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               A  TREATISE

Pyorrhea    Alveolaris.
Prompt, Positive and Permanent Cure.
           By Junius E. Cravens, D. D. S.,

Professor of Operative Dentistry in Indiana Dental College ; Secretary of the National
   Association of Dental Faculties; Member of the American Dental Association;
     Member of the Ninth International Medical Congress, and Essayist in
       Section on Dental and Oral Surgery, Washington, D. C.,1887;
          Member of Tenth International Medical Congress, and
            Clinician in Section on Dental and Oral Surgery,
              Berlin, Germany, 1890; Member of the
                 World's Columbian Dental Con-
                    gress, and  Secretary of
Section IV, Materia Medica, Etc., Chicago, 1893; Charter Member of the American
   Dental Club, of Paris, France; Member of the Mississippi Valley Dental Asso-
         ciation ; Member of the Indiana State Dental Association.
W. M. IIERRIOTT, Publisher,

     Indianapolis, Ind. 
WLl
 cseat
/a-C.
Entered according to Act of Congress, in the year 1894, by

            Junius  E. Cravens,
     In the office of the Librarian at Congress, at
              Washington, D. C.
Press of Baker-Randolph Co., Indianapolis. 
INSCRIPTION.
  This little volume which is  intended to convey to  my pro-
fessional co-laborers some of the results of twenty years of ob-
servation and study of pyorrhoea  alveolaris, and assiduous ef-
forts to discover  a means of cure, is most affectionately in-
scribed to my fellows of the  National Association of Dental
Faculties, with whom I have enjoyed  such happy relations
since 1887.                        Junius E. Cravens.
  Indianapolis, Ind., June, 1894. 
CONTENTS.
                                                                PAGE
Acid—Sulfuric, dilute .................................................................   34
Anaesthesia—Local......................................................................   28
            General..................................................................   29
Bromo-Chloralum........................................................................   40
Calculus—Visible......................................................................   10
          Invisible................................ ...................... ..............   14
Care, after treatment...................................................................   39
Clement, Dr. George B........................................................6,  7, 19; 20
Cocaine..................................................................................   30
   "   How to apply................................................................   31
Diagnosis...................................................................................   25
Etiology....................................................................................   12
Galleries.................................................................. .................   21
Gingivitis.................................................................................   11
Grottoes......................................................................................   22
Health Line..........................................................................   24
Hot Water..................................................................................   27
Inscription ................................................................................    3
Instructing Patients....................................................................   36
Introduction.............................................................................    5
Mechanical Considerations...........................................................   17
Nitrate of Silver, solution............................................................   38
Pathology........................................... ..........,..........................   13
Pericementum .........................................................................   19
Phagedenic Pericementitis  ..........................................................   10
Pocketing...................................................................................   12
Progress of the Disease................................................................   18
Properties, Some ..........................................................................   41
Pyonal Calculus...........................................................................   16
Riggs' Disease..............................................................................   10
Salivary Calculus......................................................................43-48
Scalers.....................................................................................   41
Septse—bony, Loss  of....................................................................   23
Surgical Procedure.......... ...........................................................   33
Symptoms, Constant, Inconstant...................................................   24
Touch Cultivated......................................................................   27
Treatment—Primary..................................................................   26
    ''      Second ary..................................................................   37
Watt, Dr. George......................................................................43-45 
INTRODUCTION.
   In all the history of dentistry the best efforts of the  best
operators, and the best thoughts of the best thinkers, have been
persistently baffled by Pyorrhoea Alveolaris—erstwhile known
as Riggs' Disease.  Occasionally apparent cures have fallen
to the lot of all intelligent practitioners who may have aspired
to its treatment;  but unfortunately isolated cases of recovery
failed to reveal a system by which this much dreaded affection
might be treated  with regularity of procedure and certainty of
cure.
   The many methods and remedies  suggested  have served to
lead only to hopeless confusion—one might almost  say—to
despair; so that,  for all the years of the marvelous develop-
ment of dental surgery, pyorrhoea alveolaris has  been gener-
erally conceded to be incurable.
   Condemned in  advance on the slightest indications of  the
presence of this disease, thousands of teeth that are entirely
free  from dental caries are sacrificed to the forceps annually.
   In their emergency dentists have appealed to the medical
profession  for  guidance,  only to meet with disappointment,
while this destroyer has marched  on, triumphant over  all
theories, all appliances, all  drugs; a despair to conscientious
practitioners and a humiliation to science.  The etiology of this
disease  still is  unsatisfactorily explained;  its pathology is  er-
roneously written and diagnosis hopelessly ambiguous.
  Having been so widely at fault in the premises, how has it 
6
PYORRHEA ALVEOLARIS.
been possible to know how to cure or what constitutes a cure ?
  The writer is not quite ready to assert positively that a cure
of pyorrhoea alveolaris is assertion or reassertion of exce-
mentosis ; but there are not lacking reasonable proofs favoring
such a phenomenon.
  Whilst attending the World's Dental Congress at Chicago,
1893, it was the good fortune of the  author  to  make  the ac-
quaintance of Dr. George  B. Clement, of Macon, Miss., who
is a skillful microscopist, and  had  prepared a number of mi-
croscope slides mounting  specimens of cementum  cut  from
tracts that had been involved in pyorrhoea  " pockets."   Dr.
Clement holds that " the lesion within the socket is a disease
or result of a disease of the cementum;"  that  it induces an
obstruction of the  lacunae and  canaliculi  by  deposition  of
lime salts therein (obstructive  calcification);  that by this pro-
cess the external structure  of cementum becomes solidified, so
that the physiological  relation with pericementum  is  sus-
pended, thus leaving the  cementum practically dead.   Start-
ing from these premises Dr. Clement's conclusion is  that there
must be a  reassertion of cementum over the obstructed tract in
order to restore lost vital  relations to cementum before a  cure
of pyorrhoea alveolaris is possible.   Believing that to thus in-
duce  an  excementosis  is impossible, Dr. Clement holds
pyorrhoea alveolaris to be incurable.
   The author is ready to confess that if the conclusions of
Dr. Clement are correct the prospects of relieving the partic-
ular suffering of poor unfortunate men and women would be
unpromising indeed.  The specimens exhibited  at Chicago by 
PYORRHCEA ALVEOLARIS.
7
Dr. Clement certainly demonstrated  clearly enough that the
lacunae and canaliculi do become obstructed—even to obliter-
ation—in the peripheral lamina when long bathed in pus in
" pockets " of this lesion.
  It is well understood that the functional relation of perice-
mentum  to cementum  is  dependent upon canaliculi, conse-
quently the complete obstruction of these little  canals shuts
off  vital  connection with pericementum  and  renders that
membrane  a useless  covering  to the solidified  tract; under
these conditions the membrane recedes toward the line of at-
tachment.  It certainly is  doubtful that where once receded
the pericementum may be reasserted entirely.
  It belongs to  the future  to disclose whether  the conditions
reported  by Dr. Clement, and amply  illustrated, are to be ac-
cepted as  constant facts or  only accidental to  a number of
cases.  Very much is dependent upon this proposition.
  In  August, 1892, at  Niagara  Falls, N.  Y.,  the writer re-
ported a  case in practice before the American Dental Associa-
tion, by  kindly permission of Dr. T. W.  Brophy, Chairman
of the Section on Oral Surgery and  Pathology.   In that re-
port were given in detail the method and remedies resorted to
successfully in  a case of some nineteen " pockets," the result
being a complete and surprisingly rapid cure of ali.
  The permanency of cures in this case was not only a matter of
grave doubt to some, but others actually disputed that there had
been any cure whatever.  The writer  had the fortunate oppor-
tunity to carefully examine this case thirteen months after the
reading  of  the  report, and  of all the nineteen " pockets" 
8
PYORRHCEA ALVEOLARIS.
treated there was not one in which there was any evidence of
recurrence of the disease.  A letter received within two months
from this patient (who resides in a distant State), gives assur-
ance that there still is no reappearance ot pyorrhoea alveolaris
after more than twenty months.   That there has been a cure,
and a permanent cure in this case, would appear assured.
  This system was also given in detail by the writer at the  ■
recent Dental Congress at Chicago (1893).  Section IV.  (See
reports in Dental Cosmos).
  As early as the summer of 1891 the writer was enabled to
cure a number of cases, which are still free of the disease, but
was not successful in establishing a  definite system by which
uniformly good results were attainable until in  July, 1892,
the experiments  culminated  in  the  case  reported at Niagara
Falls in August of that year; from that time to this date the
same system has been pursued with a long succession of cases—
many being  desperately bad—with  no failures whatever  re-
ported.   Nearly every case treated has been under surveillance
and subjected to monthly inspections.

