully descrilied in another chapter by the 
inventor. These instruments are for cutting away 
dead and diseased bone about and ])eyond the roots of 
the teeth and are not styh'd nor intended for removing 
calcarious deposits. 

The instruments above described are the ones most 



Instruments. 



249 



generally used. Tliere are many others just as efficient 
for good work but nearly all of tliem are modifications 
of these standard types. 




Fig. 39. Tompkins' Pyorrhea Files. 

As many of the points are made in pairs, or right and 
left, it is advisable, where possible, to buy for cone 
socket handles. 

The writer prefers a double end, octogen-shaped, hard 
rubber handle. These save handling so many instru- 
ments. They can be boiled. The shape and size is just 
right to prevent cramping. Younger and Good use the 
various colored sealing wax knobs on their handles for 
this purpose, while Sarrazin has aluminum knobs with 
set screws, to use on small handles for the purpose of 
preventing slipping and cramping of the hand from 
long use. 



CHAPTER XXVII. 
TREATMENT AND INSTRUMENTATION 

THE YOUNGER METHOD.- — STRONG DRUGS USED AND OBJEC- 
TIONS TO THEIR USE. THE JOSEPH HEAD METHOD 

If there is one general criticism that can be made 
against the dental profession it is in regard to the gen- 
eral method of dealing with patients presenting them- 
selves with cases of pyorrhea. It has been the experience 
of all of ns who have treated a considerable nnmber of 
such cases to see patients with merely a condition of 
slight irritation of the gnm margins who had been in- 
formed by some dentists that their case was incurable. 
We find that dentists, as a general rule, do not like to 
treat these cases, preferring to throw them off with the 
simple statement that the case is incurable. This' cer- 
tainly lessens the respect of the patients for the dental 
profession, but of much greater importance is the fact 
that it means the loss of many teeth which should have 
been saved; the patient, believing absolutely in the 
integrity of the dentist, has' gone on and on without seek- 
ing other aid. 

If a splinter should stick in the finger the tissue 
soon turns red and suppuration takes place. Now, exactly 
the same thing takes place in the mouth. If a dentist 
should stick a splinter in his hand, he probably would 
not inject any of the strong pyorrhea remedies. Rather 
he would remove the cause. The same thing is true in 
pyorrhea. The pathology of the tissue surrounding the 
splinter is the same as that which makes the red tinge 
on the gums and the final suppuration. The pathological 
picture is simple and plain; Dr. Tolbot goes so far as to 
say that the dentist, allowing a patient affected with 
disease to go out of his office without telling him of his 



Teeatment of Pyokrhea Alveolaeis. 251 

condition, is guilty of mal-practice. Incipient pyorrhea 
is easily cured. Just as removing the splinter cures the 
finger, so incipient pyorrhea will get well in a few days 
if the teeth are cleansed and the tartar removed from 
under the gum margin. 

Every dentist should know the facts, now so well 
established regarding the beginning of this disease; no 
matter what the condition, a great deal can be accomp- 
lished b}^ treatment that is simple and easy, giving the 
patient great relief and saving teeth for future service. 

Of course, it must be realized that hard work will 
often not be paid for at the fees we are accustomed to 
receive for other work; but if we do our duty towards 
this end, we will soon become more expert and in time 
our success' will enable us to receive reasonable compen- 
sation. 

Dr. D. D. Smith says: ''Pyorrhea alveolaris is by no 
means a subject to be treated in a hit or miss haphazard 
manner ; it is a foe worth}^ of the steel of a valiant aggres- 
sor and consequently requires careful consideration, 
a steady hand, a keen sense of touch, and sound judg- 
ment. ' ' 

Dr. M. M. Bettman, of Portland, Oregon, says: ''The 
main point in the treatment of pyorrhea is the thorough 
scaling and polishing of the roots and the correction of 
any malocclusion which mav exist, no matter how 
slight." 

Dr. E. G. Hutchinson, Jr., says : 

"The time will never come when every dentist can 
successfully treat pyorrhea. It is unreasonable to expect 
that what requires special training can be accomplished 
by one who only occasionally engages in such practice. 
It is also unreasonable to believe that because the opera- 
tion cannot be accom])lished by the majorit\^ it is 
impossible." 

The Younger method, as carried out ])y Good and 
others' of this school, consists of first thoroughlv remov- 



252 Practical Pyorehea Alveolaeis. 

ing all concretions and carious bone, tlien injecting pure 
warm lactic acid into these cleansed pockets, with care 
that it does not run over the external gum margin. This 
is effected by the use of a small caliber, round pointed 
steel needle on a hypodermic syringe. The particular one 
as used by Grood, can be procured from Sharp & Smith, 
of Chicago. 

This treatment is repeated three or four times at 
intervals of several days' and only a few teeth are treated 
at a sitting. The object of this treatment, as claimed by 
these operators, is, that the acid produces somewhat of a 
solvent effect upon whatever concretions have remained 
and also upon the carious bone. In addition to this, it 
has a somewhat stimulating effect on the granulation 
tissue which surrounds the tooth roots and a new attach- 
ment is formed. 

"Wliile it is undoubtedly true that this treatment has 
produced good results it is just as true that their method 
cannot be said to be without objection. I believe the 
success that they obtain can be attributed more to the 
thorough cleansing of the pocket than to the injection 
of this acid. 

I am led to believe that the same result could be ob- 
tained by the injection of almost any other strong drug 
such, for instance, as Tartar Solvent which, it is said, 
does not have the disadvantage of dissolving the tooth 
root. If you will place a tooth root in pure lactic acid 
and allow it to remain for twenty-four hours, it becomes 
changed into a jelly-like mass. This is prevented in the 
mouth by the fact that the injection remains only a 
minute before it is washed out by the surrounding 
liquids, but there is the possibility that some of it may 
be retained in a remote cavity. 

One of the most perplexing cases that I have had to 
diagnose was that of an army officer who had been 
treated by the lactic acid method. He had received great 
benefit from the treatment, but from time to time he 



Treatment of Pyorrhea Alveolaris. 253 

suffered excruciating pain on the side which had been 
treated. Several examinations, at intervals, were made 
in an endeavor to diagnose the cause of this trouble, but 
without success until an X-Eay was made that showed 
a cavity in the upper cuspid root about the middle third. 
The instrument was inserted through the old pocket 
opening and, when high enough, fell into this cavity. 
The patient almost leaped out of the chair with pain. 
There was nothing that could be done except to extract 
the tooth. It was found that the constant application of 
this acid had dissolved the tooth with the final result of 
exposure of the pulp. There was no sign of decay ex- 
cept such as acid produces on tooth substance. While 
this is probably a rare termination of the treatment, at 
the same time, it is well to call attention to the possibility 
of this complication occurring in deep pockets. Another 
objection to the filling of these pockets with this or any 
other strong drug, is the great amount of pain which 
sometimes accompanies such treatment. It is well, if 
possible, to secure some degree of anesthesia of these 
sensitive teeth before subjecting them to the pain of this 
treatment. 

Another drug used by many is trichloracetic acid. 
After thorough instrumentation, sections of the gnim 
are dried with cotton rolls or napkins and the pockets are 
saturated with a ten per cent, solution of trichloracetic 
acid, using small ropes of cotton, or wood tooth picks. 
This treatment is repeated in three or four days but 
should not be used more than three applications. 

After the operation of curetting out these pockets, 
if suppuration continues. Dr. Kelsey recommends the use 
of phenol-sulphonic acid to be applied with a small 
pointed wood applicator. 

Deliquesced chloride of zinc, very slightly diluted, ap- 
plied on small wood applicators into pockets, has some 
advocates. 

Fieler, of the Eoyal University of Breslau, modifies 



254 Practical Pyoeehea Alveolaris. 

the Younger treatment as follows : "After scraping away 
deposits, the teeth, including their necks, are polished and 
when they have been dried we introduce iodine or lactic 
acid and iodine tincture because the former is borne 
badly on account of its nasty taste, and also because in 
some cases it produces severe pain. I introduce both 
medicants into the pockets on Ja])anese bibulous ]^aper 
wound around nerve needle. Often from two to four 
medical after-treatments suffice, carried out once or 
twice a week." 

The result obtained by the use of these drugs is the 
cicatrization of the tissue. 

Several years ago, Dr. Joseph Head, of Philadelphia, 
gave a most sensational report claiming that bifluoride 
of ammonia has a 'most peculiar action of dissolving 
tartar from the teeth without harming the tooth struc- 
ture. As teeth and tartar are the same chemically, this 
seemed most remarkable. This preparation has a place 
in the treatment of pyorrhea and we quote at length from 
his own description of this method. One precaution that 
must be observed is to secure a suitable syringe, prefer- 
ably the celluloid syringe. This holds a small quantity 
and will deliver drop by drop. Dr. Head tlius describes 
his method: 








Fig. 40. Cklluloid Syringe with Plattnum IVjint. 
No flooding of the nioiilli. Oiu; or two dro|).s at tlic IjoIIomi oI' llic 

|)ocket. 

''Through an extensive series of experiments it was 
proven that a twenty to twenty-three per cent, solution 



Treatment of Pyorrhea Alveolaris. 255 

of bifluoricle of aniiiionia (aii acid salt of liydrofluoric 
acid) will disintegrate the tartar on a tooth as readily as 
hydrofluoric acid itself and also leave the tooth apparent- 
ly unsoftened. Later experiments have shown that this 
solution can also be applied to the gums with the most 
beneficial effects, as it seemingly stimulates the tissues 
and diseased bone to such healthy action that deep 
pockets around loose teeth speedily fill up with healthy 
firm tissue and the sensitive teeth are reunited to the 
gums, becoming secure and useful agents in the process 
of mastication. After one or two injections, the soreness 
will largely disappear and all the tartar scale that could 
not be so easily and painlessly removed at the first two 
sittings tends to be so loosened that its thorough j^emoval 
by the scalers is easy for both patient and dentist. After 
four or five applications, one week apart, black scales 
that have escajDed the scaler will sometimes be found 
floating loose in the pocket so that they can be readily 
picked out and the root will be as smooth as velvet to 
the touch of the instrument. 

"In closing, perhaps, it would be well to tersely run 
over the steps of my treatment of pyorrhea. Take off all 
tartar tliat can easily be removed and cleanse the mouth 
as thoroughly as can be painlessly accomplished, at the 
same time instructing the patient in the use of brush, 
floss silk and mouth wash, pointing out particularly 
where he fails to reach the bacterial plaques, and 
demonstrating what motions of the brush are neces- 
sary to remove the plaques. The syringe should then 
be filled with bifluoride of ammonia and the platinum 
point inserted near to the bottom of the pocket or 
pockets, which should be filled full from the bottom to 
the top. During the operation of injecting the pockets, 
the cheek and tongue may be guarded with napkins with 
which all excess or overflow should be wiped away. Then 
the patient should be allowed to spit for a minute or two 
when the mouth may be slightly rinsed with water to 



256 Peacticax, Pyoeehea Alveolaeis. 

remove any excess of acid. Less irritation to the mucous 
membrane occurs from this method than that formerly 
advocated, which consisted in allowing the solution to 
rest in the pocket for a minute or two minutes. The 
patient is then dismissed with the instruction to return 
in a week. He is also cautioned to carefully observe all 
directions on home prophylaxis. When he returns next 
week the teeth are again scaled as far as feasible, clean- 
ing them thoroughly with brush and pumice and a coat- 
ing of tincture of iodine. When this is finished another 
application of the bifluoride is' made as before. The 
procedure for the third sitting is as for the second, but 
usually after that the teeth are free from tartar, the 
pockets have started to heal and the treatments need be 
for a period of only about fifteen minutes, just long 
enough for the application of the bifluoride and the little 
cleaning and scaling required. The bifluoride should not 
be applied oftener than twice a week and usually once a 
week is more desirable. Of course loose teeth should be 
tied to their secure neighbors whenever feasible." 



CHAPTER XXYIII. 

THE AUTHOR'S METHOD AND SYSTEM OF 
TREATING PYORRHEA. 

For the first time the author is afforded the proper 
opportunity of giving in full detail each step in a sys- 
tematized method of treatment which has for many 
years proved highly efficient in his practice. 

"While many papers have been read and published 
and clinics given, only parts of his work could be presen- 
ted. For this reason many of these contributions' were 
not thoroughly understood nor were the methods gener- 
ally adopted; but the author has the satisfaction of 
knowing that some dentists who have visited his office 
and seen his methods in practice have adopted them suc- 
cessfully. 

The author's treatment having proved so successful 
in his own hands, it is herewith given in full detail with 
the hope that it may prove equally useful to others. 

The instruments which the author uses consist of the 
following : R. B. Adair revision of the Alport ; the Smith 
set of files with the author's modification; Good's revis- 
ion of the Younger; the Fletcher, and the Hartzell sets. 
As the manner of using the above sets are fully described 
elsewhere, this part of the work is omitted from this 
chapter. The author believes that proper instrumenta- 
tion is the only solution for the cure of pyorrhea. He 
does not claim that the above mentioned instruments are 
superior to all others, or that they are entirely adequate 
for every requirement. 

In the description of this treatment we will consider 
that we have a case of pyorrhea where the teeth are 
loose, the gums swollen, and the pockets are of medium 
depth containing some cheesy disintegrated lalveolus, 
in other words, a typical case of pyorrhea. 



258 Peactical Pyorrhea Alveolaris. 

Several days before the surgical work the patient is 
given several sittings, at which time the month is spray- 
ed ont with some antiseptic solution or AA Dental Mouth 
Wash. Each time the mouth is mopped ont with a 
"Knoris," the cotton having been dipped in a weak solu- 
tion of hydrogen peroxide and then applied to the gum 
surfaces. A coating of Skinner's Disclosing Solution 
(formula given elsewhere) is next applied; other good 
antiseptic solutions for this preliminary treatment are: 

DR. MEDALIA's mild ANTISEPTIC DR. BUCKLEy'S PYORRHEA 

SOLUTION ASTRINGENT 

Compound solution of iodine Potassium iodide 

(U. S. P.) Zinc phenol sulpbonate aa grs. 60 

Glycerine aa gTS. s s Iodine grs. 80 

Distilled Avater grs II Water m 192 

Glycerine grs. 100 

Any one of these three preparations is good. They 
are applied on gums with a cotton pledget wound round 
a toothpick or with a camel hair brush. 

This preliminary treatment has the advantage of 
getting acquainted with the patients, gaining their con- 
fidence, and getting rid of any bad odor. By staining the 
debris around the tooth it is more easily removed. 

On the hour of appointment for the operation the 
room and instruments are prepared just as for any other 
surgical operation. All the instruments needed for the 
operation are thoroughly cleaned and sterilized, the in- 
strument table is wiped off with alcohol and a sterile 
napkin is placed on the table, upon which are laid all of 
the instruments. 

Tlie 7)oint of l)eginning tlie operation having been 
sel('ct(;d — generally tlie right side of the upper teeth — this 
section of tlie gums is dried oif with cotton or bibulous 
paper and either a solution of 5 per cent cocain is applied 
or, better still, a fresh solution of cocain and adrenalin 
as prepared by the Park-Davis' Company. Also, of late, 



Treatment of Pyoerhea Alveolaeis. 259 

a preparation called ^ ^ Peritimdo, " put up by the J. W. 
Edwards Co., of San Francisco, lias been used with ex- 
cellent results. This preparation contains eucain and 
adrenalin. You make your solution fresh for each case. 
The anesthesia obtained from this preparation is fine 
and it gives the minimum amount of hemorrhage. The 
anesthetic is inserted into the pocket with a clean hypo- 
dermic syringe, using for the purpose a long steel point. 
Do not use a sharp needle. 

