Difficult Dentition, 
REFLEX ACTIONS, 
AND THE 
U£E OF T[lE E|UM LANCET 
»V 1/ 
/. MORGAN HOWE, M. D., M. D. S.,‘ 
NEW YORK. 
Reprint from the “INDEPENDENT PRACTITIONER” for November, 1883. 
• Baker, Jones & Co., Printers, 222 Washington St., Buffalo, N. Y. DIFFICULT DENTITION, REFLEX ACTIONS, AND 
THE USE OF THE GUM LANCET. 
BY J. MORGAN HOWE, M. D., M. D. S., NEW YORK CITY. 
Primary dentition has long been regarded as a cause of many 
infantile ailments. This view, based largely on clinical observation, 
has been that of some of the most eminent physiologists and practi- 
tioners, and has come to be so commonly accepted that it is quite 
probable that the origin of many disturbances has often been falsely 
attributed to teething, as it furnished a convenient scape-goat for 
indolence and ignorance ; a just antagonism of this evil has 
perhaps been the pendulum rod on which some have swung over to 
the conclusion that it is all a mistake, to suppose that so simple a 
process is capable of producing any serious disorders of nutrition, 
or of functional activity ; and to fortify this position the fact that 
dentition is a 'physiologicalprocess is set forth, with apparent confi- 
dence that it should be sufficient to convince all disbelievers in their 
opinion. Although the use of this truth as basis for an argument 
has had force or plausibility enough to have caused its repetition by 
several writers, it hardly seems to be conclusive, and we propose 
to offer some facts and suggestions as reasons for believing that the 
deductions of so many, reached by clinical experience, that dentition 
is a cause of nervous irritation and of numerous reflex disturbances, 
is not a mistaken one; and in doing so, we quote from two writers 
who, from their position and special knowledge in dental science, 
may be the more likely—if their views are erroneous—to mislead. 
In an address on Oral Surgery before the American Medical 
Association, 1882, Dr. D. H. Goodwillie, of this city, in deprecating 
the fact that teething has often been given as the cause of death in 
mortuary certificates, says; “ Alas! a normal physiological process the 
cause of death. If first dentition in the child is the cause of death, 
why not carry it through the process of second dentition, which 
lasts nearly to adult age ? Perhaps it might be found that malaria, 2 
smallpox or some of the other diseases lie buried in the jaws.” And 
Dr. W. C. Barrett in an editorial in the Independent Practitioner, 
March, 1883, says; “About the time when the molar teeth are in 
process of eruption, digestive ills of all sorts attack the child, and to 
the mere physiological process of cutting the teeth is attributed the 
flatulence, diarrhoea, convulsions and death,” etc. * * “ Diges- 
tion and assimilation being properly performed, there is nothing in 
the mere process of the eruption of the teeth which can cause any 
serious disturbance. Nature has provided for the absorption and 
disappearance of the tissues covering the growing teeth without any 
febrile symptoms, any diarrhoea or nervous convulsions and again 
he says; “ The gums and investing tissues have not such an exquis- 
itely nervous organization, are not so thoroughly supplied with 
nerve fibers as to produce any grave disturbances by the mere force 
of an advancing tooth. There is little or no sensitiveness in the 
raised gum. Pressure over the coming tooth is not annoying to 
the infant; on the contrary it often seems grateful. Whence then 
this idea of dangerous reflex nervous disturbances ?” 