                   SOME PROPOSITIONS.
  It may be stated  as a general  proposition, that wherever a
tooth retains  good attachment upon one or more sides of its
root, it may  safely be  classed as curable, without regard  to
looseness or the condition of the pulp.
  The conservation of pulps in pyorrhoea alveolaris is depend-
ent entirely upon the demands or convenience of the case in
hand, according to the judgment of the operator in charge. 
PYORRHEA ALVEOLARIS.
9
  Inferior incisors that  are loose and wabbling about in their
funnel-shaped sockets, without  attachment other than semi-
ligamentous  at  the apices, have usually gotten beyond this
specific lesion (into the exfoliative condition), and are hopeless.
Pyorrluea may be stopped in these cases, but substantial attach-
ment cannot be  induced.
  When, after  treatment, there is no longer accumulation of
pus, no congestion of the gum, and a notable shrinkage of gum
immediately over or adjacent to  the " pocket," the case may
be considered fairly cured—certainly not before.
  Whilst it  devolves upon a practitioner to maintain cleanli-
ness of a mouth containing teeth that are under treatment, or
that have been, and a  continuance of sanitary  care of all
"pockets"  treated—for  several weeks after—he cannot justly
be  held  responsible for constitutional failure of the patient
and consequent  inability to recuperate or reproduce bony sup-
port for the  roots that have  become denuded in the progress
of this disease.
  Eradication of the disease is the end of the dentist's Junction
in any case, after which he can do no more than to  co-operate
with an intelligent physician  in guiding as to habits, diet, etc.
                                    Junius E. Cravens. 
CHAPTER  I.
                 PYORRHCEA ALVEOLARIS.
      (Phagedenic Pericementitis; Riggs' Disease.  Calcic Inflammation )
  Whatever may be the apparent present cause of a given case
of phorrhoea alveolaris, it must be admitted that the formation
of calcarious matter in crusts about  the necks of teeth is con-
ducive to establishment of that disease.
  Whatever tributary effects are to  be anticipated from pro-
gressive organic disease as in affections of the kidneys, bladder
or lungs must be left largely to the  future of individual cases
to determine ; that such influences are operative in a measure,
is manifested  often by extraordinary tendency to  calcarious
deposition upon the teeth of certain subjects, or by an observa-
ble inconstancy of the gum  about the necks of some or  all
teeth.  Either of these manifestations would indicate organic
disturbance extending far back  of  any local  conditions, and
depending  upon constitutional  obliquity that may be heredi-
tary or acquired—and in the latter case may be temporary.
  For the purposes of this work I  have classed salivary cal-
culus under two heads—visible and invisible.
               VISIBLE CALCULUS—TARTAR.
  The first class consists of accumulations of salts of lime that
constantly are precipitated from saliva in the mouth, together
with particles of oral and extraneous matters that become  in-
volved in the  mass which  is commonly observed  and called 
PYORRHCEA ALVEOLARIS.
11
" tartar."  Tartar forms hard crusts, adhering to teeth and in
contact with the gum.  It is well known that the gum recedes
from  contact with tartar, such  recession affording  space  for
further accumulation and addition to the mass that thus rap-
idly grows—sometimes to enormous proportions.
  This process of deposition, recession and  redeposition  when
occurring upon a  root, may contiuue until  the affected side is
denuded of gum and process almost to the apex.   It is also
true that such a  root  usually remains securely attached  upon
all other aspects, often continuing firm, or fairly so, in its im-
paired socket, revealing no " pocket " and  exhibiting no pus.