The Sharp and Smith needle is most useful, the point 
is small and not expensive and better than anything I 
have found or had suggested to me for general use. 

Five or six teeth having been anesthetized, we are 
now ready for the surgical work. Great care must be 
exercised that the gingival margin be not injured for at 
this border there seems to be a fibre which acts like the 
draw strings on a tobacco sack and when once severed, 
it is never reunited. It is a good plan to pack small 
shreds of cotton saturated with the anesthetic into the 
spaces between the teeth, keeping the portion free from 
saliva for a few moments until complete anesthesia is 
obtained. Generally the beginning of pyorrhea at the 
gingival border is more painful than the deep pockets so 
this method is most important to use. 




Fig. 41. A Small, Inexpensive Steel Point Essential in Pyoerhea 

Work. 

We endeavor to use the instruments so as to give the 
minimum amount of pain. However, it sometimes hap- 
pens that the very case in which we expect the least pain, 
is the most sensitive. The patient's fears are allayed 
when they see the operator is taking steps to prevent 
pain. 



260 Peactical. Pyoeehea Alveolaris. 

In a systematic way begin at tlie gingival opening of 
pocket and gradually proceed towards the apex of the 
tooth nntil the sense of touch tells us that the instrument 
has removed all deposit and dead membrane and reached 
the extreme de^Dth of the pocket. 

While each instrument is in the hands of the opera- 
tor, he should operate on just as much surface of the 
tooth or teeth as possible, that is, he should go as far as 
he can before another instrument is taken up. 

Wlien through with an instrument or before placing 
it in a new location or pocket it is dipped in a glass 
having an inch of its depth filled with smallest size shot 
covered with antiseptic solution. By dipping instru- 
ments into this glass we not only disinfect the point but 
the shot effectually cleans the edge from any adhering 
matter or blood clot. 

Each selected section is taken up and finished before 
scaling other teeth. A section as spoken of means from 
three to four teeth. 

The ^'root planing" having been completed, I take 
the proper Smith's files and smooth otf all roughness 
which may remain or possible grooves cut in the teeth. 
With Adair's small bone curette the disintegrated bone 
and sharp edges of the alveolus are most carefully re- 
moved, its point, having a rounded end, will not remove 
sound tissue. Any carious bone or sharp corners of 
alveolus would retard the healing of tissue over it. A 
delicate sense of touch and experience is imperative in 
using a curette in pyorrhea work. 

One of the greatest aids for thorough work is the use 
of a good compressed air syringe, such as that made by 
the A. C. Clark Co. However any of the syringes applied 
with switch-boards would answer. This one is the least 
in the way. 

A stream of warm compressed air at from twenty-five 
to forty pounds is directed into the pocket and if the 
latter contains any foreign material, calculus or serumal 



Treatment of Pyorrhea Alveolaris. 261 

tartar, it can generally be seen. This syringe can be 
handled by the operator but it saves time to have the 
assistant trained to do it. 




^ 



Fig. 42. The Clark Air Syringe, Which the Author Finds the 
Best for His Work. 

In working on the lower jaw, it is advisable to have 
the saliva ejector in place, nsing the compressed air 
syringe in the manner above described. The air distends 
the gum from the tooth so that with the mirror, the 
operator can see and remove the smaller deposits which, 
when dry, show up so much better than when in a moist 
condition. 

When cleaning teeth or removing tartar, place the 
electric mouth light on one side of the alveolus opposite 
the root of tooth to be cleaned ; you will be able to locate 
the tartar on the opposite side and by reversing the 
light from side to side, enables the operator to find tartar 
deposits even if they extend almost to the apex of the 
roots. 

Having satisfied myself that the teeth are surgically 
clean and that the disintegrated bone and sharp edges 
of the alveolus are rounded off so that the soft tissue or 
gum can festoon itself over the surface without any 
irritation from projecting bone, the entire surface 
operated upon is then washed out with a liberal supply 
of warm water, normal salt solution, or, better still, an 
antiseptic solution such as AA Dental Mouth Wash. 
This solution is placed in a spray bottle, having for a 
point the Good needle which we advised for use in the 
hypodermic syringe. Plenty of solution should be used; 
a full spray bottle is not too much for each tooth. 

Another apparatus which I use with good results is 



262 Practical, Pyoeehea Alyeolaeis. 

that used by Dr. Conrad Deichmiller, of Los Angeles, 
consisting of a Valentine irrigator placed near the ceiling 
and a common bulb s^^ringe inserted at the end of tube 
to get a greater pressure. This is not only a useful 
apparatus for the treatment of pyorrhea, but in other 
dental surgery as well, such as washing out the antrum, 
abscesses, etc. A quart of hot normal salt solution 
should be used in this apparatus. (Normal salt solution 
is made by adding one dram of salt to a pint of sterile 
water.) 

Tlie entire area of the diseased gums is thus syste- 
matically gone over in turn. AVhatever success the 
author has had in the work, he believes it is due to the 
thoroughness with which the surgical technique is car- 
ried out. If any scale of deposit, any carious bone, or a 
sharp edge is left, that particular place will not heal, 
and if it shows up before the patient is dismissed the 
pocket is again opened up and this irritant removed. 

Thorough irrigation with plain warm water or nor- 
mal salt solution is used for no other purpose than that 
it will wash out the debris. AVe do not use any solution 
which would tend to destroy or prevent organization of 
the clot. It would be preferable not to wash out the 
pockets after instrumentation were it not for the fact 
that loosened scales of deposit might remain to become 
reattached and give future trouble. If nothing stronger 
than the solution named be used for irrigation, we find 
that we have as good blood clot as though the thorough 
washing had not been done. 

It matters little whether all the teeth are completed 
at one sitting or not, as the field operated upon is sealed 
from infection from the other parts of the imouth. Wliat- 
ever section is oijerated upon, must be finished at this 
time; if this is not done, when the patient returns in a 
day of two for another hour of surgical work, we will 
probably liave forgotten just where we left off or 
whether or not we have finished certain teeth. 



Treatment op Pyoerhea Alveolaris. 263 

In our operative procedure, we will find fillings 
which have a shelf overhanging the entrance to a 
pyorrhea pocket and the operator is prone to leave this 
for future consideration. However, as we have given 
this as a causative factor, it should be eliminated almost 
as soon as found. Sometimes the quicker way to do this 
is to remove the filling and put in some temporary stop- 
ping, waiting until we have finished the operation and 
can knuckle the filling up in the proper manner without 
any overhanging edges ; ill fitting crowns and bridges 
should also be promptly removed. 

Sometimes the deposit of tartar is so hard that it is 
good practice to remove it with a burr, placed in the 
dental engine. It is well to first allow the burr to revolve 
against a stone so as to modify its cutting qualities in 
order that it will not gash into the tooth root itself. The 
burs with long shanks and small heads, as described by 
Dr. Fletcher, can be used to advantage in removing 
carious bone or cleaning out between the roots of the 
teeth when it is not practicable to obtain sufficient force 
or effectiveness with a hand instrument. 

I expect the same healing that I would from any 
fresh wound which is filled with a blood clot. I do not 
mutilate the gum at the cervical border. T endeavor to 
have the operation joractically painless and without any 
great strain on the patient. While our object has been 
to produce a clean wound sometimes after treating for 
a few da3"s, we will find a trace of pus which shows that 
something has been left in the pocket which must be 
removed. In such an instance it will be necessary to 
again open up the pocket or to inject some medicant to 
overcome the infection which has spread into the body 
of the alveolus. 



CHAPTER XXIX. 

THE AUTHOE'S METHOD AND SYSTEM OF 
TREATING PYORRHEA- CONTINUED. 

THE MEDICAL, TEEATMENT. PEACTICAL HINTS FOR APPLICA- 

TION. AN" UNEXPLAINED CHEMICAL FORMATION 

USEFUL IN TREATMENT 

Many cases would undoubtedly get well with the sur- 
gical procedure alone, but no medical treatment known 
will aid these cases unless this surgical procedure has 
been well done. However, in the same patient, with the 
same degree of operation on both sides of the jaw, I 
have tried the experiment of using my medical dressing 
preparation on one side only. For the first few days the 
side not dressed showed inflammation, the teeth were 
elongated ,and it was very sore to touch, while the op- 
posite side where the preparation was used showed no 
such symptoms. The reason for this is logical. A sur- 
geon who had performed an operation, follows it by ap- 
plying a dressing which has a great deal to do with the 
proper healing of the wound. For years the dental pro- 
fession tried and experimented in an effort to get some 
method of covering the operated surface in pyorrhea 
work. Some have tried sponge grafting; some, tying 
strijos of rubber dam about the teeth; still others, pack- 
ing the pocket with strong irritating drugs. The diffi- 
culty that we have hitherto had was that the treatment 
or medicament could not be kept in place. It was im- 
mediately washed off by the constantly flowing saliva. 
The failure to use a suitable protection left the field of 
operation a veritable culture tube — the mouth contain- 
ing stagnant saliva, decayed teeth, and many different 
kinds of bacteria. Hitherto, the antiseptics we have used 
have proved failures, for, if strong enough to destroy the 



Treatment op Pyorrhea Alveolaris. 265 

bacteria, tliey destroyed the membrane of the mouth or 
kept it in a raw state. 

Some years ago, Dr. R. B. Adair, made a solution of 
iodine, creosote, tannin, chlorate of potash and glycerine. 
He was most successful with this treatment, but the com- 
bination was difficult to make and it was not stable. He 
gave the formula to the profession but few men had done 
anything with it. It was hardly possible to get a pre- 
scription for this preparation filled jDroperly as the con- 
sistency more than the quantity was the requisite. In 
attempting to get it filled at drug stores, I found diffi- 
culty in getting it just right. I improved this formula 
and in order to supply the prescription to those dentists 
who had shown an interest in it and wished to give it 
a trial I had the preparation placed upon the market 
under the trade name of "AA Pvorrhea Treatment Nos. 
land 2." 

Tfhis preparation was shown for the first time last 
year (1913) at the National Dental Association at Wash- 
ington. I not only wished to give the profession the op- 
portunity of using this '^ dressing" that had filled a long 
felt want in my practice, but also to stimulate others to 
investigate the nature of this preparation. I certainly 
do not know and no one has been able to find out, al- 
though some of the most prominent men in the profes- 
sion have successfully used it for sometime. The name 
treatment is a misnomer ; it should be dressing, as it can 
be used in combination with any treatment. 

METHOD OF MAKING NOS. 1 AND 2 PYORRHEA DRESSING. 

ORIGINAL PORMULAE BY DR. R. B. ADAIR. 

Take one oz. chemically pure iodine crystals. Pour 
over this just enough chemically pure beachwood creo- 
sote to cover crystals of iodine. Let stand for 48 hours, 
then stir thoroughly with a glass or wood rod, making 
a thick mixture. When this is settled, pour off from 
sediment at bottom. This liquid is the No. 1 preparation. 



266 Practical Pyorrhea Alveolaris. 

Procure large moiith bottle of about 3 oz. capacity 
STicli as vaseline comes in. Pack into such a bottle tannic 
acid crystals. Use a wood rod and pack tight, having one- 
half inch space at the top of bottle. Into this space pour 
Glycerine C. P. — about one-half oz. Let stand for 
several days. If on examination the glycerine seems to 
have reached the bottom, place it on a water bath and 
leave until the whole has become a thick syrup. If 
glycerine has not reached the bottom, add a small quan- 
tity of glycerine. After heating on water bath, mixture 
should stand and age for about a week. The mixture 
will become clear and will have the consistency of thick 
molasses. This is the No. 2 preparation. 

These preparations are rather hard to make in small 
quantities. They must be just the proper consistency 
which is best obtained by aging. The preparation as 
manufactured stands several months before bottling. 

'Simple cases will need only three or four applica- 
tions ; the severity of the condition and the extent of the 
operation determine the number of applications neces- 
sary. This ''dressing" does not stain a clean tooth — 
really bleaches it — but it does stain every bit of foreign 
matter on the tooth root. I have found it a good idea 
to use a few applications before the operation as a sub- 
stitute for a disclosing solution, as this staining will show 
up the tartar and other accumulations'. It softens and 
loosens the attachment of accumulations. This "dress- 
ing" which we use comes nearer filling all requirements 
than anything yet found. It furnishes the strongest anti- 
septic known and, when used in the mouth, it forms an 
astringent membrane which seals and protects from any 
infection. The foi-mation of this preparation is similar 
to surgeons' collodion. It holds from twenty-four to 
forty-eight hours and gives the longest period of mouth 
medication known. We know that the surgeons of today 
are depending more and more upon iodine for steriliza- 
tion. This "dressing" gives us the constant penetrating 



Treatment of Pyoerhea Ax.veol.aris. 267 

effect of this drug. Even thoiigli it had no antiseptic 
properties, the astringent effect upon the gums and the 
sealing of the gums to the teeth, would make it of great 
advantage. 

Many experiments have been performed outside of 
the mouth under all conditions but so far, we have been 
unable to effect this peculiar formation outside of the 
mouth. 

The experiment may be tried of placing No. 1 on a 
dried section of the gum and the No. 2 over it ; no combi- 
nation takes place. Let the patient spit and the moment 
the saliva comes in contact with the preparation, a mem- 
brane is formed over the coated surface. Under twenty- 
four hours it is impossible to remove the formation from 
the gums; after this time, it loosens and comes off in 
small pieces, resembling rubber dam. Instead of exces- 
sive hemorrhage from the operation, we have just the 
minimum amount. 

Outside of the mouth, on the hand, or anywhere, 
the preparations are put on in the same manner and 
covered with saliva, under any and all conditions, but no 
formation takes place. "\^^iy? 

DIRECTIONS FOR POST OPERATWE DRESSING: 

The Applicators 

The applicators recommended are made by dipping the 
end of wood tooth picks into Sandarac Varnish, and 



^^ ^ / 



^ 



Fig. 43. 



268 Peactical Pyoeehea Alveolaeis. 

twisting a few strands of dry cotton about the end, these 
making a secure and convenient swab for painting the 
gums. Several hundred of these can be made in a few 
moments by your assistant, to be thrown away as used. 
It is absolutely essential that a separate applicator be 
used for applying No. 1 and No. 2 preparations. 

NapMns for Drying the Gums 

The application is greatly simplified by the use of 
small doilies which can be thrown away. These are in- 
expensive and used in all treatments about the mouth. 
Buy from 3^our dry goods store, a bolt of English long 
cloth, costing about $1.00. Mark otf the stop of bolt into 
squares about 3x5 inches, some longer, some smaller. 
Your printer will, with a few strokes of his cutter, con- 
vert the bolt into several thousand doilies. These should 
be sterilized and kept under cover ready for use. 

Technique of Applying Dressing. 

Immediately after instrumentation and irrigation, 
the mouth is dressed by drying sections of the gums witli 
the aseptic napkins, which should be heJd so as to pro- 
tect the lips and cheek while applying with applicator 
a coat of No. 1 pyorrhea treatment, giving a moment 
for absorption; then freely paint over No. 1 with No. 2 
letting it flow around and between the teeth; when the 
napkin is removed and the saliva comes in contact with 
the medicated gum, the combination of these two prep- 
arations forms a membranous coating or dressing simi- 
lar to that produced by collodion as used by surgeons. 