It seems to have been Dr. Goodwillie’s intention to ridicule the 
idea of dentition ever being a cause of death, basing the assumption 
of its absurdity on the fact that it is a physiological process, which 
he calls normal; whether he meant to assert that it is always 
normal may be doubted, if that were true, it would be of value to 
the race as well as to his argument; if it is admitted that it is not 
always a normal physiological process, it would be interesting to 
know of how many other human physiological processes the claim 
would be made, that they could not be the cause of such irritation 
and disturbance as directly or indirectly to cause death. All the 
tissue changes and movements involved in the developmental proc- 
esses of the human animal are so frequently attended with more or 
less manifestation of abnormality, that it is difficult to perceive why 
any one should assume that dentition is exempt from anomalies which 
so commonly cause other physiological processes to produce serious 
derangement of the system; merely to mention gestation and 
parturition, is to call to mind morning sickness, eclampsia, post 
partem hemorrhage, and various other complications, and there is 3 
abundant reason for regarding dentition as similar to these proc- 
esses, in that it makes great demands upon the vitality of the sub- 
ject, and that its expression is one of irritation during a considerable 
portion of its continuance. One of the earliest signs of the 
advancement of the partly calcified developing teeth, is increased 
salivation—drivelling; it is as rarely absent perhaps as the morn- 
ing sickness of pregnancy, and seems without doubt to be the 
result of gland excitement, through the irritation of afferent nerve 
filaments in the tooth pulp. This phenomenon, generally 
accompanied with fretfulness and signs of pain, makes its appear- 
ance at the time (fifth to sixth month) when the developing incisor 
teeth would be advancing toward the orifices of the alveolar 
crypts, the margins of which should be enlarging by absorption to 
admit of their passage ; * but in case of irregularity of the eruptive 
force, and lack of corresponding absorption of the obstructing 
tissues, pulp irritation would necessarily ensue, and we may well 
suppose, with any such anomalies, a greater or less degree of local 
hyperiemia. Similar reflex excitement of the salivary glands, by 
irritation of the filaments from the trigemini in the tooth pulp, is 
witnessed daily in the dental chair, the saliva being frequently 
thrown out in jets, upon instrumental or other irritation of the 
dentine, or dental pulp ; and it is equally patent that dental irrita- 
tion of whatever kind is generally attended with increase of saliva- 
tion, the glands being excited much more readily by irritation of 
nerve filaments distributed to the deeper parts, than of those in the 
gum tissue, for the latter, as Dr. Barrett says, “ have not such an 
exquisitely nervous organization.” 
In turning the attention to the development and eruption of the 
permanent teeth, we find no such disturbances of the system as have 
been generally attributed to teething in the infant subject; the con- 
clusion is therefore not unnatural, that first dentition is not the 
baleful process it has been called. We think, however, it is sufli- 
cient to call attention to the fact that the latter period is one of 
peculiar susceptibility to derangement of the harmony of vital proc- 
esses from any cause. The liability of the alimentary tract to irri- 
* Tome’s Dental Surgery, p. 14. 4 
tation from slight variations of food, or from thermal and atmos- 
pheric impressions, is indicative of the liability of all the organs and 
tissues of the body to be disturbed by predisposing or immediate influ- 
ences, so that anomalous movements in the physiological mechanism 
are more likely to be produced and to disturb the system when they 
occur. Dr. Barrett attributes to injudicious feeding almost all the ail- 
ments that have frequently been considered due to teething, and 
certainly it is one of the most common and important causes of 
infantile ills, but we think dentition is as common and equally 
important a factor in producing those well known disturbances, 
which so frequently endanger life at this time. 
There are occasional instances in second dentition, during the 
efforts of nature to erupt the third molar, especially of the inferior 
jaw, of irritation, which differs, if at all, only in degree and in its 
reflex manifestation, from that which is commonly produced by the 
eruption of the deciduous teeth. This has occurred sometimes under 
our own observation, when, neither at the time nor after the appear- 
ance of the tooth,could any unusual position of the growing tooth or 
of surrounding parts be discovered, and no reason could be assigned, 
except a lack of absorption of the super-imposed mass of gum tissue, 
in response to the probably too fitful and irregular pressure of the 
tooth. Such irritation is, however, more frequently observed, when 
(1) the space between the posterior surface of the second molar and 
the compact bone of the ascending ramus is insufficient for the pas- 
sage of the crown of the third molar, or (2) when the latter tooth is 
tipped anteriorly, so that its progress is arrested,and the eruptive force 
is expended on the posterior surface of the second molar. These com- 
plications are not very uncommon, and from them frequently arise 
reflex neuralgias of the severest nature, often with fever; but without 
detailed subjective symptoms these cases would also afford fruitful 
ground for difference of opinion, for in many there are no local 
indications of inflammation, either of the soft tissue around the 
developing tooth,or of the second molar, and no soreness of the gum 
or of the growing tooth to pressure ; and in other cases, principally 
those first referred to, even when a considerable degree of inflam- 