                A WORD  ABOUT GINGIVITIS.
  The very  common condition called gingivitis, consisting
of inflamed, swollen and  readily bleeding gums, is scarcely to
be dignified as  a disease, although it  often is mistaken  for
pyorrhoea  alveolaris, and is treated  accordingly.   Gingivitis
readily responds favorably to simple treatment, which need
consist merely in removal of deposits of tartar from about  the
cervix, to be followed by  local applications  of stimulative and
astringent character.
  While experience has shown that in some instances salivary
calculus  may prevail in large masses on teeth, without serious
consequences, unfortunately it appears that there often are evil
influences from  visible tartar that extend  beyond  the  mere
fact of gingival  irritation, and  contributing to the  establish-
ment  of a definite pathological condition of the periosteum or
pericementum—or both,  in  varying degrees.  Owing,  how- 
12
PYORRHCEA ALVEOLARIS.
ever, to the obscurity  of the  parts involved, to the  hemor-
rhage  attending operations,  and to the  extreme  sensibility
of imposed tissues it is difficult, if not impossible, to determine
the degree in which  the pericementum or periosteum  may be
affected.
                        ETIOLOGY.
  In certain cases inconstancy of gum forming the  gingivae is
general, a condition suggesting heredity, but sometimes—prob-
ably the more frequent—is  only a diathesis  that has  been
induced by general debility, thus inviting pyorrhoea  alveolaris,
the debility itself passing away on  opportunity for recupera-
tion of the individual; the obliteration of a diathesis, however,
will not carry  away with it  pyorrhoea alveolaris  once estab-
lished.
  Beyond the gum tissue the invading calculus  encroaches
upon the periosteum  that envelops the bony process forming
the orbit of the alveolus  or socket; the immediate effect of this
encroachment is to  establish periostitis at that point.  The
congestion of the periosteum  may extend slightly within the
socket, where, because of the extremely limited space between
the cementum of the root and the wall of the socket the peri-
ostitis  is  aggravated, increased  vascularity  demands   more
space, which is afforded  only  by resorption or  removal of the
involved section of alveolus wall.
                        POCKETING.
  After the  enlargement of  a portion of the socket  in the
manner suggested, the pericementum—for a time at least—loy-
ally adheres to the  cementum;  the periosteum,  although 
PYORRHCEA  ALVEOLARIS.
13
badly congested, maintains  relations with the bony wall;  the
space between the membranes thus separated becomes occu-
pied by saliva entering in from the  oral cavity, carrying with
it  in  solution and otherwise, various  extraneous substances.
Other elements  emanating  from  the membranes involved in
the sockets are projected directly into  the  space  made by the
inflammatory action and resorption referred to; these accumu-
lated  elements become stagnated and putrefaction and pus  fol-
low in rapid order.  Thus is formed what is  called a "pocket,"
containing pus,  and  the establishment of definite pathological
conditions to which  is given the name pyorrhoea alveolaris.
                        PATHOLOGY.
   The pathology of pyorrhoea alveolaris  has never been  sat-
isfactorily written;  indeed it is difficult to set forth; but from
facts appearing  in  its etiology and observations of the prog-
ress of this lesion, it evidently is a culmination of an inflamma-
tion affecting the periosteum first  about the socket and later
within  it; sympathetically  the pericementum  is affected, not
congested, but in a form or  degree of hyper-nutrition through
which calcic infiltration eventuates in  the structure of the ce-
mentum itself.  The final  effect  of such calcic  infiltration is
solidification and  peripheral obliteration  of the  little lakes
and  canals of the corticle  structure of the root (obstructive
calcification).
   It is possible that the pericementum may also become acutely
but temporarily inflamed because of conditions of environ-
ment, but if so  it evidently occurs in the incipient stage of
the disease, because, when teeth that are "pocketed" are ex- 
14
PYORRHCEA ALVEOLARIS.
tracted  a congestion of tracts involved in the pus  cavities is
rarely observed.
  The progress of the disease is indicated by a deepening of
the " pockets," to which the further encroachment or even the
continued presence of calculus of any character is not essen-
tial.  On the other hand,  incrustations  may serve to perpetu-
ate the chronic character of the disease without inducing acute
manifestations or apparent progress.
                   INVISIBLE CALCULUS.
  At a remote, or at best an  obscure point upon the affected
side of a root, in a deep "  pocket," the observant operator dis-
covers an incrustation  that is essentially different from that
which has been called visible or plain salivary calculus.   The
hidden calculus usually is discoverable  to the sense of  touch
through a delicate instrument.   Efforts to remove the crust
prove it to be more adherent than ordinary visible tartar; that
the mass is smaller, or often  is spread  thinly out over  the
surface of the root;  that it is found separate from  the visible
variety, from which  it differs materially in appearance.
  Probably there is  no point in connection with a considera-
tion of the entire subject  of pyorrhoea  alveolaris, upon which
there exists a greater diversity of opinions than as to the char-
acter and origin of the calculus found so tenaciously adhering
to roots in the pus " pockets."   This  particular deposit  has
been variously ascribed as salivary, sanguinary and serumal__
the latter two terms being employed synonymously by many.
  The terms sanguinary and serumal are applied to the calcu-
lus in those cases  where there appears to be no opening for in- 
PYORRHCEA  ALVEOLARIS.
15
gress of saliva  to  the  place  of the  calculus; these are called
blind " pockets " as a distinction from the open ones; the dis-
tinction, of course, is carried  inside the socket itself, and so we
have the claim set up that the calculus found there is not only
of a very  different character, but has a  different origin from
that  of salivary calculus, or that found in open "pockets."
  As a precise fact  I  doubt the  existence  of any  really
blind cases, but hold that for every one there  is a means of
ingress  from the  mouth as well  as a necessary  means  for
drainage into  the mouth.   The dental surgeon may  not be
able  to  discover an opening to a " pocket"  with such appli-
ances as usually are at hand, but it is there nevertheless and it
ought to be discovered.
  From observation of cases in practice I know that a fairly
open " pocket" may occasionally be closed  by orbicular con-
traction, rendering ingress difficult, and doubtless such cases
have been passed  upon as blind.  This  is a  passing condition,
the opening again becoming  free or fair.  An exception to
this, and rarely observed, is  where a fistulous opening through
the gum affords drainage, much as in cases of ordinary alveo-
lar abscess; I  have had but  one  such case, in which an in-
cision was made to reach the calculus.
  Professing to entertain the highest regard for opinions ex-
pressed by  the distinguished  writers upon this subject, and
disclaiming any aspiration to  appear to differ from others, it
is my privilege, perhaps my duty, to take exceptions to certain
conclusions, particularly where their expressions have appeared 
16
PYORRHCEA ALVEOLARIS.
ambiguous as to the immediate derivation  and character of
the calculus found in these pus cavities.
  The calculus  of pyorrhoea alveolaris, whether in open or
blind " pockets,"  possesses a composite character that at least
has escaped  a  proper emphasis hitherto; it contains  all the
elements of visible or salivary calculus, athough the extran-
eous elements that usually are involved in oral tartar are here
in modified proportion, in a ratio  corresponding to difficulties
of ingress ; also, this hidden calculus possesses characteristics
and elements that cannot be accounted for orally, being almost
wholly of an organic derivation, a circumstance that contrib-
utes to support of the sanguinary or serumal hypothesis.
  It is my belief that the source of these peculiar elements of the
deeper "pocket" calculus is to be found in the pus itself;  that it
should be called pyonal calculus.  The mass  is thus composed
of a  combination  of pyonal  calculus and ordinary salivary
calculus.
  The pus analysis from an average specimen, by Payne, in
Quain's  Dictionary  of Medicine, shows that  in 1,000 parts
there  are alkaline salts—other than sodium chloride—3,2, and
of earthy  phosphates and iron, 2.1.  This  gives  a total of
5.3  in 1,000.
  Prof. Dalton's analysis of human  saliva,  parotid, as  given
in Litch's American System of Dentistry, reports in 1,000 parts
that calcium phosphate is in 0.240; in a specimen from the
submaxillary glands there were of 1,000 parts, calcium carbo-
nate, calcium phosphate and magnesium phosphate, combined 
PYORRHCEA ALVEOLARIS.
17
1.16.   In the same volume, the analysis  of human saliva by
Bidder and Schmidt,  in  1,000  parts, shows one item of 0.98
composed of sodium,  calcium and magnesium phosphates.
  From the preceding analyses, it is evident that the propor-
tion of lime salts in pus  is far  in  excess  of that in saliva at
any point of production, singly or mixed.
  With these facts in view, it should be rather a matter of
surprise that the deposition of calculus wTithin these " pockets "
continues so small.
              MECHANICAL CONSIDERATIONS.
  In response to  a proper instrument—properly applied—the
invisible calculus may be brought away, but always in small
particles: never   in   liberal  masses  like ordinary  salivary
calculus.
  Should the root be  affected upon a side that  is flattened or
grooved, the crustation  will extend along the  flat or in the
groove, and  in some cases  approaches the apex; but if the
surface be convex, the  calculus frequently may be found crossing
horizontally, feeling to the operator like  a ligature of small,
hard cord or wire; this latter form is always near the cervix,
and easily removed.
  The absolute and complete removal  of the concealed incrus-
tation  should be  the operator's first and chief solicitude, as
failure in any part of this procedure insures failure  to effect
a cure.
  Sometimes, but fortunately  not  always or  often, this con-
2 
18
PYORRHCEA ALVEOLARIS.
cealed tartar is of a coffee-brown color, when it is particularly
tenacious and  unaccommodating, and  its removal is  accom-
plished with great labor, persistence and patience.
  Often after the first sitting for removal of hidden calculus,
on return of the patient, the shrinkage of gum  is so great as
to expose a number of brownish particles adhering to the root,
which the operator readily removes.

           PROGRESS  OF PYORRHCEA ALVEOLARIS.
  As a result of continued periostitis, the wall of the socket
is gradually destroyed along the axis with attendant deepen-
ing of the "pocket," affording space for greater acummulation
of pus and rubbish.  In time, the  periostitis tends to spread
laterally, all the while occasioning removal of more and more
of the alveolus wall,  until finally the loss or unstableness of
support  results in looseness of  the root,  a condition  that
seriously compromises prospects  for recovery of usefulness
of the tooth, but does not prevent eradication of the  disease
in that socket.
  Instances are frequently noted where the resorbing process,
due to continued  periostitis has completely girdled roots that
wTere held in place by a sort of ligament of hypertrophied per-
icementum, permitting motion  in  all directions  within the
funnel-shaped socket.   In such cases (most frequently of  in-
ferior incisors), the disease has literally run itself out, and the
wide-open socket is merely a receptacle for refuse matter that
may chance to get into it.   These are hopeless cases. 
PYORRHCEA ALVEOLARIS.               19
                   THE  PERICEMENTUM.
  Just how the pericementum may be  affected  in  pyorrhoea
alveolaris is not definitely known.   Certainly it cannot main-
tain a state of unimpaired health in a continuous bath of pus.
In profound " pockets"  of long  standing the pericementum
disappears, commencing  at the cervix and extending toward
the apex ; later, in some  instances, it appears to be have been
reasserted at or near to the cervix, which probably is due to
accidental or other removal of the  incrustation at that point.
One fact bearing upon this point should be noted, that the  en-
during calculus will not attach to the pericementum directly,
but encroaching upon that  membrane causes it to recede, and
the calculus is thus  enabled  to  fix itself directly  upon  the
cementum.  By this process the pericementum becomes perma-
nently thickened  and corrugated  near the apex, definitely
marking the chronic stage.  This corrugated membrane is not
dead  because it is sensitive, besides if dead it would  slough
away; it can not be induced to  reattach itself to the cementum
it has abandoned, consequently  before a cure  may be hoped for
the whole or a portion  of  the detached membrane must be
brought  away, to the end that a new and active  and healthy
membrane may be asserted.