As each section is treated, have patient rinse mouth 
with dental mouth wash. Tfhis at once removes the dis- 
agreoa1)le taste and puckering of the y)yorrhea treatment. 
Anothei- section is dried and treated in tlie same way 
until all tlic affected teeth and gums' are sealed. It is 
better to treat the u])por jaw first. It is not necessary to 



Treatment op Pyorehea Alveolaeis. 269 

have dressing extend more tliau 1-4 in. from gum margin. 
Be careful not to seal the ducts of Whorton and Steno, as 
this would cause a disagreeable swelling of the glands. 

The benefits of the iodine contained therein, we all 
know. The inflammation is deep seated, and iodine is the 
one agent that will penetrate. The astringent effect is 
produced by the tannin. This dressing draws the gums 
to the teeth; food, saliva, and toxic products are thus 
excluded. The blood-clot in pockets is protected until 
organized into new tissue. 

This dressing is not to be removed for 24 hours. 
See the patient regularly every day, removing the mem- 
branous or leathery coating of the day before from the 
gums by a gentle massage with a soft tooth-brush 
moistened in hot water; the mouth is sprayed with mouth 
wash, and the dressing of No. 1 and 2 is again applied. 
After a week of treatment it is not always necessary 
to use the No. 1 as the septic condition is under control, 
and the subsequent api)lications may be of the No. 2 
alone. 

Sometimes, when an excess of these preparations is 
used on the gums, blisters similar to the so-called ''fever 
blisters," appear in the mouth. When this condition 
arises, suspend all applications for a few days, until the 
condition disappears. 

The patient's name is engraved on his tooth brush 
using a small bur in the dental engine, afterwards tracing 
with ink. The office assistant keeps these brushes in 
alphabetical order in a small formaldehyde sterilizer. 

At each sitting or treatment the brush is softened in 
warm water and the teeth brushed correctly, as described 
in the chapter on ''Brushing the Teeth"; this removes 
the pyorrhea "dressing." I have always found it the best 
policy to brush the teeth myself, having the patient hold a 
mirrow so that he can acquire the proper idea of using 
his brush. A strand of flat floss silk saturated with 
dentrifice, is then run l)etween the teeth and the mouth 



270 Practical Pyoekhea Alveolaeis. 

is sprayed out with dental mouth wash. The same pro- 
cess of dressing is made again and the patient dismissed 
for from twenty-four to forty-eight hours. 

After the patient has been treated about a week or 
ten days, he brushes his teeth before me at each sitting 
and in this manner he is compelled to get a good idea 
of the technique of brushing his teeth. It is sometimes 
necessary to take the patient's hand and guide him into 
brushing correctly. After being taught in this manner, 
if the patient comes up in the future with case of oral 
sepsis, no one is to blame but the patient, himself. 

After treating the patient in this way from two to 
four weeks, and when I am fully satisfied that the neces- 
sary tissues has formed to resist the force of mastica- 
tion, and all signs of inflammation have subsided, several 
hours are spent in polishing the teeth. Sometimes, I am 
surprised to find that so much tartar -has escaped my 
notice and every bit of it will be shown up by "AA 
Pyorrhea Treatment Nos. 1 and 2." I now turn my at- 
tention to this and every scale of accumulation is re- 
moved with the scalers, the porte polisher or the polish- 
ing wheel. 

This "treatment" on account of its standing qualities 
is not for the lazy dentist, but in the hands of a careful 
man gives the greatest opportunities for making the 
mouth perfectly clean and for instructing the patient in 
the proper keeping of his mouth. Its use has proved 
gratifying both to the patient and ourselves. 

Before dismissing our pyorrhea patients, we must 
have them understand that where the gum is receded 
and the dentine is exposed, tartar is more readily collec- 
ted and that these surfaces must be kept free from all 
accumulation. For this reason, these patients are dis- 
missed only on probation and they are instructed to re- 
turn in a month for inspection, when they are again 
taken through the "tooth brush drill". We endeavor 
to persuade all the resident patients to take up our sys- 



Treatment of Pyoerhea Alveolaris. 271 

tern of monthly prophylaxis either under our own care 
or that of the dental nurse. 

"We have under observation, cases treated from ten 
to fifteen years ago who, before treatment, had been ad- 
vised that extraction was the only thing that would re- 
lieve them; but they have never lost their teeth. Some 
of these cases were in such a serious condition that a 
continued neglect of the mouth condition would probably 
have resulted in death from septiccemia. 

An interesting case in the author's' experience was 
that of a woman who had suffered for several months 
with very severe pains in the head; her physicians had 
been unable to afford any relief. The surgeons had ad- 
vised that an operation be performed on the trifacial 
nerve. Being called in as a consultant, I found a severe 
case of pyorrhea and by treating this for a few days was 
able to give the patient almost complete relief from pain. 

Many cases of interest like the above are contained 
in my records but I do not feel that there is room for 
them in a work of this kind. 



CHAPTEE XXX. 
TREATMENT— CONTINUED. 

TREATMENT OF MEEEITT, PATTEESON, SAEEAZIN, DUNLOP, 
LUNDY AND FLETCHER. 

Report of an Interesting Case of Pyorrhea and the 
Treatment Employed. By Dr. A. H. Merritt, New York. 

(Dr. Merritt, at my request, wrote me this description 
of a pyorrhea case in a patient 18 years of age, stating 
that it is the youngest patient in all his experience, with 
so advanced a case. The radiographs of this case were 
made by Dr. George M. MacKee.) 

''This case I am seeing for the last time on June 21st. 
The gums have already resumed normal color, the dis- 
charge of pus which was enormous, has entirely ceased, 
the teeth are markedly more firm and except for slight 
sensitiveness to thermal shock, perfectly comfortable, 
though the patient was in constant pain all about the 
gums, with a calcic abscess on gums over one molar when 
treatment was commenced in Ai)ril. Treatment to date 
has been entirely local, except the administration of 
calomel and sodium phosphate for constipation. The 
local treatment consisted of a very thorough scaling of 
the root of each tooth with scalers made from my own 
design, finishing in some instances with fine files, with 
these latter the edge of the alveolar plates, and where 
necessary smoothing off ragged edges. This was fol- 
lowed each time by the application of weak solution of 
tincture of iodine (85 to 50^/r) with careful pro])hylactic 
treatments. 

''All weakened teeth were ground off so as to relieve 
them from undue stress. The patient was carefully 
instructed in the home care of her teeth, proper brush 
provided and instructions given in its use (two minutes 
each time, four times daily, straight up and down over 



Treatment of Pyorrhea Alveolaris. 273 

all tlie gums). Tins briefly outlines the treatment I fol- 
low in all such cases with most gratifying results. This 
particular case was exhibited at a public clinic before 
treatment was begun and will again be shown next 




Fio. 44. Radiographs of Dr. Merritt's Case. 

autumn to the same men to confirm my experience in 
such cases, 

"To me it seems that there is too much theory in the 



274 Practical Pyoerhea Alveolaris. 

treatment of all pyorrhea cases, making it appear to be 
very difficult, when in reality it is comparatively simple." 

TREATMENT OF PYORRHEA ALVEOLARIS 
BY JOHN DEANS PATTERSON". 

(From Johnson's "Operative Dentistry," by permission of P. Blakis- 
ton's Son & Co.) 

"In beginning the operation of scaling, it is wise to 
select only that number of teeth for one operation which 
can be entirely finished at one sitting. If the disease is 
in the incipient stages, frequently a number of teeth can 
be treated; if the condition is in the advanced stages, 
from one to four should be the limit. ^ In all cases each 
operation should be limited to an hour, for, in the first 
place, whatever the means used for obtunding, the opera- 
tion is more or less painful; the teeth operated upon are 
also left in a condition acutely sensitive to thermal 
changes, and if many teeth are treated at one sitting, the 
discomfort is distressing for many days on this account ; 
so it is surely best to confine this discomfort and the 
painful scaling to a limited time and a limited area to 
prevent accumulated discomfort in cervical territory on 
account of thermal irritation, and to prevent shock from 
the unavoidable pain of the operation. With the correct 
diagnosis as to the extent of the disease and the selection 
of the suitable instruments, there must be a determina- 
tion upon the part of the operator that the roots selected 
to be operated upon at any sitting shall be entirely freed 
from irritating deposits and the surfaces left in a con- 
dition to encourage the new tissue of repair to form. 
The surgical part is not complete upon the removal of 
deposits, but after that these surfaces should be 
smoothed and polished as perfectly as may be. About 
the crowns and the cervix of the tooth engine instru- 
ments with brushes, strips, rubber cones, etc., of a great 
variety of shapes, are applicable ; beyond the gum margin 
hand instruments must be used. The various wood and 



Treatment of Pyoeehea Alveolaeis. 275 

other points, held in suitable porte-polisher and charged 
with an abrasive, must reach all possible surfaces. 
Experience has taught that the time spent in smoothing 
the roots is well worth the endeavor, for the rapidity and 
permanency of recovery is greatly enhanced, and the 
operation cannot be considered completed until as much 
time is given to the polishing as to the removal of 
deposits. 

''The polishing concluded, then comes the removal of 
all loosened detritus with the hot water used in a strong 
force syringe with slender special points which will reach 
well down into the pockets ; these points are best made 
of silver or German silver, and can be fashioned by any 
instrument maker. 

''The surfaces from which the coating of deposit is 
removed are a source of great discomfort to the patient 
in whatever manner they may be treated ; the writer uses 
a 10 per cent, solution of silver nitrate, which, as is well 
known, renders those surfaces much less painful. AVhen 
the discoloration is not an objection, a saturated solution 
of the silver nitrate brings results not secured by any 
other drugs. The 10 per cent, solution is just short of 
the discoloring strength. In using the silver solution the 
parts should be protected from saliva for a few seconds. 
After this treatment, all inflamed and diseased gum 
tissue should be bathed with drugs or combinations of 
drugs which stimulate absorp'tion, act as counter-irri- 
tants and obtuncl irritated surfaces. 

"If the operation has been well done, it is inadvisable 
to disturb the pockets, which are soon filled with the 
plasma, out of which repair comes. The very common 
practice of frequent probing and medicating is strongly 
condemned." 

the sarrazin treatment. 

Dr. J. J. Sarrazin, of New Orleans, La., has worked 
out an elaborate system of prophylaxis and j^yorrhea 



276 Peactical Pyoeehea Alveolaris. 

treatment. The Dental Cosmos (May, 1910) gives Ms 
system of treating pyorrlieal conditions. 

From this article I quote: 

''There are two ways of handling a jaw which is 
affected generally by the disease. One is to begin at the 
most posterior tooth on one side and stop at the median 
line; then continue by starting at the most posterior 
tooth on the opposite side and again come to the median 
line. This has the advantage of allowing time for molars 
on one side of the mouth to lose much of their tenderness 
before the molars on the opposite sides are made too 
sore for mastication. The second way will grow out of 
aggravated conditions in some localities, in which 
instances the operator will see that such places must be 
operated upon at the start, so that ample time may elapse 
to watch their behavior while the surgical treatment is 
being continued elsewhere. 

"I am partial to pull-cut instruments for accomplish- 
ing just exactly what is wanted on roots. On a smaller 
scale, the motion of such instruments should be more 
like that of a vulcanite scraper on a plate, and still more 
similar to that of a pencil eraser on paper, the push 
stroke being much lighter, and not like that of a plane 
on wood. Instrument points should be so directed as to 
operate on only a small speck of a root surface at a time, 
making sure of having completely scaled that point 
before ])assing to an adjacent spot either horizontally or 
vertically. Such operating should be done not only where 
well-defined pockets exist, but also wherever soft tissues 
fail to closely hug and adhere to cementum. If the 
alveolar tissue be affected beyond, diseased portions 
surely lead to it, if they are ])roperly followed. On the 
otiier hand, soft tissue should be respected wherever it is 
attached to tlie pericementum, but instruments should 
reach quite to the lines of such attachments in every 
direction. 

''If operations have been severe, wounds should be 



Treatment of Pyoekhea Alveolaris. 277 

frequently irrigated, just as is practiced in general sur- 
gery, until such a time as the tissue shows a proper 
tendency to heal. Bismuth paste following such irriga- 
tion acts very favorably, at the same time warding off 
the danger of impaction of fermentative material. 

''However thorough the scaling of a single or multi^ 
rooted tooth may have been, there is safety in making 
use immediately after operating, of a drug capable of 
dissolving calcareous particles. Wherever the alveolus 
has been seriously affected, greater reliance may prob- 
ably be placed on 50 per cent, sulfuric acid in glycerin, 
because long clinical experience indicates its marked 
action on hard tissues, with a reduced irritation to 
soft ones." 

TREATMENT OF PYORRHEA WITH ETHYL BORATE GAS 
BY DR. W"M. F. DUNLOP, NEW YORK. 

"The Dunlop Treatment consists primarily in the 
introduction of oxygen into the tissues and circulation, 
and stimulating nerve control. It had long been recog- 
nized that oxygen could probably cure pyorrhea, and 
many experiments have been made with a view to forc- 
ing the gas directly into the gums. These attempts failed 
because pure oxygen unfortunately burns up live tissue 
as well as dead tissue. 

''I use the ethyl borate gas under pressure, which is 
introduced by means of a small needle at the free margin 
of the affected gums. The features of this gas as against 
pure oxygen are : first, that it destroys only dead matter, 
by stimulating the circulation. The live tissues are not 
attacked by the gas at all. Secondly, the gas travels 
through the pus passage and ramifications about the 
roots and along the jaw, not ]>y ]iressure, but by its own 
natural affinity for pus and dead matter. 

"Wben a case of pyorrhea has been cured and the 
passages have been emptied of microbes and putrifying 
secretions, tlie gums refuse to take the gas. 



278 Peactical Pyorehea Alveolaris. 

''I belive that this gas cures by virtue of its burning 
up dead matter and its stimulation of blood circulation. 
Eecent experiments suggest that gas gets results as a 
germicide by increased circulation. 

"Before applying the gas it is first necessary to 
remove the original cause of the disease, viz. : the local 
irritation. 

"After the operation is completed we are ready for 
the vapor treatment; the gums are sprayed and all the 
pockets fully impregnated with the antiseptic from the 
machine. Before the patient is discharged, place a strip 
of the pocket packer over the free margins of the gums, 
pressed firmly in between the teeth, both lingual and buc- 
cal. This must remain in place in order to keep the tender 
surfaces of the gum free from contact with the secretions 
of the mouth and any other foreign substance. The 
deeper pockets are to have a small portion of the pocket 
packer forced up into them, and a warm instrument 
passed into it while in position. This will hermetically 
seal the space or pocket. 

"When the patient presents himself for the second 
sitting, the pocket packer is removed, the gums thor- 
oughly sprayed with the machine, the same being 
properly charged to throw this spray without the use of 
the needle. You next put the needle on the tube. Open- 
ing the valve on the machine it will be found that a dry 
gas or vapor escapes from the needle. In passing the 
needle around the gingival margin, or perhaps slightly 
under it in some cases, it will be seen that the gas is 
taken up by the inflamed ducts, and it will pass up 
through the gums, forming little stringers, and will only 
stop when they seem to reach their destination in the 
glands themselves. This action is visible to the naked 
eye. 