mation in the soft tissues is present, the local conditions seldom if 5 
ever appear adequate to explain the severe reflex neuralgia from 
which the patient often suffers; we would be very likely to look 
elsewhere for a cause of such violent distress as frequently occurs, 
than to a developing tooth, if the patient’s own apprehension 
of the cause were taken from us. During first dentition we have 
no subjective symptoms to aid us in the formation of diagnoses, 
and these cases of difficult eruption of third molars may well be 
considered fair illustrations of the irritation possible from all 
impeded dental growth. There seems to be abundant reason 
for regarding the pulp as the point of irritation of afferent 
nerves when reflex actions are produced, whether it occur through 
obstruction to the growth of a wisdom tooth, or of the deciduous 
teeth. In the latter it is quite true that there is no anomaly of 
arrangement worth considering, and “nature has provided for the 
absorption and disappearance of the tissues covering the growing 
tooth,” but we see no more reason for claiming that this is accom- 
plished in perfect accord with all the other movements involved, than 
that all other physiological processes are accomplished in a perfectly 
normal manner. When the possibilities, in the direction of nervous 
disturbance, from an irritated pulp are considered, argument 
against dentitional irritation, because the gum is not an exquisitely 
sensitive tissue, seems hardly convincing ; when the susceptibility 
to derangement and to nervous irritation of the infant is consid- 
ered, the pulp irritation of anomalous wisdom teeth may we think, 
give us some light on the sufferings sometimes endured by those who 
cannot speak. The irritation so frequently produced by first denti- 
tion begins, as we have endeavored to show, at an early period, and 
may cause serious reflex disturbances at any time thereafter. The 
emesis, diarrhoea, and convulsions of this period, are of course liable 
to be produced by other causes,but the clinical experiences of numer- 
ous competent practitioners has been amply sufficient to confirm 
the old opinion, that these phenomena are often due to dental irri- 
tation, so that the conclusion will hardly be disturbed by argument 
based on the fact that dentition is a physiological process, nor by 
negative testimony from those who have not observed such ailments 
under circumstances which have convinced them of its truth. 6 
It must be admitted that positive and satisfactory diagnoses are 
not always easily formed, but the difficulty is probabiy not greater 
in these cases than in most others where subjective symptoms are 
wanting. There are many instances which appear to indicate 
dental irritation so clearly as to hardly leave room for doubt; such 
are those in which nursing infants occasionally give sudden mani- 
festations of distress, with gastric, intestinal or cerebral disturb- 
ance, without other assignable cause ; there is increased salivation, 
and the child not unfrequently indicates in various ways that the 
seat of pain is in the mouth. All this ismuch more likely to occur 
in the case of infants who do not nurse, but it cannot fairly be 
attributed to improper feeding when the child has been thriving on 
the same food up to the period of such disturbance. Such cases 
have occurred, and are appearing more or less constantly, (with 
numerous variations of circumstance), in which the use of the gum 
lancet is followed by marked relief. The literature of this sub- 
ject is very meager, but Dr. Samuel Sexton * has called attention 
to the fact that some aural diseases have their origin in dental 
irritation by reflex action, and has graphically shown how this 
takes place through the Otic ganglion. He has clinically recog- 
nized the fact that the processes of dentition, especially of the 
deciduous teeth and of the wisdom teeth, often cause this irritation, 
as well as dental caries, pericementitis, and alveolar abscess. 
It is not our present purpose to endeavor to indicate the avenues 
by which the numerous reflex actions of dental irritation are 
accomplished ; they are probably often of a very complicated 
nature, but we will merely call attention to the direct connection of 
the fifth nerve with four ganglia and one plexus of the sympathetic 
system, the controlling influence of which over vascular supply and 
gland action is well recognized ; and to the comparatively simple 
manner by which cerebral circulation may be influenced through 
the vaso motor nerves of the internal carotid artery and its encra- 
nial branches, through the connection of the fifth pair of nerves 
with the Otic ganglion and the carotid plexus. 
* American Journal Medical Sciences, January, 188U ; also Circular of information of the 
Bureau of Education, No. 5, Washington Government Printing Office, 1881. 7 
The treatment of cases giving evidence of difficult primary 
dentition should of course be governed by a careful consideration 
of that process itself, as well as by tbe character and severity of the 
symptoms manifested in each individual case. 
Whatever means give reasonable promise of raising the tone of the 
system, may cause the disappearance of reflex symptoms, whether 
produced by dental irritation or by other causes. Hygienic measures, 
especially if these have been neglected, are always to be considered. 
High temperatures have a general debilitating influence, and on 
this account, as well as, that reflex phenomena are more easily pro- 
voked under these conditions, * a change of location giving lower 
temperature and other favorable circumstances is often beneficial. 
Change of diet may be indicated, and therapeutic measures judici- 
ously directed to meet the symptoms of the case will often be all that 
is needed to cause the latter to subside, and enable the processes of 
development to progress more harmoniously. 