  To  Dr. George B. Clement, of Macon, Miss, (to  whom re-
ference is made in the introductory chapter of this little vol-
ume), doubtless belongs  the credit of having discovered  the
cause  for the apparent loosening and disappearance of perice-
mentum  in "pockets" of long standing pyorrhoea  cases, and
the apparent futility of attempting  to induce a resumption of 
20               PYORRHCEA ALVEOLARIS.

its proper physiological relations with cementum  that it once
has abandoned, unless there  be  first induced a  return  of the
cementum  itself to normal conditions—at least as to the per-
iphera.
  Dr. Clement has demonstrated that  in  at least  some cases
the canaliculi  and lacuna? of cementum involved in these  pus
" pockets " become filled by obstructive calcification, necessar-
ily confined to the outer laminae, thus effectually shutting off
vital connection with  the imposed pericementum, which disap-
pears or possibly  in some cases  remains a useless  covering to
the solidified tract—a discarded  mistress.
  Taking into consideration  the conditions described, and ac-
cepting them as facts, it is possibly true that, as Dr. Clement
concludes, there can be no cure  for such cases except by asser-
tion of at  least one stratum by excementosis over the solidified
tract; this may be realized only under the activity of a new
pericementum; hence the necessity for surgical removal of the
loosened, hypertrophied and  torpid pericementum, as well as
the solidified superficial cementum in " pockets" of chronic
pyorrhoea alveolaris. 
CHAPTER II.
                     CHARACTERISTICS.
  Pyorrhoea alveolaris may appear upon any aspect of a root,
but most frequently affects the approximal faces.
  While a pus "pocket" exists upon the labial face—for ex-
ample—of an inferior incisor root, each approximal face may
also present a " pocket,"  as well as the lingual face, and each of
these  " pockets " be entirely separate from the others.
  In  some instances  two " pockets" upon the same root will
be found connected by a gallery; this connecting gallery may
remain  concealed  from the operator's observation, and cause
him much embarrassment in treatment.
                     AS  TO GALLERIES.
  Galleries are not common to all pus "pockets"—for which
one may be  thankful, but are more frequently present than
may be supposed.   I am satisfied that galleries are directly re-
sponsible for many failures where operators have been skillful
and painstaking  in treatment.   They  are to  be found in at
least two varieties—simple and blind.  Simple galleries connect
two " pockets," while blind galleries, having but one opening,
are confined to a single " pocket."  The simple galleries are the
more  easily discovered, because water forced  into one of the
two connected " pockets " will pass through the gallery and ap-
pear at the opening  of the other " pocket."   Blind  galleries
must be discovered by careful probing. 
22               PYORRHCEA ALVEOLARIS.

                         GROTTOES.
  The attention of readers is called to a differentiation from
the galleries, one that enhances complications and is very diffi-
cult of management by the operator, even should he be fortunate
enough to discover its existence; this, also, is much oftener
present than  may  be  suspected—I  refer to excavations be
tween the roots of molars and two-rooted bicuspids.  I have
a number of times found a  " pocket" extending up the ap-
proximal  face of a root of a superior molar, and passing  in
between the roots, having excavated the bony process to such
an extent that the inner  faces of the roots were exposed for a
third of their length.  These grottoes are  also simple  and
blind; the blind passing into  the crotch, and terminating there;
the simple passing entirely through, possibly  beginning  and
ending in " pockets."
  The inferior molars are also subject to the grottoing process.
  Pyorrhoea  alveolaris is often symmetrical, but quite as often
is not, therefore  one may  infer that it is not always inherited,
nor  even constitutional.  It does  not necessarily prevail  en
sequence, and is not contagious—even from socket to socket in
the same jaw.
  A tooth that  is  in proper relations  with other teeth in the
arch  may develop chronic  pyorrhoea alveolaris  upon  any
aspect,  and  so continue the  sole case of pyorrhoea  in that
mouth for years.
  Given an  entire  phalanx of inferior incisors, each member
of which  presents  an approximal " pocket" on each side,  a
selection of alternate  teeth may be  made from such  phalanx, 
PYORRHCEA ALVEOLARIS.
23
treated  and completely  cured, the other  members remaining
uncured—untouched—the  cured teeth will remain free from
the disease indefinitely.
  After a cure has been affected in any cases, and the " pock-
ets " closed, there is no notable tendency to a recurrence of the
disease.
  Although  an untreated " pocket" always contains pus, the
latter may not be exhibited by pressure, because  in  some
deeper cases  the external plate of process remains intact, and,
although  much thinned by resorptive or erosive action, still
remains  strong enough to resist and hold against  ordinary
finger pressure ; therefore the symptom of oozing or expressible
pus is not always observed.  In such cases the pus is revealed
by probing.
                     THE  BONY SEPT.E.
  The destruction of alveolar  process, due to periostitis, in
pyorrhoea  alveolaris—is peculiar to  the  bony septse in which
often the loss is very extensive.
  The festoons of gum immediately overlying the " pockets "
are always quite spongy, and the first  reliable  indication of
recovery of health to the part is a marked contraction of the
spongy gum ; this  contraction is incident to forming eschar,
and must bring the gum well to the bone,  and the  extent
of shrinkage therefore Mill be in proportion to the  amount
of bone that has been lost.  Often this shrinkage of gum is so
extensive as to alarm  the patient and  annoy the operator, but
as it is essential  to reliable indication of cure it  should  be 
24
PYORRHCEA ALVEOLARIS.
hailed with pleasure  by both.   The contraction between the
teeth usually results  in forming  a  dimple, which  marks the
triumph over pyorrhoea alveolaris.
                        SYMPTOMS.
   The symptoms of pyorrhoea alveolaris are divisible into con-
stant and inconstant.
                   CONSTANT SYMPTOMS.
   Pus is always present in untreated " pockets."
   The gum tissue overlying a " pocket," is puffed and glazed,
the color being a modification of violet.
   In interdental  spaces the gum appears to take a secondary
growth, sending a wedge-shaped process toward the articular
line; this process usually is of an  angry red color.  This con-
dition of gum generally indicates  the earlier stage of the dis-
ease.   Incidental shrinkage occurs  later, after which the vio-
let color becomes more apparent.
   In all cases, the " health line" dips to  the  orifice of  the
socket.   In proportion as a  state of health obtains,  the
" health line " is reasserted.
   In chronic cases where there are a  number  of " pockets,"
the patients report feverish  discomfort in parts involved at all
times; a disagreeable  taste emanating about the teeth—par-
ticularly after protracted sleep; frequent lassitude; impaired
digestion.
                  INCONSTANT  SYMPTOMS.
   Pus expressible  from "  pockets " with a finger or  other
means. • 
                 PYORRHCEA ALVEOLARIS.               25

   Frequent lancinating pains in affected sockets, and  some-
times regional neuralgia that may involve an entire side of the
jaw.
   Slow but progressive recession of gum at the cervix, attended
by excessive sensibility of exposed surfaces.
   Distressing night-pains when in bed, sometimes  described
by the sufferer as a drawing sensation in the" pockets "—relief
from which is obtained by sitting up in any manner to avoid
sleeping in a recumbent  position.   This  symptom is peculiar
to cases of long standing, and indicates extremely deep " pock-
ets."
   Loosening of teeth in their sockets, at times elongating or
lifting, and soreness.
   Rotation of one or more teeth, sometimes pushing them out
of the arch—a condition  more common to incisors,  but occa-
sionally affecting bicuspids.
   In very bad cases where there are many " pockets " of un-
usual pvorrhceal  activity, the faces of patients may appear
puffed, particularly  under the eyes, skin appearing doughy ;
extreme languor ; bad gastric condition.