"Generally, where this inflamation is pronounced, 
there will be a cyanotic condition of the gums, caused by 
improper elimination, or a lack of oxygen. This gas 



Treatment of Pyoerhea Alveolaris. 279 

being carried into the tissues is robbed of its oxygen, 
and the solids are precipitated into the tissues, causing 
an inflammation, which brings blood to the parts, the 
same as any other irritation will cause an influx of blood, 
but with the difference that in this case the tissues are 
thoroughly oxygenated and circulation is re-established, 
the cyanotic condition disappearing. The tissues produc- 
ing cells are stimulated to action, and constantly fed by 
the application of this gas until they will receive no 
more. If this is kept up at intervals — with a few days 
apart— and the surfaces kept clean, we have not only the 
rebuilding of this lost material, but there is a re-attach- 
ment of the root of the tooth to the alveolar dental mem- 
brane and a consequent cure." 

The above article on the Dunlop method is given for 
the reason that it is entirely a new departure in our 
methods of treating pyorrhea. The author has endeav- 
ored to secure more data as to its relative efficiency, but 
it has not been on the market long enough to gather any 
definite information. 

There are many who claim that deep infection in the 
alveolar process can be relieved by its use. However, 
there is some opposition developed against it as voiced 
by the following quotation from Talbot, in his '' Inter- 
stitial Gingivitis and Pyorrhea Alveolaris." 

''Within the past year a machine has been placed 
upon the market for the supposed purpose of forcing 
oxygen through the tissues in the treatment of this dis- 
ease. I have watched this process of treatment 'with 
fear and trembling' since the method of application 
forces the pus germs through the inflamed alveolar pro- 
cess. Why infection does not occur is a mystery. This 
method of applying drugs and forcing pus germs into the 
tissues without infection is a strong point in favor of 
the non-infectious theory of interstitial gingivitis." 



280 Peactical Pyokrhea Alveolaris. 

treatment of dr. e. a. lundy, of los angeles, californl\. 

''The majority of cases preseutiiig are simply an oral 
manifestation of a systemic clistnrbance. For twelve 
years past my treatment lias been both from a local and 
systemic standpoint, and results obtained have been far 
more satisfactory. 

"My systemic treatment varies in individual cases, 
bnt is arranged with a view to the establishment of a 
normal elimination and assimilation. I find in the 
majority of cases that constipation is present with resul- 
tant autointoxication, and my treatment is with a view 
to overcoming such conditions. My first efforts may be 
by internal medication, but later I resort to that of a 
proper dietary, in which I try and prescribe such foods 
as are compatible and require chewing, I also try and 
prescribe a non-uric acid dietary. 

"My favorite remedies for local treatment at present 
are Dr. Sens solution of iodin and i^otassium iodide, one 
part to water four hundred parts, making practically a 
one per cent, solution." 

Fletcher's method of removing diseased alveolus. 

The following quotation is taken from "Alveolitis — 
the Disease of Which Pyorrhea Alveolaris is One Stage," 
by Dr. M. H. Fletcher, printed in the Dental Summ.ayy. 

"To operate in any of these cases is surgery and not 
dentistry, so that the stomatologist also needs to be skill- 
ful in operative surgery to a degree Avhich gives him 
suitable knowledge and confidence in himself to handle 
a |);iti(']it undergoing the removal of part of the alveolar 
])rocess eitlier above or lielow. Fui'tlier, tlie oyx'i-ator 
should l)e so in touch with this patient and the extent of 
tile opei'aiion as to know wlicllier ilic opci-alion slionid 
be perfonned under local or general anestii(^sia, and 
whether it should all l)e done at once or at intervals of a 
few days or weeks for general and systemic coinpli- 




4 



u 



H 



A 



g 



f 



Fig. 45. Fletcher's Set of Bone Curettes and Alveolar Burs 

FOR Cutting Away Dead and Diseased Bone. Not 

Intended for Removing Deposits. 



282 Pbactical Pyorrhea Alveolaris. 

cations from secondary and acute infection may occur 
at any time. 

''The curettes, or hand instruments are all of the hoe 
and hatchet type, varying only in size of blade and length 
and shape of shank. The attempt is made by these varia- 
tions to reach any extended tract of necrosis. The 
necrosed portions are usually friable — that is, in the 
state of osteoporosis — and can easily be cut away with 
the curettes; but certain phases of the disease and certain 
kinds of infection often result in osteosclerosis ; that is, 
hardened or eburnated bone, on which the curettes make 
little headway. For cutting these hardened bones I have 
made some extra long bone-cutting burs, both for the 
straight and right angle hand-pieces. The contra-angle 
seems to be more suited to the work, however, than the 
right angle. The burs for the contra-angle will reach all 
cases in the lower jaw and most of the upper, but a bur 
two and one-half to three inches long — that is, one long 
enough to reach to and into the antrum — is often neces- 
sary for the upper jaw. 

"The laws of regeneration do not permit of complete 
healing of bone tissue inside of several weeks at the 
shortest, and often require several months, so that 
patience and careful watching are necessary on the part 
of both patient and doctor. One patient now on my list for 
nearly a year, who would not submit to a radical removal 
of cancellous bone in the superior maxillary, has sub- 
mitted to a small amount of removal from time to time, 
and is gradually recovering under two dressing treat- 
ments a week. This case, however, was the result of a 
dental abscess arising at the apex of a superior lateral 
which had discharged into floor of the nose. 

''After curetting and burring have been done, the 
cavities should be washed out with a warm antiseptic solu- 
tion to remove the cuttings. The blood shouhl be allowed 
to clot in the cavity. My plan is to be careful not to dis- 
turb the blood clot as long as it remains aseptic. If there 



Treatment of Pyorrhea Alveolaris. 283 

is a tendency for pus to form, the wound should he 
washed out every one, two, or three days, according to 
conditions, and, if pus continues after ten days, a second, 
third, or even more attempts must be made to remove the 
offending' material. 

"Aseptic blood clot is Nature's 'false work' or 
scaffolding on and into which she builds all new tissues, 
no matter of what kind. The less the healthy clot is 
disturbed, the more prompt is the repair. In the blood 
clot is formed the granulation tissue of repair, which is 
the second stage of the building of new tissues. Any dis- 
turbance to these granules is also a hindrance to repair; 
hence packing is seldom called for. 

''If I have suggested anything new or valuable, T 
believe it is the necessity of either curetting or burring 
about all teeth where the disease is found, and of more 
thorough removal, if the disease is deep seated." 



CHAPTEE XXXI. 
TREATMENT— CONTINUED. 

A TECHNICAL DESCKIPTIOlSr OF THE SURGEEY OP THE EOOT 

SURFACE AND THE INSTRUMENTS MOST USEFUL 

IN ACHIEVING IT. 

BY THOMAS B. HARTZELL, D. M.D., M. D., MINNEAPOLIS. 

'^In undertaking to write an article descriptive of the 
technical procedure, which must be observed in success- 
fully treating pyorrhea, I realize that I am undertaking 
a very difficult task. To portray in words or visualize 
technical procedure, is always difficult, but by the help 
of word pictures and illustrations together, I hope to be 
able to convey a comprehensive idea of the operation. 



''The necessity for root surface surgery is now so 
thoroughly understood that we need not discuss that 
phase of the question at all, though it will be wise to 
discuss the histology of the root surface in order that we 
may have a reasonably clear idea of the necessity for the 
operation, and also that we may know how much of the 
root surface we should remove and where the cutting 
should stop. 

''The root is suspended in its socket, as we all know, 
by fibres of sharpey ; these fibres originate in the alveolar 
process. When the bone of the process is lost from any 
cause whatever, then these fibres hang dead upon the root 
surface and their decaying remains afford culture media 
in which micro-organisms may rapidly grow and accu- 
mulate. The root surface is, therefore, uneven and pitted 
with thousands of small depressions. These depressions 
were occupied by fibre ends, and offer to the eye, when 
ol)served under tho microscopo, a honey-comb like 
surface. 



Treatment op Pyoerhea Alveolaris. 285 

"The operation on the root surface may involve two 
things: first, the removal of any calculus deposited 
upon the root surface; and, second, the removal of the 
pitted root surface itself. Observing the structure of the 
root, from the pulp chamber outwardly, we note first 
that dental tubuli form the great bulk of the root. Just 
external to the tubuli, we may note a layer of typical 
bone which contains thousands upon thousands of lacunae 
connected by branching canaliculi. Approaching more 
nearly to the surface of the cementum, we see that the 
lacunae and canaliculi become fewer and fewer until the 
root surface is almost reached, at which point we note a 
narrow zone of bone which contains neither lacunae nor 
canaliculi. This dense layer is not clearly defined as 
something that could be stripped up and peeled off, but, 
nevertheless, nature seems to have deposited this thin 
layer of hardened bony material as a foundation into 
which the Sharpey's fibres insert to form the suspensory 
ligament which is the sling or stirrup by which the tooth 
rides in its socket. 

•'The object of skinning the root surface is to rid that 
root surface of its bacterial holding power. Therefore, 
the amount of root surface which may be cut away with 
benefit to the tooth is that portion external to this dense 
layer which was created to support the fibre ends. And, 
because of the fact that this dense layer is very thin, one 
should guard carefully against cutting enough of it away 
to open the bone cells which are so plentifully dis- 
tributed in the body of the cementum. Therefore, one 
should work with instruments so designed as to make it 
impossible in any single stroke to penetrate this hard 
layer. 

"The instruments should be so designed as to offer 
the greatest amount of steadiness and accuracy of move- 
ment. To that end, it is desirable that the cutting bit, 
which is used to skin off the porous surface, should be 
flat and thick and sharpened to a right angle. It is also 



286 Practical Pyorrhea ALVEor.ARrs. 



Fiij. 40. The IIartzell Tyi'e of 
Instruments. 



Treatment of Pyorrhea Alveolaris. 287 

desirable that the iustrument should rest on at least two 
IDoints, rather than on the cutting edge alone. If the 
instrument's bit rests upon the cutting edge and that 
portion of the shank immediately contiguous to the cut- 
ting edge, we have the so-called two-point rest instru- 
ment, which certainly offers greater security and accu- 
racy of movement than a razor-edged, one-pointed 
instrument possibly could afford. The following is an 
illustration of the instrument to be applied to root 
surfaces. 

''On account of the unevenness of the root surface 
and on account of its convex and at times concave char-' 
acter, it is necessary to have instruments which can be 
readily adapted to convex surfaces as well as to concave 
flat surfaces, in order to accurately skin every bit of 
dead membrane pitted surface from any given root. This 
necessity at once creates the demand for three t^^pes of 
plane-heads. By the word "plane-head," I mean to 
describe the cutting bit and the portion of the shank 
immediately contiguous to it, which makes the two points 
of contact to the root, which must or should be in contact 
with the root surface as the instrument is moved. The 
plane-head, therefore, is to the tooth's root plane just 
what that portion of a carpenter's plane is, which is 
immediateh" in front of the cutting bit. It limits the 
depth to which the cutting bit must penetrate the tissue, 
and, as stated a moment ago, we need three types of 
plane-heads for ordinary tooth root surface surgery: 
concave plane-heads to fit convex root surfaces; convex 
plane-heads to fit concave root surfaces; and flat plane- 
heads to fit concave root surfaces; and flat plane-heads 
to fit flat root surfaces. This at once necessitates three 
types of plane-heads in any efficient set of instruments 
for root surface work. To that end, the author di\"ides 
the instruments into three groups for these three types 
of surfaces. 

"The next necessity, which the operator feels keenly, 



288 Practical Pyorrhea Alveolaris. 

is the need of different sizes of instruments : long instru- 
ments for deep pockets, medium length instruments for 
medium depth pockets, and short instruments for shallow 
pockets. This again divides the instruments into three 
groups, dependent on length of the shank. 

"The third need which the operator is compelled to 
notice is that in order to work far back in the mouth with 
ease, it is necessary to bend the shank of the instrument 
at an angle which will permit him to reach back in the 
mouth and up or down, according to whether he is work- 
ing on the upper or lower jaw. Therefore, the case of 
instruments is again divided into large groups. One 
groujD of instruments is intended for working far back 
in the mouth and exhibiting such bend as will readily per- 
mit facile movement. The other group, which is more 
nearly straight, the operator can apply in the anterior 
part of the mouth. 

''A fourth need, which must be met in any given set 
of instruments, is to have a sufficient number of pairs of 
instruments to enable the operator to apply his plane- 
head to every aspect of a root, without changing his 
position in relation to the patient, without changing his 
finger rest, and without flexing his wrist. 

''To that end, the various types of instruments are 
divided into families of eight each. Each family of eight 
are so designed as to enable the operator to work upon 
eight different sides of any single root, without chang- 
ing his initial finger rest or the bend of his wrist, so that 
the whole set of instruments at command of the operator, 
whether it is for concave, convex, or flat surfaces, or 
whether it is an instrument with a large bend for use 
far back in the mouth, or an instrument more nearly 
straight for the anterior part of the mouth, will present 
a series of four pairs of planes in whatever size, bend 
of the shank is desired. This really affords, in every 
group of eight, four pairs, of which one and five afford 
instruments to fit the mesial and distal of any given root; 
two and six making a second pair ; number two designed 



Teeatment of Pyorrhea Alveolaris. 289 

to fit the first right molar of any given patient, two and 
six designed to present a pair of blades which will fit the 
mesial buccal and distal lingual surfaces of the molar in 
question. Three and seven of this group of eight present 
a pair, which fits the buccal and lingual surfaces of a 
patient's right lower molar. Four and eight constitute 
a fourth pair designed to fit the distal buccal, and mesial 
lingual surfaces of a right lower molar. 

''It does not necessarily follow that the operator need 
use every instrument of any given group of eight to plane 
a lower molar, but it is exceedingly helpful to have the 
instruments so planned as to make it possible to approach 
at least eight ditfrent aspects of any tooth in the mouth, 
without changing finger rest, if the operator so desires. 

"A fifth essential is that in all of the instruments of 
whatever type, concave, convex, or flat, long, medium, or 
short, for operation far back in the mouth or almost 
straight or slight bend for operation in the anterior part 
of the mouth, or for what iDarticular tooth or surface an 
instrument is intended, the cutting blade of the instru- 
ment should be directly in line with the center of the 
handle. This makes every instrument, no matter what 
bend the ' shank may have, in effect a straight instru- 
ment. ' ' 



CHAP TEE XXXII. 

IMPLANTATIOlSr. — BIFURCATION TEEATMENT.— EEMOVAL OF 

PULPS.- — AMPUTATION OF TOOTH EOOTS. TREATMENT 

OF PYOEEHEAL ABSCESS 

For many years the experimental surgeons in denti- 
stry have endeavored to find some system whereby lost 
teeth could be replaced in the jaw by other human teeth. 
Dr. Younger was one of the first to make a success of 
this operation and it is to be doubted whether his first 
technique has been improved upon. 

Dr. Kells also makes the practice of the implantation 
of one missing tooth, but these are planted in a favor- 
able situation. I have seen in his office a lower molar 
tooth that had been implanted for seven or eight years. 

Dr. Eobert Good, of Chicago, is doing a great deal 
of this work in pyorrhea cases. His method is so unique 
and original that I will describe it in detail as I have 
seen it carried, out in his office. 

Some years ago, a travelling man, a patient of Dr. 
Good's, presented himself to me for treatment of his 
gums. He stated that Dr. Good was beginning to treat 
him. His anterior teeth had all protruded and had 
rotated in their sockets. At that time, if he had asked 
me, I would have told him to have them all extracted 
as the only thing to do, and in fact if the case had been 
one of my own, I would have extracted all the teeth and 
placed a bridge. However, I gave him a treatment and 
asked him on his next trip here to stop in and let me 
see what Dr. Good had done. In about a year the same 
man presented himself again ; this time his teeth in new 
sockets and in perfect alignment and comparatively 
firm. Had I not seen the case before, I could not have 
believed that this could have been done. 