There are instances, however, in which all such means are insuf- 
ficient, and afford at best but partial and transitory relief, the child 
gives frequent evidences of oral suffering, or of nervous irritation 
by reflex disturbances; in some such cases the gum lancet affords 
the means of rendering the most prompt and efficient relief. Its use 
is clearly counter-indicated in such early stages of teething as when 
the advancing teeth are probably obstructed by alveolar tissue, but 
when the enlarged gum indicates both to sight and feeling the pres- 
ence of the tooth beneath it, when the former tissue has a tense 
appearance (whether it is sore, swollen and red, or not), with the 
disturbances before referred to, which more general treatment has 
failed to relieve, a free incision through the gum to the tooth, with a 
sharp lancet, will in most instances be promptly followed by very 
marked amelioration of all symptoms of irritation. We have repeat- 
edly performed this trifling operation with such salutary results, in 
a very few instances without them. The ineffectual use of the lancet 
may prove a mistaken diagnosis, or that the irritation proceeded 
from teeth less advanced in development than those released by the 
incision ; it does not prove that dentition is incapable of pro- 
♦(Brown-Sequard, Cayrade.) Kuss Lectures on Physiology, p. 54. 8 
during irritation which may, through reflex action, endanger life. 
The instances, however, in which gum lancing is not followed by 
relief, lohcn it has been indicated by the conditions and symptoms, 
are so rare that it may be regarded as one of the most certain and 
effectual of minor operations, and so far as we know is contra-indi- 
cated only by a hemorrhagic diathesis. 
The objection, urged sometimes, that the gum will be made much 
harder (if it should heal) by the formation of a cicatrix, and the 
temporary relief hoped for be followed by an aggravation of the dif- 
ficulty of absorption of the gum, is invalid, from the fact that a 
cicatrix is not found after gum lancing, and if there should be a 
formation of cicatricial tissue it would absorb more readily than the 
primary tissue. 
The valid objection to the lancing of the gums of teething 
children is the “ almost indiscriminate ” practice of it, which Dr. 
Barrett believes is “ falling into desuetude.” There are probably few 
who will not be glad with him, and hope that all other practices 
that approach the indiscriminate may find the same limbo; but 
judicious gum lancing, practiced with discrimination and judgment, 
not for the purpose of depleting a congested gum, but to release an 
imprisoned or obstructed tooth the pulp of which is irritated, is both 
reasonable and commendable, and its value should not be over- 
looked. 
Oases of obstructed eruption of wisdom teeth often demand local 
treatment. 
Those which from their position in the angle between the body 
and ramus of the jaw are covered with a mass of soft tissue, that 
is not absorbed sufficiently to prevent it becoming inflamed by the 
pressure of the growing tooth and of antagonizing teeth in the 
superior jaw, may be made less troublesome by proper lancing, but 
permanent relief is only obtained, in many instances, by the removal 
of the tooth for which nature has failed to provide a place. 
Extraction of the wisdom tooth must also frequently be resorted 
to when neuralgic or other disturbances arise through its obstruc- 
tion by the second molar, together with the maxillary ramus, 
or when the former is tipped forward so that its progress is 9 
arrested by the second molar. When the third molar, how- 
ever, occupies so nearly a horizontal position that the crown is 
in contact with the neck of the secotid molar, the extraction ol the 
former is often an impossibility, without resorting to an entirely 
inexpedient operation, and in such case the removal of the second 
molar—the obstructing tissue—must be chosen as the least evil. 
But wisdom teeth placed anomalously in the niaxillse not 
unlrequently attain to complete development before meeting in 
their advance such resistance as to cause pulp irritation with local 
and reflex disturbance, and as interference is not demanded, it 
would unquestionably in such cases seem to be a blunder. 
Notk.—Dr. C. F. W. Bodecker, of this city, reported at the last meeting of 
tlie First District Dental Society a case which illustrates the subject, and of 
which he has kindly written the following account : 
“ A few days ago I saw a case with some very interesting reflex phenomena. 
The patient was a lady about twenty years of age, with a good constitution. 
When she entered my office she was suffering severely, so that she was hardly 
able to speak, and could only breathe with difficulty. The patient told me 
that for the last week whenever the paroxysm of pain came on she had 
experienced great difficulty in breathing, especially on the right side. On this 
side the first upper molar had been lately filled with amalgam, and ever since 
the filling had been introduced she had suffered excruciating pain. As the 
tooth was not sensitive to percussion, I diagnosed pulpitis, and perforated the 
pulp chamber. From the moment that the blood began to flow from the drill- 
hole the patient was relieved from pain, as well as from the dyspnoea, which 
up to this time has not recurred. 1 removed a part of the amalgam filling, 
which upon examination proved to be just the offending portion. It had been 
laid directly upon the exposed pulp, and a little eminence on this piece of 
filling showed that it had entered the pulp chamber. The pulp by the unskillful 
manner of filling had been irritated to such a degree that I found it dead 
the next day. ”