                         DIAGNOSIS.
   By inquiry ascertain the  observations of the patient, and
note to  what  extent they may comport with the symptoms
stated herein.
   Observe any gingival inflammation and sponginess of gum,
and bluish or violet color about the necks of teeth. 
26
PYORRHCEA ALVEOLARIS.
  Apply firm pressure with a  finger or other means upon the
gum at cervical regions and watch for possible  expressure of
pus.
  Test all  gingival  borders with a delicate, flat, non-rigid
probe, in quest of" pockets."
  Interrogate  the patient as to gastric disturbances—due to
ingested pus.
  If the  complexion is sallow, and  the face puffed,  particu-
larly under the eyes, inquire for urinary disturbances.

                       TREATMENT.
  First remove from the mouth all visible salivary calculus.
  Having located a  " pocket" and  determined the form and
depth, the  operator  should, if possible, definitely locate the
calculus, and inform himself as to its extent, etc.  These points
are  essential to a proper selection of instruments most available
for  the proposed operation.
  In  conducting  the preliminary examination  it should  be
borne in  mind that the pus " pockets " are of two kinds, simple
and complex.  A complex " pocket" is galleried  or  grottoed,
while simple ones have direct  continuous  sides that are easily
followed  by a  probe.   Complex " pockets" seriously compli-
cate procedure, even when fully understood.
  For the  purpose  of examining the " pockets" the writer
has found most practicable a steel sound, not exceeding half a
line in width, the angles all carefully reduced, the end rounded
and smooth; the  handle should be  octagon and  slender, the 
PYORRHCEA ALVEOLARIS.
27
blade flat and long and slightly curved.  The advantage of
this  instrument is the  facility with which it may be inserted
into  narrowest  or  smallest pus "pockets" with safety to all
parts; it does  not needlessly distend  the entrance, and may
be easily passed to all parts of nearly all cases.
                   CULTIVATED TOUCH.
  As very much depends upon the  sense of touch in operat-
ing in these cases, clumsy instruments are inadmissible, and it
is essential that the cushions of the  thumb and fingers of the
operating hand shall be soft and sensitive  to a high degree.
This condition  may be attained by submitting  the hands to a
bath of fairly hot water  immediately preceding an operation,
and  it may be renewed once  or twice  during an operation
should the fingers feel  glassy.
                        HOT WATER.
  For the purposes of the surgical  operation, have at hand a
supply of water heated to 140° Fahrenheit, and an ordinary
three-ringed syringe; charge the syringe with the hot water and
proceed to wash out the " pocket" selected  for an  operation,
projecting as forcible a current as may be developed withihumb
and  fingers.
  In every instance  this process  of hot douching should be
repeated four or five times in rapid succession, as it not only as-
sures the thorough cleansing of the " pocket" by removal of
pus and extraneous substances, but the stimulating effect of the
hot water is essential.
  Hot water excites  both pericementum and periosteum to a 
28
PYORRHCEA ALVEOLARIS.
high state of receptiveness, permitting quick effect of a  solu-
tion of cocaine, which should be applied immediately within
the "pocket" to induce local anaesthesia.  If properly applied
this solution will obtund even the cementum in most cases.
  There is no danger of using the hot water too freely if the
temperature is carefully maintained at 140° Fahrenheit.
  The ordinary nozzles that come with the three-ringed dental
syringes are too large for the treatment of pyorrhoea alveol-
aris, as they frequently cannot be inserted into the '"pockets"
without force, which is not admissible.   Accordingly the oper-
ator should  supply his case with a number of  syringe-nozzles
of various sizes from the hypodermic to the ordinary, with a
variety of curves  for convenience  of direction.   The  hypo-
dermic nozzles should be ground  stubbed at the end, instead
of pointed.
  The operator should  bear in mind  that 150° Fahrenheit
scalds, but that as  high a temperature as may be safely used is
best;  in order  that accuracy may be had there should  be  at
hand  a common dairy thermometer, costing about  25  cents,
and the fact that 140° Fahrenheit is about as high a temper-
ature as safety to soft tissues would warrant, should be remem-
bered.
                    LOCAL ANAESTHESIA.
  It is absolutely essential that the surgical  operation shall be
attended with  little or no pain (far  better none), otherwise  it
often will be impossible to induce a patient to submit to com-
pletion of a sitting; even where, possibly, the endurance of a
patient has been equal to the suffering  inflicted during a first 
PYORRHCEA ALVEOLARIS.
29
sitting without anaesthesia of any character, he leaves the of-
fice of the dentist with a mental  reservation that he will not
return for another sitting.   It is far better to avoid this dread
than to have to labor to overcome it.
  By a proper application  of local anaesthesia this operation
may be rendered so free from pain that  patients may be de-
pended upon to  return cheerfully for any number  of sittings
that may be deemed necessary.
  Often the dentist finds it necessary, or  at least  desirable, to
operate upon several teeth at a single sitting, requiring pro-
tracted effort on  the part of the operator, and subjecting the
patient to a test of endurance that  without due  safeguards
might result in nervous collapse, or in something akin to sur-
gical shock.   In such protracted operations the patient should
be fortified  and  protected  by an  effective local anaesthetic or
obtunder of some character.
                  GENERAL ANAESTHESIA.
  General anaesthesia is not practicable in operations in pyor-
rhoea  " pockets."  It adds seriously to the difficulties of the
surgeon, who has enough to occupy his whole attention with-
out  having the  care of an  insensible and unaccommodating
subject of anaesthesia;  it also contributes the element of dan-
ger to annoy the operator under circumstances where all should
be perfectly safe ; besides, it requires  special  assistance, which
sometimes is objectionable to patients, and  might  necessitate
the presence of a physician. 
30
PYORRHCEA ALVEOLARIS.
                         COCAINE.
  A saturated solution of cocaine in water may be used effect-
ively for obtunding sensibility in gum or other soft tissues,
which sometimes is advantageous in preliminary manipulations,
but seldom can be made effective to reduce sensibility in the
pericementum or cementum.   But cocaine may be made effect-
ive for these tissues, even to the apices of roots, without hypo-
dermic administration or danger of any ill effects, and so thor-
oughly obtund all parts involved that an operation of consid-
erable magnitude may be carried to completion without notable
discomfort to the patient.
  The preparation of cocaine that in my hands has  produced
the very best  results, and with greater uniformity, upon the
pericementum and  even upon the  cementum itself, is a solu-
tion of the alkaloid in Squibb's chloroform; it is a saturation,
but  attains a  strength of only about 8 per cent.   It  is pre-
pared as follows:
  Put half an ounce of the chloroform  in  a suitable bottle,
add freshly pulverized  hydrochlorate of cocaine, shaking and
waiting a few seconds after each addition of the alkaloid, un-
til the solution clears.   To  this solution  add six  to  eight
drops each of  oils of cloves, cassia  and menthol, and to this
add  ten drops of  Mary  Stewart extract or some  other of
equal strength of flavor.   The idea is to perfume the solution
and render it agreeable.
  Although a saturation of cocaine in  chloroform cannot ex-
ceed a strength of 8 per cent., yet the addition of the essen-
tial oils and flavoring extract  increases the  solvent property 
PYORRHCEA ALVEOLARIS.
31
of the mixture, and it will take up enough more  cocaine to
make fully 10 per cent., which it should be given.   After the
completion of the solution it should be of a clear amber color
and a beautiful preparation, with a very agreeable odor.
  This solution of cocaine is absolutely stable for any length
of time, and because of the addition of the essential oils there
is scarcely any perceptible evaporation of the chloroform dur-
ing use from the bottle.   Aside from their therapeutical values
the essential  oils, by their combined  odors, help to disguise
the odor of chloroform,  which is so familiar to many and al-
ways  alarming to some, to others intensely disagreeable.
  All water solutions of cocaine are  extremely unstable, and