Dr. Good's assistant haunts the places whore teeth 
are extracted, hunting for peculiar kind of teeth. The 



Implantation in Pyoerhea. 291 

tooth lie wishes is that of an old person, especially if 
it has an exotosis on the end of the root. The searcli 
has evidently been successful, for he had large jars of 
these kept in liquid in his laboratory ready for selection 
on a moment's notice. 

Dr. Good seems to think it a very simple matter, if one 
cannot cure a tooth affected with pyorrhea, to extract the 
tooth, clean it off, deepen the socket, and force the tooth 
back, secured by a retainer of twisted linen or silk thread. 
If the tooth is out of line, which they frequently are in 
pyorrhea work, it is rotated with one movement of the 
forceps. 

However, the most original work which I saw was 
where an upper molar tooth was needed for an attach- 
ment for a bridge. A new socket was bored at about the 
position of the second molar and a large cuspid root, 
with the crown cut off, was driven tight into place. 
Previous to the insertion, he had made a platinum cop- 
ing so as not to disturb the root when, he was ready to 
make this bridge. 

He uses no special instruments other than a Younger 
root reamer. The canal is properly filled and the tooth, 
having stood in a strong solution of lysol while the socket 
was being made, without being washed off, was driven 
home tight. After such a tooth has stood for some four 
or five months it is generally ready for bridge work. 

For the encouragement (?) of those who wish to try 
this for bridge work in pyorrhea cases, I will say that I 
have tried it on several teeth, but to this date I have 
never been able to get one to stick in a pyorrhea case. 

Another method of replacing pyorrhea teeth Avhen 
they are needed for extra abutments for bridge work is 
by inserting some device made of metal ; one of these is 
made and sold by Dr. Greenfield, of Wichita, Kans. It 
is a platinum frame work made in a circle which is 
inserted into the jaw to fit the trefined socket which has 
left a central core. This method, while possibly the best 
one now in vogue for attaching teeth to a bridge at the 



292 Practical Pyoerhea Alveolaeis. 

alveolus, is uot so successful iu pyorrliea cases, because 
the alveolus, having been partially absorbed, does not 
give the proper support. 

To those who desire to experiment along this line is 
suggested the following method, which has been tried by 
several of our j)ractitioners : either drill a new socket or 
use the old one and select a common wood screw with 
large threads w^hich will fit the socket tightly. This hav- 
ing been fitted and cut off to proper length, is unscrewed, 
the impression taken, and cast in either tin or silver. A 
hole is drilled in the larger end and the coj^ing fitted. 
The cast screw is then forced into place and after a few 
weeks, when the tissues have about resumed their normal 
state, the crown or bridge is fitted thereon. 

After implantation, by the use of A A Pyorrhea 
Treatment, we are enabled to seal the gums to the teeth, 
prevent infection and keep out all food particles. This 
preparation will hold from 24 to 48 hours, is an astrin- 
gent, and really acts as a splint, drawing the gum close 
to the teeth. 

While there are some men who seem to be making a 
success of implantation work, it cannot be said that it is 
as great a success in pyorrhea cases ; greater absorption 
of the alveolus having taken place together with the 
greater danger of infection, makes the chance for hold- 
ing less than in a healthy mouth. Still this is a great 
field for research work and it is to be hoped that at some 
future time methods will be devised for overcoming these 
difficulties. 

TREATMENT OP EXPOSED BiFURCATIOlSr IN" MULTI-ROOTED TEETH 

When there is an exposure of the bifurcation of multi- 
rooted teeth, especially the lower molar or buccal roots 
of the upper teeth. Smith suggests making a positive 
retention cavity between the roots and filling this with 
hard gutta-percha, forcing it, while soft, against the pro- 
cess and gums and finishing it flush with the tooth. He 



Eemoval, of Pulps iisr Pyorrhea. 293 

says, further, that this simple procedure will arrest all 
recession at this location. 

The copper cements also give excellent results in 
good locations and have the advantage of moulding over 
the gum tissue without pressure and into nooks where 
it is difficult to place gutta-percha. 

REMOVAL OF PULPS IN PYORRHEA WORK. 

Whether or not it is best to remove pulps in operating 
for pyorrhea, is a subject which has not been agreed 
upon. There are operators of well known ability who 
never destroy a pulp if they can avoid it. Other dentists, 
equally capable, destroy pulps in pyorrhea work. These 
latter men claim that in the removal of the pulp, the 
nutriment is diverted to the outer surface of the tooth, 
where it is most needed. It has not yet been explained 
by these operators, the modus operandi of this changing 
of nutriment. They claim that a devitalized tooth is 
never attacked by pyorrhea, but it has been borne out by 
observation that this is not true, nor does the author 
deem it advisable to remove the pulp of the tooth for 
the purpose of curing pyorrhea, for if there is ever a 
time when a tooth needs all the vital force and nerve 
energy which it originally possessed, it is at the time 
when it is lame from pyorrhea; whatever results have 
been attained fromi the removal of pulps, were in those 
advanced cases, where the pulp was infected by the 
extension of the disease or was cut off by tarter deposit 
at the end of the root. Such teeth are generally 
extracted, but the teeth which we leave for operative 
procedure seldom have pockets extending to the end of 
the roots. It is not advisable to remove these pulps. 
However, if extra sensitiveness, due to infection, is a 
constant symptom, it is advisable to remove the pulp; 
remember that it is a i^eculiar coincidence that teeth 
affected witli porrhea seem to have the most crooked 
roots. 



294 Practical, Pyorrhea Alveolaris, 

*■ amputation op roots. 

If, on examination, the probe can be pushed entirely 
aronnd the root of any multi-rooted tooth, and over the 
apex, then it is useless to attempt to save this root as it 
only constitutes a foreign body, and together with tlie 
surrounding pocket, forms a trap for future infection and 
food. In such cases, provided the other root or roots 
have good attachment, amputation of the offending root 
may be effected and the remaining portion of the tooth 
made to do service for years. There has been a great 
deal written on the subject of amputation of roots for 
alveolar abscesses, but few men outside of specialists in 
pyorrhea seem to have realized the great value of this 
simple surgical procedure, 

I have performed this operation successfully in sev- 
eral hundred cases. Many of these teeth so operated on 
over eight years ago, are still proving successful abut- 
ments for bridges. I am therefore led to urge upon the 
general practitioner the adoption of this procedure as a 
routine method in suitable cases. 

Many dentists with whom I have talked, have 
expressed the idea that it is extremely difficult, and that 
they were afraid to undertake it. This is an erroneous 
supposition; the field for operation is uncomplicated by 
any important anatomical structures such as nerves or 
arteries, and is easily accessible, without much cutting 
or the necessity for an anesthetic. In pyorrhea work 
this operation is confined to multi-rooted teeth, that is, 
molars. The one thing to be decided before determining 
to amputate the root of the tooth is that the disease and 
the destruction of the surrounding bone is confined to this 
one particular root. 

The most frequent places where amputation is needed 
are: first, the palatal root of the molars; second, the 
posterior buccal root; third, the anterior buccal root. On 
the lower molar teeth we most frequently amputate the 



Amputatiozst of Eoots iist Pyoeehea. 295 

posterior roots ; tliese are tlie most difficult roots tliat we 
have to remove. 

TECHNIQUE OF EOOT AMPUTATION. 

This operation, to be satisfactory, requires that the 
root he normally separate from the other root, or roots, 
that is, they must not be fused together for their full 
length. The small curved probe or pyorrhea instrument 
can be introduced between the roots to determine this. 
If the root is anastomosed almost to the top with its 
adjoining root, the case is not one for successful opera- 
tion. This caution applies particularly to the buccal root 
of the upper molar, as it is very seldom that a complete 
union of the palatal root or the lower molar root takes 
place. Before beginning the operation, it is advisable 
to remove the pulp of the tooth and' fill the pulp canals 
in the best way possible, for after one of the roots is 
taken out, it is very difficult to find the canals. However, 
the writer has frequently removed roots of teeth without 
paying any attention whatever to the tooth pulps, for 
the shock of going straight through so paralized the 
nerve that there was little pain to the operation. The 
best instrument for this operation is a long shank cross 
cut fissue bur. This is to be used in a right-angle hand 
piece. The bur is introduced in the bifurcation and with 
engine revolving rapidly give the hand piece a saw-like 
motion towards the crown of the tooth; this produces 
the proper slant for easy removal of roots and self 
cleansing space; the angle at which we point the hand 
piece towards the crown of the tooth has all to do with 
the easy removal of the separated root. As a general 
thing, after separation of the root, it drops back into the 
pocket which surrounds it and can be easily withdrawn 
with a pair of pliers. As the tooth upon which we are 
operating may be loose, the operator always braces the 
tooth securely, either with his hand or by placing a small 
amount of warm modelling wax against several of the 



296 Practical Pyorrhea Alveolaris. 

teeth, making a brace so as not to have any undue force 
on the part of the tooth which we wish to preserve. 

It is not advisable to start on one side of the tooth 
and later remove the bur and begin from the other side 
of the root, as this makes a ragged operation. How- 
ever, this may have to be done in some cases. The root 
having been removed, the next step is to polish the sur- 
face from which it was removed, so that there will be no 
sharp or jagged edges to irritate the gums or catch food. 
If the tooth is a large upper first or second molar, it is 
sometimes advisable to remove that part of the crown 
of the tooth that overhangs the place where the root came 
from, as too much leverage would tend to tip the tooth 
in that direction. This is not so necessary in the lower 
jaw, as here the crown of the tooth is braced by the 
adjoining tooth. The socket from which the root was 
extracted needs very little attention except to be thor- 
oughly washed out with warm water and some mild anti- 
septice solution to keep it free from food until it fills 
up. In some of our cases it is hard to tell that an ampu- 
tation has been done, as the gum soon falls into place 
where the root was removed. 

As this operation is performed in such a manner that 
the parts are easy to keep clean, it has not often been 
found that any decay set in from exposure of dentine. 
Sometimes it is very important to make correction of 
malocclusion in these teeth in order to prevent any undue 
force being put upon a tooth which is naturally weaker 
than normal. In fact, it is a good idea to lower the 
occlusion on a tooth from which a root has been taken. 

AMPUTATION OF ROOTS FOR BRIDGE WORK. 

The prettiest result of root amputation is where the 
remaining part of the tooth is to be used as a bridge 
abutment. Every abutment which can be used in bridge 
work adds to its strengtli and should be saved, especially 
in pyorrhea mouths where all the rest of the abutments 



Treatment of Pyoerheal. Alveolar Abscess. 297 

may be in a shaky condition. We have all observed in a 
boat landing where piles were being driven, that one or 
two of them seemed loose, but when lashed together an 
ocean steamship could hardly shake them. In the same 
way it is desirable to give every possible support for 
bridge work, even though some of them, alone, may seem 
very weak. 

In using these teeth for bridge abutments it is desir- 
able that the whole of the crown be removed and small 
platinum coping be placed just under the gun margin, I 
have always found this to be easier and of better success. 

TREATMENT OF PYOERHEAL ALVEOLAR ABSCESS. 

If the operator is familiar with the formation of a 
pyorrheal abscess (described elsewhere) the treatment is 
a simple matter. 

The patients come in very much alarmed at the sudden 
condition of one of their teeth. This alarm can be quickly 
turned to quiet and confidence if the proper treatment 
is given. 

Do not attempt to lance the swollen area but with a 
Younger instrument. Number 1 or 2, carefully insert at 
cervical edge between gum and tooth toward the swelling. 
This should not hurt the patient; almost the weight of 
the instrument will be sufficient to enter the pocket and 
allow the pus which is under pressure to escape. Now, 
at this stage, do not attempt to do any root scraping or 
planing, but with a small pointed syringe insert at the 
point where the instrument was passed and using gentle 
pressure wash out the cavity. Repeat this several times. 
Do not use any strong irritating liquids, but use either 
hot normal salt solution or water with phenol, five drops 
to six ounces. - This operation should be repeated the 
following day. 

At some subsequent date when the tissues are less 
painful, the tooth should be treated for the pyorrheal 
condition. 



CHAPTEE XXXIII. 

VACCINATIOlSr TREATMENT. BEIDGE WORK AND 

SPLINTS FOE PYORRHEA. THE X-RAY AND PYORRHEA, MACKEE. 

AUTOGENOUS VACCINATION FOR THE TREATMENT OF 
PYORRHEA. 

Autogenous vaccination for the treatment of pyorrhea. 
The author has been so successful in treating pyorrhea 
according to methods described elsewhere, that the sub- 
ject of vaccines has not had much attention in his prac- 
tice. In discussing this subject at the last National 
Dental Association in Washington, Dr. Rhein made the 
statement that when vaccination became necessary, the 
ordinary dentist was not a necessity because the patient 
was a fit subject for the hospital. 

Several years as oral surgeon on the staff of the City 
Hospital of Atlanta, gave me an opportunity to see 
extreme cases of oral sepsis. At that time only stock 
vaccines were to be had, and we used only the vaccine of 
the predominating infection. I never could see any 
special improvement and several of the patients died. 

In order that the reader of this book may become 
familiar with the elementary facts on which this treat- 
ment is based, I give the following article by Dr. George 
B. Harris, which was published in the Dental Summary. 

"The use of vaccines in the treatment of pyorrhea is not to take 
the place of the local treatment of instruanentation in any way. How- 
ever, it becomes a very valuable agent when used to overcome the 
infection present and in maintaining a condition that makes the growth 
of bacteria impossible over a period of sufficient length to permit re- 
generation. It not only does this, but it also prevents the recurrences of 
pyorrhea after a cure has been effected by fortyfying the individual 
against the bacteria. Protection against recurrence is 'as important as 
a cure itself. Stock vaccines may be used to do this, but it has been 
my experience that the Autogenous Vaccines give from 50 to 75 per 
coit. better results. 

"The first step in making a vaccine of this kind is the obtaining 



Autogenous Vaocination. 299 

of the pus. This should be obtained in as pure a culture as possible. 
Carefully remove all tartar deposits from the teeth j paint the tooth 
and gum with iodin and dry. On the following day remove all food 
particles, dry with alcohol again, paint the gum with iodin, and diy. 
Then carefully force out a small amount of pus from under the gum, 
collect on a sterile platinum wire and inoculate an agar tube. Allow 
this to genninate from twenty-four to forty-eight hours. If a pure 
culture has been obtained, which is generally the case if the preceding 
operations have been carefully done the vaccine may be made directly 
from the first culture and several days saved; otherwise new cultures 
must be made from the predominating culture in the initial tube. 

"Remove as many of the cultures as possible, care being taken not to 
take up any agar with the cultures. These are now transfei-red to a 
tube containing distilled sterile water. This is shaken vigorously to 
break up all clusters. A centrifugal machine should be used for this 
purpose, but if one is not to be had it can satisfactorily be done by 
hand. One-half a cubic centimeter is now drawn up and transferii^ed 
to another test tube. This is used in the determination of the number 
of bacteria we may have in the concentrated solution and is not made 
into vaccine. To this is added two cu. em. of water to make the counting 
easier and more accurate. About half a cu. em. of this diluted solution 
is now drawn up in an opsonizing pipette and an equal amount of 
normal blood taken directly after. This is blown out on a slide and 
mixed. A drop is then placed on a cover glass, dried, mounted and 
stained. Place the slide on the counting chamber and count the cor- 
puscles and germs in the successive fields until at least 250 corpuscles 
are counted. Since there are 5,000,000 corpuscles in a cu. mm. of 
blood, by a simple proportional equation we can determine the number 
of bacteria in the dilute solution. By multiplying the number of 
germs in the dilute solution by the number of times it was diluted, 
we determine the number of germs in the concentrated solution per cu. 
mm.. Since there are 1,000 cu. mm. in a cu. em., by multiplying the 
number per cu. mm. by 1,000 we determine the number per cu. ce. For 
example: Suppose we counted 250 corpuscles and 50 bacteria. Since 
we know that there are 5,000,000 corpuscles on one cubic millimeter of 
blood, the following proportion is established : 250 :5.000,000 : :50 :X. 