are expensive  unless  prepared in very small quantity at a
time as needed.
                    TO APPLY COCAINE.
  Referring  again  to the  forcible  douching  of  pyorrhoea
" pockets " with water at  140° Fahrenheit,  the last  injection
of hot water should be  immediately followed by the cocaine
solution, which should be introduced directly into  the  deep-
est part of the "pocket" in  barely sufficient quantity to flood
the pus  cavity without  overflow; for this purpose  one drop
will be enough in almost any  case.  After  each  introduction
of cocaine the case should be protected against saliva for two
or three minutes, after which expectoration may  be permitted
quickly.   The douching with hot water and following with
the cocaine solution should be performed alternately three or
four  times  before  proceeding with the  operation, the object
being to induce a cumulative effect of  the obtunding drug. 
32               PYORRHCEA ALVEOLARIS.
  Pre-application of hot water  hightens  and quickens the ef-
fect of the cocaine solution, apparently stimulating the tissues
and promoting receptiveness in  them.  Immediately after the
third or fourth application of cocaine, as herein described, the
surgical operation should be commenced, and usually it should
be painless altogether.
  In very deep " pockets " it often  is necessary to  inject the
cocaine solution in order to bring it  in contact with all parts,
but care must be  exercised that  the  injection is made into the
" pocket" only.
  It is not possible to protect an injected case from encroach-
ment  of  saliva always, but in excessive flow of saliva the
dentist will have to repeat the cocaining process two or three
times extra in  order  to be fully successful.   If patience  and
perseverance are exercised there will be splendid results from
the application of cocaine, as here given.
  For  most cases the most convenient, effective and economi-
cal device, for applying any of  the  preparations used in this
treatment, is a common goose-quill shaped like a slender tooth-
pick and  scraped thin to secure flexibility,  leaving the long
feather stem for a convenient handle.  A quill is  practically
unaffected by medicinal agents used  in dental practice.   This
indestructible property is particularly valuable in the secondary
treatment, where some  of  the remedies used  are highly cor-
rosive.  But this will be fully explained in its proper place. 
CHAPTER III.
                  SURGICAL PROCEDURE.
  Having selected a suitable instrument for a particular case,
it should be passed gently along the surface of the root, within
the pus "pocket" to the  point of attachment of membranes
wherever that may be.   Press the  hooked blade of the instru-
ment firmly against the root, beyond the incrustation, and with
steady  retractive efforts remove all obstructions from  the sur-
face of the  root, and  if possible  reduce  all roughness; this
may require expenditure of considerable time and exhaustive
persistence.   After removal of all discoverable  calculus,  the
surface of  the  root itself  should be well and  thoroughly
scraped, no effort being made to conserve pericementum.
  If during  a protracted operation, there should promise  a
return  of sensibility to the part, prompt resort should be had
to hot  water, to  be followed with the cocaine solution, after
which  the operation may be proceeded with in assured insen-
sibility to pain.
  There is no possible danger of the scraping of the root being
overdone;  removal of thickened  pericementum within  the
''pocket"  and the  scraping  away of subjacent cementum
which  has become partially or wholly solidified by obstructive
calcification, or saturated with pus, will conduce to reassertion
of a healthy  pericementum and assured superficial excemen-
tosis, i. e., certain cure. 
34
PYORRHCEA  ALVEOLARIS.
  To the experienced and skillful  operator success should at-
tend the first operation  in nearly  every case;  whenever this
initial success is  not realized, the operator may rest assured
that either some particles of attached calculus remain, or that
the cementum itself requires further scraping, or possibly that
both deficiencies exist.
  The surgical operation must be  repeated as  often  as neces-
sary to attain completeness.
  As before suggested,  the dentist  may rely on the beneficent
power of cocaine to  carry his patient through the most pro-
tracted operation incident to treatment of pyorrhoea alveolaris.
                 DILUTE SULFURIC ACID.
  Water solutions of sulfuric acid  are stable.   Before enter-
ing upon the surgical work described, the dentist should have
at hand a solution of one part commercial  sulfuric acid in ten
parts of pure water;  or, if he desires to be exact, a five per cent.
solution of C. P. sulfuric acid in distilled water.
  The  surgical  operation should be  followed, within a  few
minutes, with  an   application  of the  dilute  sulfuric  acid,
directly within the treated " pocket."  As  sulfuric acid is a
severe irritant to raw surfaces, it is better  to obviate pain by
continuing the use  of the cocaine  solution once in the same
manner, as at first.  This will so  obtund  sensibility in the
parts, that the acid will occasion  no discomfort whatever to
the patient.
  For applying  the diluted sulfuric acid  in  this treatment,
there probably is nothing better than a syringe, as the prepa- 
PYORRHCEA ALVEOLARIS.
35
 ration  should be forced to all the parts of the "pocket," no
 account being taken of overflow, except reasonable precaution
 should be taken as to quantity used.  In some deep cases, the
 quill device should follow the syringe, to  insure the diffusion
 of the  acid to all parts of the " pocket."
   The  application   of  sulfuric  acid completes  the surgical
 sitting; after this  application, the parts  should  be guarded
 for a moment against encroaching saliva, until the surface of
 blood-clot at the entrance to the socket becomes well glazed.
 This clot blackens under the influence of the sulfuric acid,
 and  for a time  acts as a hermetical  dressing, preventing the
 ingress of extraneous matter—possibly even of saliva.
   After completion of the first  sitting, the patient should be
 required to return  in five days, when possible, for secondary
 treatment.
                      OPERATIVE  NOTES.
   The chloroform solution of cocaine is a subtle fluid, and  in
 spite of one's best efforts will escape  to some  extent and flow
 about the mouth; under such circumstance, there may be pro-
 duced  some  sensations to the  patient  that  are  unpleasant,
, possibly  alarming; this effect, however, is merely  local, and
 is  readily dissipated  by laving the mucous surface well  with
 some form of diluted alcohol.  The  matter of use of alcohol
 should be rather a choice, according to the taste  or prejudice
 of the  patient—a simple inquiry  will settle that point.
   Alcohol maybe diluted by adding one  tablespoonful,  to  a
 half-glass of water; or the same amount of  ordinary drug-
 gists' bay rum  (perfumed alcohol, 50 per cent.), in a fourth 
36
PYORRHCEA ALVEOLARIS.
 of a glass of water; or, as is preferable in most cases, a table-
 spoonful of whisky may be held in the mouth for a  couple  of
 minutes; the effect gives almost instant relief, and the patient
 leaves the office of the dentist with no unpleasant impressions,
 which should always be  the case in  order to insure a return
 for necessary subsequent sittings.   I would  suggest that the
 bay rum should not  be swallowed, as the dentist can not well
 know  the medicinal properties of the elements of perfumery
 it may contain.
                INSTRUCTIONS TO  PATIENTS.
  Patients  should be cautioned to carefully avoid  the use  of
 alkalies in the  mouth, as far as possible in diet, and particu-
 larly in dentifrices or mouth-washes.   During treatment, and
 for some months subsequently, common  pulverized  sulfur
 should be used as  the  sole dentifrice;  it  polishes  the  teeth
 much better than chalk, and exercises a mildly antiseptic influ-
 ence ;  the extremely small per cent, of free sulfuric acid that
 always  is present in commercial sulfur aids in acidulation of
 saliva.  Sulfur thus used is  a great aid  to  the recuperative
 period.  Sometimes there is  an  aversion to sulfur on the
part of patients, which usually is based on  early  reminiscences
 of the ills of childhood ; a little  reasoning and good advice
 may overcome such objections to the extent of a promise of reg-
 ular use of the  stuff for a specified  number of weeks.
  All cases are much benefited by  the frequent use of a  solu-
tion of alum in clean rainwater, the brush may advantageously