"Solving this proportion, we find there are 1.000,000 bacteria per 
cu. mm. Since there are 1,000 cu. mm. in a cu. ec. we find 1,000,- 
000,000 bacteria to each cu. ce. in the dilute solution. Since we diluted 
the solution four times, there are 4,000,000,000 bacteria to each cu. ce. 
in the concentrated solution. The vaccine is now ready to be stand- 
ardized. It is first diluted to the strengih we wish to have it; heated 
at 60 degTees for an hour, then 4 per cent, tricresol added to prevent 
contamination, and sealed. 



300 



Peactical Pyokehea Alveolaeis. 



Any loose tissue may be selected as the site of injection. The most 
importaut things to look out for are: 
''1. Be sure the solution is sterile. 

"2. Absolute cleanliness of the skin at the site of injection. 
"3. Use gTeat care in avoiding veins. 
"4. Be sure the count is accurate." 

BEIDGE WOEK IN PYOEEHEA. 

In treating a case of pyorrhea, bridge work is often 
necessary. The character of this work has a great deal 
to do with the permanency of onr resnlts ; many special- 
ists prefer to do this mechanical work themselves accord- 
ing to their own ideas, and in fact, one or two specialists 
will not accept a case referred to them by other dentists 
unless this provision is made. The reason for this is that 
considerable deviation from the regular established sys- 
tem of bridge work is often indicated, in that we have 
to use more teeth for support than we would in a normal 
mouth. 




Fii;. \i. STvrj''. of Ukidck Work Most UsKinrii tn l^'Ol;l;ll^;A Mouths 

(TirTKRr'ir). 



Tn the construction of this work all sides of the abut- 
ment teeth should be accessible for instrumentation, and 
the central idea for bridge work of this kind is that it 



Splixts in Pyoeehea Alveolaeis. 301 

must l)e so constructed as to be easily cleaned by the 
patient. Tliis fact is sometimes lost sight of by the 
mechanical man whose sole idea is to restore the lost 
teeth and to fill the space completely. 




Fig. 48. Lixgual Surface, Upper Jaw, Bridge Work in 
ProRRHEA Cases. 

After finishing onr treatment, if we find several teeth 
still loose and several to be replaced, we can not only 
replace the lost teeth, but can bind the loose ones 
together furnishing the best kind of splint. Thus the 
pressure is distributed over a larger area so that it is 
not too great on any one tooth. For any extensions on 
the bridge, it is well to make saddles to extend on either 
side of the alveolar ridge so as to give the extension sup- 
port from lateral strains. All soldering of abutments 
should be as near the occlusal surfaces as possible, so 
that we may have better access to the root surfaces in 
case a pocket develops there at any time. Smaller 
amounts of solder can be used if platinum wire is 
soldered or waxed in and cast into the abutments at the 
places of joining. 

SPLINTS. 

Many varied and ingenious devices for the retention 
of loose teeth in pyorrhea have been described in dental 



302 Practical. Pyorrhea Alveolaris. 

journals and demonstrated in clinics; the author dis- 
cusses, in the following pages, the use and making of 
splints. 

The very fact that teeth have to be splinted in order 
that they may be saved, makes them a source of frequent 
infection, and they will need frequent attention from the 
dentist to keep them in proper shape. 

Splints are of two kinds, temporary and permanent. 
The temporary splint is of greatest advantage. It is 
sometimes well to use some form of temporary splint at 
the time of operation so as not to give the teeth too much 
strain during the operation. If this is not done, it is 
well to do so after the operation^ so as to give the teeth 
a rest and chance to regain some strength. This applies 
particularly to the lower anterior teeth and the superior 
laterals. 

Perhaps waxed floss silk, laced in between the teeth 
in figure 8 fashion, forms the best temporary splint; 
this can be removed every day or two. To prevent the 
splint from slipping down into the gums a little cement 
can be placed upon the surface of the teeth. Orthodontia 
wire is also excellent for this purpose. Di*. J. W. 
Jungman suggests the following : ' 'Eoll out the ordinary 
Angle orthodontia wire to a ribbon; anneal and gold 
plate. Start from left to right by forcing the wire down 
between the bicuspid and cuspid; then lace it, carrying 
the strands over and under so as to lock them. At the 
right cuspid, wind one strand around the other, and force 
it between the cuspid and bicuspid so as not to irritate 
the lip. Where there are one or two loose teeth, I usually 
carry to the adjoining teeth only." 

dr. w. f. spies' temporary splint. 

"There are many ways in which a temporary splint 
can be made, either by the use of silk or wire. Illustra- 
tion shows a form of temporary wire splint which need 
not be changed, is clean, and if properly applied does 



Splints in Pyoerhea Alveolaeis. 303 

not draw the teetli together as does the silk. It is made 
by using 26 gauge gold ligature wire for the slip-noose 
and 30 gauge for the wires between the teeth. Make a 
slip-noose over the teeth to be enelosd, by bringing one 
end of the wire over the other, but not twisting them 
together. Cut short pieces of wire to be used between 
each two teeth, twist the ends together, and draw tight. 
These wires should be cut to such length that the ends may 
be turned back into the interproximal space without 
touching the gum tissues. The ends of the wire of the 
first slip-noose should now be twisted together." 




Fig. 49. Temporary Wire Splint (Spies). 

Dr. Robert Good's method of ligating teeth is to use 
A, B or C sewing silk, having it well waxed. Select tooth 
for anchorage, then pass ligature twice around this tooth 
(making double loop) and fasten by making double knot 
and single knot on top double one. Now make single 
loop around next tooth and make knots the same as before 
and continue in this manner, until you have included the 
number of teeth you wish to ligate or make fast. When 
the last tooth to be included is reached, make double loop 
again and return making the loops the same as before, 
this will give two rows of ligatures, making the teeth 
quite rigid. Three rows or more may be used, making 
a splint that will remain for six or eight weeks. Care 
should be taken to place the ligatures on the teeth in a 
position where they will slip neither up or down, but 
remain where placed. 



304 Practical, Pyorrhea Alveolaris. 

lu iisiug these temporary splints, it is well to be cer- 
tain that no undue strain is placed on the teeth, pulling 
them out of position. Where space exists, nmnj knots 
may be tied to bridge this, or the wire twisted between 
the teeth, so as not to draw them into the space. 

The writer has seen cases where the wire was placed 
for temporary splints to be removed at a stated time, 
but for some cause the patient got away without its being 
removed, and it remained several years without discom- 
fort. "Wire has the advantage of being easily put on 
and easily replaced ; it shows no metal and is easy to keep 
clean. If it is desired to be permanent, little nicks can 
be cut with a fissure bur run between the teeth; this 
will hold the wire secure and prevent it from slipping 
into the gums. Sometimes a little cement to hold it in 
place will last for years. The advent of cast work has 
opened a new field for the ingenuity of the operator in 
the line of dental splints ; small inlays can be made which 
are easily inserted and this will probably be the means 
adopted for splints in the future. The old method of 
swaging these splints and soldering them up did not pro- 
duce the results which we hoped it would. 

In devising the splint, the main requisite is to hold the 
tooth rigidly in its proper position. It must be self- 
cleansing or easily cleaned by the patient. Again, it 
must not extend to the gum margin to fill up the inter- 
stitial space, but must be left so that instrumentation of 
the root surface can be done with ease. 

However, after all is said and done, it seems to me 
as though it is not of the most benefit to retain the teeth 
which have to be placed in splints, and it does seem to 
be the best policy in the beginning to extract those teeth 
which the operator will soon learn by experience will 
never be kept in a healthy condition, and which may 
require extraction later on. 




Badiograpiis Illustrating "The X-Eay and Pyori;iiea. ' '— MacKee. 



X-Eay iisr Pyorrhea, 305 

THE X-RAY AND PYORRHEA. 
BY GEORGE M. MACKEE, M. D., NEW YORK. 

'^ Wliile tlie value of the X-ray in pyorrhea alveolaris is 
exceedingly limited, yet there are factors of interest and 
of importance that should be enumerated and to some 
extent elaborated. 

' ' In the first place it is extremely doubtful if the X-ray 
possesses any therapeutic value in Rigg's disease, either 
in the early or late stages. It might be explained that 
there is evidence in supi^ort of the contention that" when 
the X-ray is applied to certain superficial bacterial affec- 
tions a local autogenous vaccine is produced. A¥e have 
here a possible ex23lanation of the rapid involution of 
some types of acne and sycosis when exposed to the 
X-ray. It should be stated, in this connection, that the 
X-ray has no direct effect upon bacteria. Pyorrhea, how- 
ever, affects tissues that are more deeply seated than are 
the diseases just mentioned and these tissues are so lo- 
cated that the ray loses much of its therapeutic value 
before reaching them. Theoretically, perhaps, certain 
types and stages of pyorrhea should be benefited by 
radio-therapeutic measures, but from a practical stand- 
point, there are no authentic or verified reports of 
pyorrhea being controlled by radio-thera]3eutic measures. 
And it should be remarked in passing, that small doses 
of the X-ray applied over a long period of time may cause 
atrophy of the glandular and interstitial tissues, sclerosis 
of the deeper hmipliatic and blood vessels, dilatation of 
the superficial capillaries and, finally, precancerous and 
even malignant degeneration. And, furthermore, these 
changes may not become manifest for months or even 
years after cessation of treatment. 

''Whatever value the X-ray possesses in relation to 
pyorrhea is in a diagnostic capacity. A radiographic ex- 
amination will determine if the alveolus has or has not 



306 Pkactical Pyokkhea Alveolaris. 

become involved in tlie process — providing, of course, 
that the bone has become sufficiently diseased to be radio- 
graphically depicted. Naturally the extent of the bony 
involvement may be detected. The presence of suspected 
or unsuspected complications may be also elicited — as, 
for instance, supernumerary, unerupted and impacted 
teeth, apical abscesses, disease of the maxillary sinuses, 
exostosis, cystic degeneration, etc. 

'^Typical pyorrhea, when well advanced, presents a 
rather characteristic radiographic appearance (Fig. A, 
published in Items of Interest, June, 1913, Dr. A. H. 
Merritt's patient). Here there is a light shadow (dark 
shadow on the original radiograph) extending from the 
margin of the alveolus around the roots and apices of 
the teeth, and indicating that the greatest destruction of 
bone has been around the necks of the teeth. Although 
this appearance is typical of pyorrhea, yet other condi- 
tions may possibly produce a similar picture — for in- 
stance, mercurial stomatitis, rachitis, etc. 

' ' Further, the light shadow already mentioned, simply 
indicates lessened resistance to the X-ray. That is to 
say, that the ray has penetrated this particular portion 
of the alveolus with greater facility than in neighboring 
regions. A shadow of this kind, then, indicates a loss 
of mineral substance and may signify atrophy, regenera- 
tion or actual necrosis of bone. In some instances it is 
possible for the radiologist, from a study of the density 
of the shadows, the presence or absence of bone detail, 
etc., to determine if he is dealing with any one or all of 
these factors — in many cases, however, this is quite 
impossible. 

''In differentiation, if necrosis or disease begins at the 
apex of a tooth and is due to infection from the tooth, 
the area of disturbance is likely to be circumscribed 
(Fig. 2, Dr. M. L. Collin's patient, published in Items of 
Interest, June, 1913). On the other hand there are in- 
stances where both conditions are seemingly present 




Eadiographs Illustkatixg "The X-Eay and Pyorrhea. "—:\rAcKEE. 



X-Ray in Pyokrhea. 307 

(Fig. 3, Dr. H. S. Dunning 's patient). Here there is a 
marked absorption of bone around the apex of the cuspid. 
The location and appearance of the shadow would lead 
one to suspect necrosis as a result of an apical abscess. 
There is, also a marked absorption of bone around the 
neck of the tooth, which resembles pyorrhea to a marked 
degree. It will be noticed that the filling extends not 
quite to the apex ; above this point the pulp canal appears 
to be obliterated. The apex itself is slightly eroded. 

"In Fig. 4, is shown an area of absorption apparently 
in relation to, and possibly originating from, infection 
through the posterior root of the molar. This shadow 
connects with the thinned bone left by a previous extrac- 
tion. The general appearance is somewhat that of 
pyorrhea. (Patient referred by Dr. H. S. Dunning.) 

"Fig. 5 depicts loss of bone in the molar region over 
a dummy tooth. This, too, has the appearance of 
pyorrhea, but is possibly due to pressure or local irrita- 
tion. (Patient referred by Dr. W. A. Hillis.) 

"Fig. 6 shows absorption around the apex, root and 
neck of the tooth. The radiographic appearance is that 
of pyorrhea, but might it not be the result of an apical 
abscess with a sinus running along the root of the tooth? 
(patient referred by Dr. T. P. Hyatt). 

"Fig. 7 (Dr. T. P. Hyatt's patient, published in Items 
of Interest, June, 1913), shows a large cavity in the 
mandible, apparently involving several teeth and due to 
an infected cyst. 

"The remaining illustrations are presented in order 
to demonstrate complications that are not infrequently 
found associated with pyorrhea. They were all published 
in the Items of Interest for June, 1913 : Fig. 8 — exosto- 
sis; Dr. N. B. Potter's case. Fig. 9 — old bicuspid root 
in situ. Fig. 10 — possible pulp stones in molars. 

"A study of these few radiographs may convince one 
of the value of radiography in pyorrhea. It should 



308 Practical Pyoeehea Alveolaeis. 

demonstrate, also, the fact that the radiologist alone, at 
least in many cases, is nnable to make a diagnosis. In- 
deed, it is not his dnt}^ to make the diagnosis. He should 
first make a careful and complete radiographic examina- 
tion and then interpret the radiographs from a radio- 
graphic standpoint. He should separate radiographi- 
cally anatomical from radiographically pathological con- 
ditions and he should call attention to photographic, 
radiographic and other forms of technical arti-facts. In 
other words it is within his province to give a detailed 
radiographic and other forms of technical artifacts. In 
perience, skill and a thorough radiographic examination 
of the patient, together with ^ careful study of the re- 
sulting radiographs. This, together with the clinical 
findings, will, as a rule, enable the dental surgeon to con- 
struct or deduce a diagnosis." 



CHxlPTEE XXXIV. 

STEEILIZATIOX OF IXSTEUMEXTS AXD PEEPAEATIOX OF THE 
MOrTH FOR SUEGICAL WOEK. 

If there is one thing about which the medical man 
has cause to laugh at the dentist, it is regarding the 
dentist's neglect of sterilizing instruments and clean- 
ing the field of operation. The colleges are largely to 
blame because they do not lay sufficient stress on these 
subjects and do not require the dental students to prac- 
tice the proper methods of sterilization in their college 
course. 

The farcical nature of our processes probably does 
not depend so much on a lack of interest or desire to do 
the proper thing, as the lack of knowledge along these 
lines. In ordinary dental work, such as bridge work, 
crowns, and plates, it may not be of so much importance ; 
but when it comes to such work as prophylaxis and 
pyorrhea, it is fully as important as in any other surgical 
work. 

Not long ago it was noted that a professor of oral 
surgery in one of our colleges, in consultation, asked his 
assistant for a nerve broach, which was handed to liim 
from the regular cabinet stock. He dipped it into 
alcohol for one second and then proceeded to use it, evi- 
dently under the impression that he was using a per- 
fectly sterilized instrument. When a teacher makes such 
errors as this, is it to be wondered at. that young dentists 
make mistakes? 

The simple dipping of instruments into alcohol is not 
effective; the sterilizers that are generally furnished the 
dentists are also inefficient. They put up a good appear- 
ance, but further than this they are not worth much. 
Methods of sterilization are of two kinds, antiseptic and 
heat. Alcohol in a jar shaped like a fruit jar with a 



310 Peactical Oeal. Hygiene. 

screw top furnishes a convenient and effective recep- 
tacle. The instruments, both before and after the opera- 
tion, must be thoroughly cleaned in running water with 
a clean brush, and then placed in the jar just mentioned 
and allowed to remain there for at least five minutes, 
when they can be taken out, and dried, or the alcohol 
burned off by bringing them in contact with a small 
flame. 

Lysol and bichloride solutions are not to be recom- 
mended for this particular line of work, because if used 
strong enough to be effective, the mucous membrane of 
the mouth would be injured. Undoubtedly, the best form 
of sterilization yet found is heat. By heat, I do not mean 
the simple dipping of the instruments into hot water, 
but the whole instrument must be boiled for at least five 
minutes. In the summer time, to have a boiling recep- 
tacle in our offices, is not the most pleasant companion. 
However, it will be found to be the best sterilizer i it also 
gives a good impression and is one of the best advertise- 
ments a dentist can have outside of good work. Undoubt- 
edly, dental manufacturers realize this because all steril- 
izers have the word ''sterilizer" written in large letters 
across the front of the apparatus. 

Not only the dentist's instruments and material 
should be sterilized, but the dentist's hands should 
be rendered as nearly aseptic as possible. After they 
have been thoroughly washed with a good grade of 
soap and a nail brush, a few drops of alcohol should be 
rubbed into them; this not only destroys the bacteria 
which may have been received from the previous patient, 
but makes the approach to the next patient more agree- 
able. The best way to manage this is by means of a shelf 
suspended above the wash bowl, on which is placed a 
fountain bottle as ])er illustration (No. 51). This is 
filled with grain alcohol, to wliicli may be added some 
good toilet water. 



Cleansing the Field op Operation. 



311 



CLEANSING THE FIELD OF OPERATION. 

Peroxide of Hydrogen is a good agent to be used in 
mopping out the mouth. It can be applied by use of a 
cotton swab held by Skinner's ''Kuoris." If it is not 
desirable to use peroxide, which is unpleasant to say the 
least of it, we can substitute a solution of aromatic spirits 
of ammonia, one part in five parts of water. This used 
as a spray or on a mop is very efficient for cutting loose 




Fig. 51. 



the thick mucus covering the inside of the mouth, and 
at the same time, it is very cooling and pleasant for the 
patient. Next the gum surfaces and the infected area 
may be coated with either Buckley's Pyorrhea Astrin- 
gent, but preferably with Skinner's Disclosing Solution, 
previously described. The ordinaiy tincture of iodine is 
not so pleasant nor does it remain on so long as the 
Skinner's Disclosing Solution. If the mouth has been 
thoroughly mopped out, the antiseptic solution applied 
over all the surfaces, and the debris removed from open 
cavities which are filled, temporarily, with sandarac 
varnish and cotton, or with gutta-percha, we have done 
about all that is possible towards rendering the field of 
operation sterile. 



CHAPTEE XXXV. 

BUSINESS SIDE OF PYOERHEA ALVEOLAEIS. 

Dental offices have been flooded with all kinds of liter- 
ature calling attention to certain medicines and prepara- 
tions which would "positively cure pyorrhea." Many 
of these preparations were accompanied by extracts 
from papers by some of the most prominent men in our 
profession, who claimed that pyorrhea was of constitu- 
tional origin, and that such and such a remedy was the 
only thing to use. Others gave their endorsement to the 
various local remedies which needed but to be applied 
several times for a complete cure. These preparations, 
having come so highly recommended by the profession, 
were tried out by the dentists, but the cases of pyorrhea 
on which they were used were not cured. The failure of 
all these remedies has made the general practitioner very 
skeptical as to the possibilities of curing pyorrhea, and 
it is undoubtedly one reason why so few practitioners 
have undertaken to treat this disease. The business of 
treating pyorrhea was hirgely the sale of proprietary 
drug preparations. 

Anotlier reason for lack of interest in pyorrhea treat- 
ment was the fact that the dentist did not try, or was 
not able to secure from the patient the ])ro])er remunera- 
tion for the work. I have been unable to understand just 
why this is so, unless it is the failure on the part of the 
patient to realize the gravity of a beginning pyorrhea. 
The patient thinks that only his teeth need cleaning and 
that it is worth probably $1.00 to do tliis. 

Within the last few years, a number of good men have 
specialized on (Mther prophylaxis or pyorrhea work and 
the good work that has be(m done has forced on the pro- 
fession the recognition of the fact that pyorrhea work 
re({uires tlie greatest degree of skill and is probably the 
greatest service that we can render our patients. This 



Business Side of Pyoerhea Alveolaeis. 313 

work should command the largest fees that a dentist is 
able to command. It is a fact that patients of means and 
refinement are most appreciative and willing to pay large 
fees to the men who can save their teeth from pyorrhea. 

One way is to charge for time, as in other dental 
work; this plan has serious drawbacks, and it seems to 
me that it is not the proper idea for surgical work. From 
the letter of a prominent California dentist, who does 
considerable work along this line, I give the following-: 

"I think that 'so much per hour' proposition in a 
professional charge, is not near so satisfactory as a 
lump sum; it has taken several years for me to fully 
appreciate that fact. I have frequently stood for the 
hour plan when patients requested a lump sum, and I 
have gotten the worst of it, in as much as: I could have 
obtained a larger fee had I mentioned a stated sum, the 
same as a surgeon would do. In suggesting a fee now, 
I run through the mouth carefully; size up the worst or 
bad teeth ; calculating in my mind the number at $15.00 
per hour, and then the others in same proportion ; and in 
that way get at a proposition of lump sum, always adding 
$25.00, $50.00 or $100.00, as the case may be, in case I 
anticipate the necessity of a compromise." 

My objection to the hour plan in pyorrhea work is 
that it seems to place our services on the wrong basis — 
emphasizing the matter of time rather than the results 
obtained. Also, in case we are interrupted by being 
called to the phone or to give a few minutes time to some- 
one else, our patient is probably wondering whether or 
not they are being charged for this time. 

A method used by a prominent dentist in New Orleans 
is to make a charge of $10.00 for each tooth, irrespective 
of time required for a complete cure 

The system under which the author works is to give 
the patient an estimate of the entire cost of the operation 
and treatment before beginning the work. This plan 
having proved satisfactory and as I have been unable to 
secure minute data from others, I will give it in detail. 



314 Peactical Pyoerhea Alveolaris. 

The examination having been concluded, I anticipate 
the question, "Now, Doctor, how much is this going to 
cost me?" I at once fill out an estimate sheet; this sheet 
gives a diagram of the work to be done and the cost of 
same. There is also a blank space for terms, which is 
always filled in. At the Bottom of this estimate is 
printed in red, the following notice: 



PRESERVE THIS ESTIMATE 

The above is only an approximate estimate of services 
the exact value of which can only be determined after the 
operations are completed. 

The CHARGES therefore will not be based upon this esti- 
mate, but entirely upon what is done. Any change in work 
named above or additional operations will be charged at 
our regular fee. 

We do not guarantee any operations. 



Fig. 52. 

A cheap and efficient means of getting up this esti- 
mate is to use the one dollar dental outfit published by 
the John C. Moore corporation, of Rochester, N. Y., and 
have a local printer insert at the bottom of page the 
above notice. A heavy carbon sheet is used between two 
sheets. The copy is torn out and given to the patient; 
the original is kept in a loose leaf binder. 

If I know the patient to be able to pay a good fee, 
to whom service is the main consideration, all that is 
necessary is to write out an estimate sheet and place it 
in an envelope with the engagement card; this envelope 
is handed to the patient on his departure. 

It has been found by all men who do operative work 
in either dentistry or general surgery that a deposit in 
advance is a most satisfactory basis upon which to work. 
I have adopted it as an absolute rule which is explained 
to the patients, and, since J allow no exceptions to this 



Business Side of Pyorrhea Alveolaris. 315 

rule, no one raises any objection. If questioned at all, 
I tell them that it is for their own protection as well as 
mine; that I know they are as good as gold, but that I 
want their teeth saved, and if I start into it that I am 
going to do the very best I can towards this end and that 
I know if they have from $50.00 to $100.00 paid in 
advance they are going to keep coming until the work is 
done. If they did not do this, the first day after their 
mouths get comfortable, there would be danger of their 
not coming back for regular treatment. If they have 
made the deposit, as I have said, they will keep all 
appointments as long as you wish. 

Sometimes a patient, whom you know to be all right, 
wishes services, but at the time finds it inconvenient to 
make a cash payment or to pay within a reasonable 
length of time. Credits along this line used to be unsatis- 
factory; at the time of treatment, the results seemed all 
that I could wish, but such patients would neglect their 
mouths until Oral Sepsis had again set in, and would 
declare that they had received no benefit and refuse to 
pay. This difficulty has now been solved satisfactorily 
in my practice by a special promissory note. If they 
are unable to make a cash payment, then I tell them that 
if they will give me notes and pay eight per cent, for 
deferred payments, I am perfectly willing to settle the 
matter up in this way. 

This note is good for any kind of dental operations, 
especially pyorrhea. If it is not met in due time and the 
patient for any reason refuses to pay same, instead of 
being humiliated by having to argue the case in court, 
this note cuts off debate in justice court and a judgment 
is immediately given to the dentist. It is a bad propo- 
sition to work for people who cannot pay, but this note 
is the best solution of the i^roblem that I have been able 
to obtain. 

If I were going to have any kind of operation per- 
formed, I certainly would want to know just exactly what 
it is going to cost me, and I believe in treating the 



316 Peactical Pyorrhea Alveolaris. 

patients with that fairness which I would ask under the 
same circumstances. 

There was a difficulty which used to present itself to 
me before I started to keeping copies of the estimates. 
The patients, after an examination, w^ere told about what 
the work would cost them. They did not have the work 
done at that time, but would come in again, probably, 
at the end of three or four months. After another 



$ Atlanta, Ga., 19 ... . 

day of next. 

promise to i^ay Dr 

Dollars, with interest 

from date, at eigbt per cent, per annum, and reasonal)le 
charges, not less than ten per cent, for Attorney's fees, if 
any should be incun'ed in the eolleetion thereof, and hereby 
waiving all homestead and exemption rights, for value 
received. 

^^This note is given for professional services already 
rendered, and I acknowledge that it is unconditional and 
binding and that no defence whatever can be set up against 
its collection. 

Witness our hands and seals 

[L-s.l 

[L. S.] 

[L.S.] 



No 

Residence . 



Fig. 53. A Good Note for a Professional Man. 

examination I would again tell them what the charges 
would be. The patient, having forgotten, would say 
that I had promised to do it $20.00 or $30.00 cheaper at 
the time I made the first examination. Now, with my 
present system, I can refer to my files and can convince 
him immediately of his mistake. Previously, when other 
work was done in addition to the work estimated on, the 



Business Side of Pyorrhea Alveolaris. 317 

patient, when settling the bill, could not be made to 
understand that more work had been done, and they 
would not think it right that any additions should be 
made to the estimate as first named. My system settles 
this question and there is never any objection, as the esti- 
mate suggests and puts the patients on notice that other 
work may be discovered and will be charged for. 

For instance, in making a bridge abutment, if the 
tooth that I hoped to use as an abutment could not be 
saved, then I would have to drop back and make the 
bridge more extensive ; they often thought that the charge 
should be the same. 

The greatest diffiuclty that I have had is with the 
question, "Now, doctor, do you guarantee the opera- 
tion?" I became so tired of hearing this that I inserted 
at the bottom of the estimate sheet, "We do not Guaran- 
tee any Operations." This immediately settles all ques- 
tions, and if the patient is not willing to trust himself 
to my reputation and skill, he is at liberty to go some- 
where where a "cure is guaranteed." 

This is well answered by Dr. R. Gr. Hutchinson, Jr., 
who says : 

"A cure does not guarantee immunity and a true re- 
currence in no way invalidates a cure." 

I find that the terms "scaling the teeth," "removing 
tarter," and "treatment of the gums," do not impress 
the patients with the seriousness of pyorrhea treatment. 
There is a fad among people for "operations," and if 
the dentist calls it by this name, which is really the proper 
term, our patients like it much better and are willing to 
pay satisfactory fees for it. I find it better to do as 
much of the work on the first day of the engagement as 
possible — enough to at least verify myself in calling it 
an "operation." In addition to this business reason, I 
get better results as described in the chapter on 
"Treatment." 

I do not care to do more than two or three Pyorrhea 



318 Peactical Pyoeehea Alveolaeis. 

operations in one day, and if I finish one half the work 
for each patient, giving each two to three hours, I feel 
that I have done enough. 

In pyorrhea work the use of a proper system in our 
business dealings with patients should not detract from 
our professional dignity and the returns will be such 
that we can have more vacations, more recreation, and 
more time with our families. 



CHAPTEE XXXVI. 

THE MEDICAL AND SUEGICAL ASPECT OF 
DEAL HYGIENE AND.PYOEEHEA. 

VIEWS OF PROMINENT MEDICAL MEN. SUGGESTIONS TO 

PHYSICIANS AS TO' CARE OF THE MOUTH IN SICKNESS. 

ORAL, PREPARATION FOR SURGICAL WORK. 

Dr. C. H. Mayo recently read a paper (Jan. 31, 1913) 
in Chicago, in which he made the following statement: 
''It is evident that the next great step in medical pro- 
gress in line of preventive medicine should be made by 
the dentists." 

The facts about oral hygiene, oral sepsis and pyorrhea 
alveolaris, are of vast importance to the physician, as 
well as to the dentist. In many cases they are of vital 
importance and yet comparatively little has been written 
on the subject. 

It should be the aim of all well informed dentists to 
instruct all their patients who are nurses and physicians, 
as to the importance of this neglected field of their work. 
Such instruction, if put into practice, would undoubtedly 
help any physician not only to give comfort to the sick, 
but a quicker restoration to health. 

Every dentist is familiar with the great amount of 
decay and oral sepsis frequently seen in convalescent 
patients who, previous to their illness, possessed a nor- 
mal mouth. On inquiry, we sometimes learn that during 
sickness these mouths received the usual care as given in 
hospitals. 

In other cases when a person becomes sick he often 
neglects the little attention formerly given the mouth. 
Vigorous chewing is dispensed with, exercise of the 
muscles of mastication ceases, aeration of the mouth 
is lessened, with the result that all self-cleansing pro- 
cesses are diminished and the saliva becomes thick and 



320 Peacticajl Pyokehea Alveolaeis. 

ropy. The moutlis of the sick are often a hot bed of 
filfth and disease, as indicated by the fonl breath, and 
are a most prolific breeding place for the bacteria of 
pneumonia, diphtheria, tuberculosis and other diseases. 