be wet with it  when brushing with the  sulfur powder.  The
taste, however,  is not of an agreeable character to  most persons. 
PYORRHCEA ALVEOLARIS.               37
                 SECONDARY TREATMENT.
  At the beginning  of a second  sitting, the  dentist should
carefully press with  a  finger all about  the  orifice of  the
" pocket " recently operated upon,  to  ascertain whether any
pus may be still  expressible, or, slightly open the " pocket"
with  the flat probe  to liberate  confined pus—if any  there
be (?).  Also, he should look for evidences of shrinkage  of
gum between the teeth, and  at any other part  in which  there
had originally been noticed the bluish or violet coloring. The
shrinkage occurs oftenest and most markedly in the festoons
between the teeth, where it usually forms little dimples—some-
times deepening into distinct funnel-shaped  pits in the soft
tissue.   The latter form always  indicating extensive resorp-
tion of the septum.
  The shrinkage of the gum is assurance of cure ; although in
some instances the shrinking of gum will be so extensive as to
alarm the patient, particularly if on or toward the labial aspect
of an anterior tooth, it should be borne in mind and impressed
upon the patient that there can  be no  cure without shrinkage
of gum  in proportion to  the loss of  alveolar  process immediately
subjacent.
  If the examination at the  second sitting shows that the sur-
gical  work  was  effective  and  shrinkage satisfactory,  the
" pocket " should again be douched liberally and forcibly as
in the first instance, the water at the specific  temperature of
140° Fahrenheit, in order  to assure thorough cleansing of the
pus cavity.   If the operator desires to  use peroxid of hydro-
gen, or the three per cent, solution of pyrozone,  he may do so 
38
PYORRHCEA ALVEOLARIS.
to better advantage or at  least to greater satisfaction after the
douching with hot water,  as the foaming makes a much pret-
tier display where everything has been thoroughly cleansed
previously; the fact is that it is not an indicator  of pus, and
that the greater the proportion of pus present the less foaming
activity of the pyrozone.
  After the thorough  washing out of the " pocket"  at the
beginning of the secondary treatment, the next step is to treat
the case with a ten per cent, solution of nitrate of silver, which
should be  made  to permeate  every possible part  of the pus
cavity.
              NOTES ON  NITRATE OF  SILVER.
  Nitrate of silver should be applied with a quill device (pre-
viously described) wherever practicable.  It is  true that  the
solution can be better applied with a syringe, but  it is  highly
destructive to the metal of which syringes are made; it fouls
rubber syringes in a most peculiar manner and  renders them
useless very soon.   It is expensive to have syringes constantly
damaged and maybe ruined  by medicinal agents, but the den-
tist who essays to succeed with this method  of treating pyor-
rhoea alveolaris must  not expect  to do so too economically.
If, in a given case,  it appears necessary to inject this solution
of nitrate of silver into a  " pocket" in order to attain success,
there  should be no hesitation at the cost of an ordinary dental
syringe.
  After applying the nitrate of silver solution, it  is well that
the case be protected against saliva for a minute or two. 
PYORRHCEA  ALVEOLARIS.                39
   Due precautions should be taken to protect any metallic fill-
ings or devices from the blackening corrosive action of nitrate
of silver.
   Observe that the ten per cent, solution of nitrate of silver is
just short of the caustic strength.
   The solution of nitrate of silver is very unstable, as are  all
solutions of this salt in water.  As it is expensive it  is best
that the solution be made frequently if necessary, and in small
quantities.
   If the dentist prefers or finds it necessary to prepare his own
solution of nitrate of silver,  he can easily do so by weighing
out six grains of the crystals and dissolving them in one dram
of filtered or distilled water.
   Observe the solution of nitrate of silver daily, and as soon
as flocks of black solid matter appear it is deteriorating, and
should  be emptied  out.  The solution keeps  better  in blue
glass bottles, and  must be kept tightly corked against organic
particles afloat in the air.
   Glass stoppers  are not best in bottles containing solutions
of  nitrate of silver; common corks are far better.
   It will do  no harm in any case to repeat the nitrate of silver
treatment at a third sitting, although one usually suffices.
   After all use of nitrate  of silver shall have been completed,
the patient's teeth and fillings should be carefully polished
free from all stains.
                     SUBSEQUENT CARE.
   In most cases, after the second treatment, the patient may
report in a week with no evidences of the disease in the " pock- 
40
PYORRHCEA ALVEOLARIS.
ets " that have just been treated; but the " pockets " will be
there until  nature can  fill them in with  new bony structure,
which requires time.   The case, meanwhile, must be kept clean
by weekly or fortnightly attention, washing out the " pockets "
with the hot water in forcible currents, and treating them with
injections of some acid astringent;  preference  may  advan-
tageously be given to strong solutions of chloride of aluminum,
or,  better still, the  standard  preparation known  as  bromo-
chloralum—which is  sold by nearly all druggists.
  The chloride of aluminum (common alum) or the bromo-
chloralum should not be used at the same sitting with nitrate
of silver, owing to the facility with which a chloride of silver
may be  formed by  such  combination in  the  mouth.   This
chloride of  silver  has a light or whitish color, and clings to a
tooth-root more tenaciously than even the calculus, and posi-
tively will not scale off, but must be scraped to the last bit.
  If possibly there are  evidences of pus in a treated " pocket"
at the third sitting, the dentist may rest assured that the surgical
operation must be repeated, and extra care  taken to make it
complete and final, if possible.   Instead of such an unfortunate
coincidence  being discouraging, it should stimulate to better
effort and a  determination to conquer success.
  The operator will  be gratified and fortified by having his
patient to return once or twice a month for a couple of months,
as these occasions for examination will afford assurance of ab-
solute successful cure, and  to warn the patient as to unclean-
liness about the teeth. 
PYORRHCEA ALVEOLARIS.              41
                   SOME PROPERTIES.
  Delicate napkins should  never be used in this treatment, as
the principal medicinal agents employed are highly damaging to
fabrics; pieces of ordinary muslin will be found effective and
economical.
  Before beginning treatment at any sitting, the patient's face
and  lips should be annointed with some oleaginous matter to
protect  from irritation and  discoloration;  for this  purpose
nothing appears simpler or better than a perfumed preparation
of vaseline, which may be  ever at hand.
  An assortment of long,  slender  scalers have proven  most
effective in the hands of the  writer.  They  have been devised
and selected so as to form a set, arranged  in pairs—straight,
curved, simple and compound;  some essentially peculiar—all
in rights and lefts.   All act on the hoe principle—both to and
from the operator.   This set is the result of developing emer-
gencies under the treatment  pursued by the writer,  who has
had  arrangements made for their manufacture by a reliable
firm*, and they may be ordered through any reputable dealers
in dental  supplies.
   Always have at hand a large apron of rubber or oiled silk,
with which  to  protect the clothing of the patient from water
or damaging agents of any sort.
   The dentist should keep a systematic and concise record of
his cases  of pyorrhoea  alveolaris, beginning  with the  initial
examination; otherwise a number of cases  on hand at the
same time, and  in various stages of treatment, would lead to
hopeless confusion.
  *H. D. Justi & Son, Philadelphia. 
42
PYORRHCEA ALVEOLARIS.
  In closing this chapter the writer urges upon the operator
to exercise perseverance, devote greatest possible pains to dis-
covery  and removal of every particle  of calculus from the
root, all loose  and  thickened pericementum, and thorough
scraping of the cementum involved; lastly, he must possess in-
exhaustible patience and sympathy.
  Absolute success must attend every case, and this is possible ;  no
partial success can be awarded any credit whatever—that has
been the stopping place for a hundred years.  Partial success