Physicians should be toM by the dentists that con- 
ditions such as the above can be changed for the better. 
The time will come when the physician will realize the 
necessity of giving directions for the care of the mouth 
as a routine procedure in every case of sickness. At 
the present time the nurse is supposed to attend to the 
patient's mouth, but most of them are woefully ignorant 
on the subject and the patient suffers thereby. 

When a physician refers a patient under treatment 
to a dentist, the latter should not be content to limit his 
work to fillings, crowns and bridges, but should recognize 
any diseased condition of the gums and should report the 
findings. This kind of service will often prove of vast 
importance in the etiology, diagnosis and treatment of 
systemic disturbances. The discovery of oral sepsis in 
a patient's mouth is of far more importance to the 
patient, the dentist and the physician than the filling of 
teeth. This view of the matter was expressed by Dr. 
William Hunter, physician and lecturer on pathology, to 
the Charing Cross Hospital, of London, in his famous 
classic upon the subject of "Oral Sepsis." 

"One would think poorly of a surgeon or doctor who declined to 
take the responsibility of treating a follicular (that is, a "septic") 
tonsillitis, but insisted on handing over the case to a throat specialist, 
or who allowed a patient to suck continuously a number of septic sores 
on his finger. I think no less poorly of any doctor or surgeon who 
declines to make himself responsible for the treatment of much of the 
oral sepsis presented by many of his cases. For this is what patients 
are constantly doing. Wherein consists the pathological difference 
between a follicular tonsillitis and a foul, septic, suppurating condition 
of the gums, with deposition of calcareous "crusts and scabs" (so- 
called tartar) covering and hiding septic wounds and ulcers, loaded, 
as miscrosoopic examination shows, with staphylococci and strepto- 
cocci'? None whatever, except that the latter is exceedingly common 
and the tonsillitis is comparatively rare. The pathological condition 
in both is the same; namely, sepsis. Moreover, it is a sepsis as easily 



Medical Aspect of Hygiene and Pyorrhea. 321 

recognized and much of it as easily removed in the case of the one as 
in that of the other, and the more urgently requiring to be removed, 
since it is more important as a potential disease factor than any other 
source of sepsis in the body 

"The chief feature of this iDarticuIar oral sepsis is that the whole of 
it is swallowed or absorbed into the lymphatics and blood. Unlike the 
sepsis of open wounds on the outside of the body, none of it is got rid 
of by free discharge on the surface. The effects of it, therefore, fall 
in the first place upon the whole of the alimentary tract from the tonsils 
downward. These effects include every degree and variety of 
tonsilitis and pharyngitis; of gastric trouble, from functional dys- 
pepsia up to gastritis and gastric ulcer, and of every degree and variety 
of enteritis and colitis and troubles in adjacent parts, e. g., appendicitis. 
The effects fall in the second place upon the glands (adenitis) ; on the 
blood (septic anemia, purpura, fever, septicemia) ; on the joints (ar- 
thritis) ; on the kidneys (nephritis), and on the nervous system 

"The following cases show to what extent oral sepsis complicates 
specific fevers, such as scarlet fever, typhoid, diphtheria, and the strik- 
ing benefits to be got from its removal. 

"In 648 cases of scarlet fever admitted to the London Fever Hos- 
pital under my care in the four years 1904-7, the incidence of oral 
sepsis, carefully noted by myself, varied from 25 per cent, to 43 per 
cent. The effect of oral antisepsis (the removal, as far as possible, 
immediately on admission, of every trace of oral sepsis around the 
patient's teeth and gaims, by daily swabbing with 1-40 carbolic acid 
solution) throughout the earlier j^art of the disease was very striking. 
The chief complications of the disease were reduced as follows: The 
incidence of secondary adenitis was reduced from 6 per cent, in 1904 
to 3.3 per cent, in 1906 and 1.8 in 1907; of cellulitis of the neck from 
5.2 per cent, in 1904 to 2.8 per cent, in 1906 and nil in 1907; of glan- 
dular suppuration from 1.7 per eet. in 1904 to 0.5 in 1906 and nil in 
1907. The striking improvement was due to the increaseing care taken 
by myself and by my residents and nurses under my instructions. In 
only one or two cases out of the whole series were any teeth extracted. 

"What are the general principles of the treatment applicable to 
medical sepsis'? The first and most important is curiosity about and 
careful observation of the actual character and degree of the septic 
foci present in the mouth (naso-pharynx or elseyhere) in every case 
of medical disease. This observation cannot be made by a cursory 
2'lanee into the mouth and a general conclusion to the effect that the 
•teeth are fairly good/ or the mouth 'fairly clean.' or that the mouth 
'requires to be seen to.' If you look closely into the mouth of your 
patients and note what you see, you will observe ever^' degTee and 
variety of septic ulceration; everj' degree of tartar deposit, as a great 
effect of these septic inflammation and ulceration; every degree of sup- 



322 Pe ACTIO AL Pyoeehea Alveolaeis. 

purative inflammation of the gums; every degree and effect of septic 
periostitis and periodontitis, Avith formation of pockets and loosening 
of teeth ; every degree and effect of septic osteitis — \e. g., rarefying oste- 
itis; eaiTsing recession of the bone socket of formative osteitis, causing 
thickening of alveolus; every degree and variety of septic caries and 
necrosis of the teeth, and as a result of all these conditions, singly or 
combined; every degree and variety of septic stomatitis, simple, ulcer- 
ative, gangrenous. You will see all this in infinitely less time than it 
takes to examine a specimen of the gastric contents, or of the feces, or 
of the urine, or of the sputum; in far less time and vpith far less labor 
than it will take you to examine the nose, or the naso-pharynx or the 
larynx; in far less time than it takes you to examine the heart or the 
liver, or, indeed, any other organ of the body. In particular cases you 
will observe that all these septic conditions are jDroduced or intensely 
aggi'avated by toothplates covering necrosed roots; by amalgam and 
gold fillings which have become septic; by porcelain crowns with gold 
collars; which, however good to begin with, are never really aseptic, 
and are liable to become extremely septic. AH these you can observe 
in a few minutes if you look for them — in less time almost than it takes 
to mention them." 

Several other interesting and anthoritative quotations 
are appended: 

"There is little doubt in my mind that bad mouth-hygiene favors 
the development of pneumonia by paving the way for pneumococcus 
sinusitis, which, as pointed out, frequently antedates a true pneumo- 
coccus infection. Any inflammation of the nasal sinuses should there- 
fore be promptly treated." — Han^ey G. Beck, M. D. {Interstate Med. 
Jour.) 

"Bad teeth are an enormous factor in the development of catarrhs. 
Many a chronic catarrh is kept up for this reason alone."^ — John B. 
Huber, M. D. {New York Med. Jour.). 

"The important part of scarlet fever is a focus of infection located 
either in the nose, in the mouth, or in the nasal pharynx, and from 
these sources the poisons are circulated through the body. Thus the 
poisons are but giving expression to themselves in the eruption that has 
been held heretofore to be of such consequence. 

"The importance of diptheria I am sure is fully understood, but the 
enlargements of the glands of the neck, of the nose, of the tonsils, and 
of the pharynx are due to absorption somewhere in the nose or in the 
mouth, a very large percentage of which takes place through cavities 
in the teeth or down the sides of unclean teeth. Not only that, but we 
are constantly confronted with instances like his, a child has been in 
a diphtheria hospital and has remained there until it seemed safe for 
the r-hiUl to jjo home. Then the cliild has gone home, and there has 



Medical Aspect of Hygiene axd Pyokrhea. 323 

followed an infection with diphtheria in that home. What is the logical 
explanation? The logical explanation is that in some hidden recess,, 
somewhere in that child, there was a focus of hidden bacteria; and 
that in all human probability a large percentage, if not an over- 
shadowing percentage, of those infections are either in the tooth 
cavities or somewhere in close connection with the tooth cavities." — Dr. 
W. A. Evans, M. D. 

In typhoid fever and allied conditions, the mouth is 
a veritable hot-bed of the very infection we most want 
to control. Just think of your patient having 28 to 30 
square inches of infected surface feeding the diseased 
intestine and no attention being given it. I have proven 
to my own satisaction that all cases of fever are more 
easily cured and have fewer complications when the 
mouth is maintained in a hygienic condition, before and 
during illness. 

Frankel, Wachselbaum, and Miller agree that the 
most frequent excitant cause of pneumonia is infection 
from the mouth. Miller says, ''The oral cavity serves 
as a gathering point for this infection, which from time 
to time is carried into the lungs with the air, until at 
last at some weak point, or as the result of some inflam- 
matory action of the lungs, through which the power of 
resistance is impaired, it obtains a foothold in the lungs. 
For this reason, therefore, and very m^ny others, the 
neglected oral cavity offers a dangerous cover of infec- 
tion, which by no means received the attention it 
deserves." 

Numerous investigators have pointed at the tonsil as 
a possible jooint of entry of rheumatoid infection. 
Billings reports cases of multiple arthritis cured by 
enucleation of the tonsils ; also, several cases of arthritis 
deformans and parenchymatous nephritis due to infec- 
tion of streptococci planted in pyorrhea! pockets. 

Dr. A. H. Stevenson, in a letter writes me : 

"It is generally believed that the bacteria of the com- 
mon infections, viz. : diphtheria, pneumonia, scarlet 
fever, and typhoid invaded the hodj through the air 



324 Practical Pyorrhea Alveolaris. 

passages, but Jonathan Wright and other investigators 
find that the turbinate bones of the nose, and the ciliated 
epithelium covering the mucous membrane of the nose, 
act as selves or screens, preventing most bacteria from 
entering the throat, bronchi, or lungs by this route. The 
mouth, therefore, must be the chief means of these infec- 
tions reaching the lungs or stomach. The function of 
the stomach may be impaired by this bacterial invasion. 
The hydrochloric acid. Nature's great germicide, is able 
to overcome the bacterial attack that occurs with the 
normal acquiring of food, but the constant ingestion of 
pyogenic material from a septic mouth seriously inter- 
feres with, and may prevent the normal secretion of the 
hydrochloric acid. This may result in the subsequent 
disturbance of the process of digestion. 

"With a wound on the surface of the body, the bac- 
teria and their toxins are eliminated with the surface 
discharge, but where there is a lesion of the, mouth, an 
alveola abscess, for example, the septic material is swal- 
lowed or disposed of by the lymphatics or the blood. If 
the resistance of the tissues is high, and the individual 
in excellent health, this daily toxic dose may be taken 
care of, but the effect falls upon the entire alimentary 
tract. Dr. E. C. Kirk calls this the "toxic habit," and 
like all offensive habits it becomes apparent to others 
before it does to the afilicted. Other results showing the 
results of oral sepsis could be continued "ad finen." The 
increase of papers on this subject appearing in the medi- 
cal journals is encouraging." 

In my experience in hospital work I have found that 
the majority of patients do not receive treatment for 
mouth conditions. The time-honored method of using a 
strip of gauze on the finger is better than nothing, but 
on account of the shape of the teeth a considerable 
amount of infectious debris is packed between the teeth 
and into the depressions arounci the tongue. 

If the mouth is first examined in office practice and 
found to need attention, the physician should send the 



Medical Aspect of Hygiene and Pyoerhea. 325 

patient to that dentist whom he has reason to know will 
put it in a hygienic condition, and instruct the patient 
in oral hygiene. 

If the patient is confined to bed, we know from experi- 
ence, that those who ordinarily brush the teeth often 
neglect this duty. 

Whose duty is it to brush the teeth of the sick patient ? 
The physician should be able to demonstrate to some 
member of the family, or if a nurse be in attendance, 
instruct her how to use the brush and mouth wash. I 
have never seen a nurse who knew how to brush her 
own teeth ; therefore I give her implicit instructions as to 
the proper manner of brushing not only the teeth, but 
the whole mouth, including the tongue. I hope the day 
is not far distant when every training school for nurses 
will incorporate a few lectures on this subject in their 
course. 

The teeth of a bed-ridden patient, even if in normal 
condition, should be washed properly several times each 
day and rinsed every few hours with some cleansing- 
solution. The most serious consequence of tooth decay, 
following sickness, is due to the infection between the 
teeth. The use of guaze will not remove the material. 
The tooth brush is a necessity. It goes between teeth, 
it removes the accumulation as gauze cannot. The tex- 
ture of the brush should be of the softest grade obtain- 
able. Some good tooth paste should be used in prefer- 
ence to a powder; a powder must be changed into a paste 
in the mouth before it becomes efficient ; before it changes 
to a paste, some of it gets lodged between the teeth, 
where it stays ; some of it is apt to be inhaled, irritating 
the throat and lungs. A paste does the work quicker 
and has the advantage that it generally contains some 
antiseptic. This must be followed by a mouth wash, and 
for this purpose lime water or salt water will answer, 
but a prescription of chlorate of potash, with a few drops 
of phenol is efficient or the purpose of cleansing and 
disinfecting. 



326 Peactical Pyoeehea Alveolaeis. 

Even though a patient cannot raise his head, oral 
cleanliness must not be neglected. Here it is good prac- 
tice to irrigate the teeth and mouth by turning the head 
to one side, having the patient draw the fluid into the 
mouth through a long glass tube, and instructing him to 
close the lips and force the fluid between the interspaces 
of the teeth, flushing the whole oral cavity and the throat. 
In other cases, the ordinary long-spout feeding-cup can 
be used without the patient moving the head. By closing 
the lips over the spout, this cleansing liquid can be drawn 
into the mouth and later emptied back into the cup just 
as it was received. In other cases, it is advisable to use 
the fountain syringe and flush out the mouth just as you 
would any other infectious cavity. Use a nozzle that will 
give a fine stream and don't be afraid to use plenty of 
pressure. 

If oral sepsis is present, in addition to the cleansing 
it is necessary to make a topical application of some 
formulae as Skinner's Disclosing Solution, Buckley's 
Pyorrhea Astringent, or AA Pyorrhea Treatment 
(formulae given elsewhere), or some similar preparation 
containing iodine, Avhich drug alone will penetrate in the 
mouth. 

Proper attention to the mouths of the sick and before 
operations by the surgeon will undoubtedly be produc- 
tive of comfort to the patient preventing infections and 
will prove one of the greatest aids that can be used to 
restore the health of the patient. 

OEAL PREPAEATIOiSr FOR SURGICAL WORK. 

If there is one place where the dentist can be of great 
help to the general surgeon, it is in the preparation of 
the mouth before the anesthetic is given for all opera- 
tions. The surgeon wears a mask, and is all attention 
to every detail, but often neglects a great source of 
infection and danger — the mouth. Dentists should urge 
the strengthening of this chain in aseptic surgery. No 



Medical Aspect op Hygiene and Pyorrhea. 327 

doubt many of the post-operative pneumonias are due 
to infection from septic mouths containing pneumococci. 
In this regard we must teach our physician friends not 
to rely on rinsing the patient's mouth with the ordinary 
solutions used as mouth washes. Undoubtedly, it would 
be safer for the patients if their mouths could be cleaned 
by a staff hospital dentist, and the day is not far distant 
when just as much attention will be given the mouth in 
hospital wards as is now accorded examinations of the 
heart, lungs or kidneys. 

The above should serve to give a glimpse into the 
many important and practical relations between medicine 
and dentistry. The solution of such problems requires 
knowledge on the part of the dentist and full recognition 
of the importance of mouth hygiene on the part of the 
medical profession. 



\ b 



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