is only modified failure, in treating pyorrhoea alveolaris. 
CHAPTER IV.
                        TARTAR.
  Salivary calculus or tartar is universal in the mouths of man-
kind, and probably in some degree common to all species that
are provided with saliva.
  All authors upon this topic agree that salivary calculus is
principally composed of certain salts of lime precipitated from
saliva in the mouth, with various other accidental ingredients
that become involved in resultant crust.  It is rather difficult
to discover very much that is instructive written upon the eti-
ology of salivary calculus, but much of an ambiguous  char-
acter.  It  seems to the writer  that the tartar so commonly
observed in  mouths  of our patients, is so ordinary and com-
monplace as to have attracted little important consideration.
  That this salivary deposit has not only an interesting etiol-
ogy, but also important physiological properties there is abund-
ant reason for believing; also, the preceding chapters on pyor-
rhoea alveolaris certainly justify conclusions as to pathological
considerations.
  Dr. George Watt, of Xenia, Ohio, wrote in his little volume
of Chemical  Essays, as  follows :   " The lime salts named are
probably present in all normal saliva—in solution.  *   *  *
Water is the chief constituent of saliva, and sub-phospate and
carbonate of lime are but slightly, if at all, soluble in water.
But  normal  saliva is saturated with free  carbonic acid, and 
44
SALIVARY CALCULUS.
thus charged  is able to dissolve and hold these lime  salts.
*    *    *    If by any process  this carbonic acid is taken
from the saliva, it cannot hold the  salts and they are precipi-
tated as tarter.   *   *   *   The alkali that nearly, if not
quite, always takes this  carbonic acid from saliva, is ammonia.
*    *    *    The ammonia may be a result of the putrefaction
of nitrogenous matter within the mouth."
  The statement of Dr. Watt  that  the ammonia may result
from putrefactive  change in nitrogenous matter  within the
mouth, means that the decomposition of meats and particles of
other articles of food left between the teeth, results in libera-
tion of enough ammonia to  cause precipitation of the salts of
lime from saliva, resulting  in calcarious accumulations and
crustation around and upon  the teeth.
  There are some  medical works that shed valuable light upon
the subject of salivary  tartar, rather indirectly certainly, but
presenting facts of pathological nature that are applicable here.
In  Vol. I, of the " Reference Hand-Book of the  Medical
Sciences,"  1885,   may  be   found  the  following  language:
" With regard to the immediate nature of the process involved
in the precipitation of the lime salts, there is  some difference
of opinion.  The simplest mode of explanation, and one which
at present may be  considered as nearly correct as any we have,
is to look upon the process as similar to that  involved in the
formation of stalactites."
  All of us have  noted  the occasional incrustation that occurs
on stones, and sometimes even  on sticks and  logs in streams
and  pools of water, the crustation  varying according to the 
SALIVARY CALCULUS.               45
term of immersion and the  geological character  of the terri-
tory in which the water was confined or through which it had
passed.   Water-pipes in our houses, and water-mains under
cities become encumbered in time with incrustations of the
lime salts that have been in solution in the water.
  Every one, probably, has recollections of a home  in which
as a child he enjoyed special privileges, among which was vis-
its to the kitchen, where he was interested in watching the old
tea-kettle whose lid danced apparently for his amusement as
the steam sputtered out just as it did for the other Watt in the
other century.  One can recall the curious incrustations of
lime that lined the tea-kettle's sides and bottom—much to the
annoyance  of the cook of early and blessed memory.  The
lime that encrusts the  stone  in the  brook, that lined the old
tea-kettle, that obstructs the water pipes, is tartar; not exactly
salivary  calculus,  but tartar nevertheless, without the addi-
tional elements of epithelium scales and general trash of in-
ternal and extraneous  origin.
  Continuing quotations from the " Hand-Book of the Medi-
cal  Sciences," we have the following :  " A certain amount of
calcarious matter is a normal constituent of the blood in which
it is held in solution by the carbonic acid  always present in
sufficient quantity to keep in solution twice the normal amount
of earthy matter."   Herein we have full corroboration of the
statement made by Dr. George Watt upon the same point.
  In the " Hand-Book of the Medical Sciences " from which
quotations are made, we read  further :  " When the circulation
is impeded,  the free carbonic acid (because of its  great diffus- 
46
SALIVARY CALCULUS.
ibility) is readily absorbed by the tissues or goes to form new
compounds, necessitating a precipitation of the calcarious mat-
ter.   *    *   *    Calcarious  matter  may be  deposited  in
either a fibrous or fluid matrix."
  There  can be no  doubt that  material environments  may
exert a great influence on the character, quantity  and rapidity
of accumulations of tartar upon the teeth of individual subjects.
  There  are mechanical conditions that conduce to the forma-
tion of scales of tartar upon the teeth.  Practitioners daily ob-
serve mouths wherein for some reason, perhaps a habit,  or
owing to a deformity, or  to a  weakness of the jaw or muscles
of mastication, due  to disease or accident, there  has been a
failure to employ a large portion of the teeth in mastication.
In such instances experience teaches us to anticipate extensive
deposits of calcarious matter upon the  unused teeth.  But we
do not always find it so;  the  fact remains, and unexplained,
that some individuals are blessed with immunity from deposits
of dental tartar, notwithstanding that they are utterly negli-
gent of  the sanitary condition of their mouths, which  per-
haps  may  be accounted  for  by  their thoroughly  employing
their teeth  in mastication of food; all of which  is in evident
accordance with creative  economy, and therefore correct.
  It would be interesting to  know certainly, to  what extent
and in what way the state of health  of the individual may  or
does modify the tendency to deposition of lime upon the teeth.
The healthiest  appearing subjects often present  the most an-
noying predisposition to  such deposits, while it is a fact well
known among dentists that  consumptives  are but little an- 
SALIVARY CALCULUS                  47
noyed with accumulation of tartar upon their teeth; but if the
lime salts are deposited in certain other  parts,  tissue or organ,
such as the bladder  or lungs,  the blessing of  immunity from
salivary calculus may be a doubtful one at best.
  Physiologists tell us that the phosphate and carbonate of lime
are to be found in all the  tissues of the body;  that they are
in solution in the water of the body by virtue of carbonic acid.
Quotations given in this chapter  show  that  there is enough
carbonic acid in the blood  alone to  enable  it to hold double
the necessary  quantity  of  these salts;  that there is nearly
always an excess of lime salts  in the  water  of saturation and
circulation;  therefore, that the  saliva should be surcharged
with these salts is a normal  and healthful state, and should be
anticipated and appreciated.
  That certain effects are produced in the alimentary canal by
the salts of lime after they  are precipitated  in the mouth and
swallowed wTith food, the following would appear to indicate;
" In ordinary food  there is more of the phosphates than the
system has need of, so that  they  are  constantly escaping with
the stools."  [See Wood and Bache's U. S. Dispensatory, 1876.]
  There is abundant evidence to show  that the salts of lime
really  temper the feces in the intestine, the phosphate acting
as a mild  laxative and  the carbonate checking  tendency to
diarrhea or too free discharges.
  After all then, the precipitation of lime salts from saliva in
the mouth is evidently physiological and therefore desirable.
Probably the only unnatural  and  pernicious  aspect  of such 
48
SALIVARY CALCULUS.
salts in the mouth consists in their accumulation on the teeth,
which simply is permitted.  The rational course is to  not at-
tempt interference with natural processes, but strive to  induce
our patients to exercise reasonable cleanliness  and to prevent
accumulation of tartar on their teeth by  employing those
organs in a manner at least approaching what Nature intended
in endowing them with teeth. 
 
 
 
 
 
 
 
 
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