cause we begin to have shrinkage of the overlying soft tissue as soon as we remove the irritating debris of the root surface, which shrinkage of the gum limits the outpour of bone from the thin process

Fig. 15 A.

requirements will we be able to gain bone. Some men deny the possibility of regeneration of bone of the jaws. The author draws your attention to a lantern slide in a case first operated by Doctor R. E. Farr, of Minneapolis, wherein he removed an inch and a half of the mandible for the removal of a malignant growth. The writer subsequently placed a splint of iridio-platinum wire connected with the left cuspid and laterals and the right second and third molars. A radiograph of this jaw some two years after the splint was put in position

Radiograph of Dr. Farr's case showing complete repair of mandible from whence one inch had been removed. An iridio platinum splint placed by the writer to hold the cut ends apart can be seen in the picture.

shows that the bone reached across from the left to the right side and that the bony continuity of the mandible has again been restored.

The writer also wishes to show in this connection, a picture which illustrates the ability of the process to pour out new bone around and against the teeth. This particular picture was obtained from the late Doctor Fletcher with whom the writer of this article had much in common. Its origin was briefly as follows: (Figures 17 A, 17 B, 17 C).

A patient had applied to a dentist for the removal of a lower bicuspid tooth. The dentist had attempted its extraction and had broken the tooth off well below the gum level and had then left this tooth in position. The gum had healed

Extracted tooth with new bone in pulp chamber. Fletcher's case.

root and subsequently had sections made, a picture of which I throw upon the screen, showing new bone deposited on the broken root end and pulp chamber of this tooth. A second picture shows an area of alveolar process photographed from the center of this chamber. While we all recognize the fact that the alveolar process is not a favorable field for regeneration, these examples show conclusively that if we can maintain our case under proper conditions that we certainly may expect a small amount of new bone at least in many cases. That bony outpour does frequently happen in the experience of

Pulp chamber of 17 A showing new bone.

root surfaces, and, having no elastic peridental membrane interposed between the root surface and the new bone, you have an analogy to ankylosis which occurs about implanted teeth. Presuming that this treatment of a case has been successfully carried to this point, is there anything further the operator may do to enhance regeneration? The author believes there is, and that the next step should be to protect the sterile blood clot in the pockets from the incursion of bacteria from the saliva and the tooth's surface. The bacterial growth is constantly recurring on tooth surfaces, and its inhibition or prevention must necessitate a constant battle to the end of life. Immediately, following the surgical treatment, the application of

some substance which will seal the pockets, shut and protect them from bacterial incursion is advisable. Many substances have been recommended for this purpose. The most valuable one of which the writer has knowledge is the following:

Merck's beechwood creosote saturated with all the iodine it will dissolve.

This makes a heavy black oily mixture

Fig. 17 Č.

Lacunae from center of 17 B. Fletcher's case.

and is to be applied to the gum edge and to the neck from one-eighth to a quarter of an inch to the gum edge and reaching up on the tooth neck to the enamel of the crown. Carefully preventing the saliva from touching this after it has been placed, we immediately apply a second coat composed of glycerine in which we have incorporated all the tannic acid that it can be made to dissolve. Thus the tannic acid most completely covers the first coat of creosote-iodine, and, if it is placed before moisture comes in contact with the creosote-iodine, the two solutions seem to unite and form a dense, tough, black brown material which will cling to the tissues from twenty-four to forty-eight hours, protecting the gingival margin from a bacterial incursion for that period of time.

If

thought advisable by the operator, the coating may be repeated every other day for several days, thus maintaining a condition of approximate asepsis. The author might state in passing that the application of this double coating to sutured incisions in the mouth protect these edges from infection and renders a wound much more comfortable than otherwise would be the case. It may also be applied to the cut edges where third molars have been uncovered by removing the gum. As soon as the bleeding has been checked by the application of hot packs, the cut surfaces may be coated with this heavy iodine solution followed by the tannic acid glycerine solution and the cut surface will be protected from infection and also from the irritation of the movement of the tongue. The method of carrying on pyorrhea treatment should follow certain definite lines and the judgment of the operator should be governed by the condition of the patient. In cases where we have only mild gingival inflammations and shallow pockets, the work may be rapidly accomplished without hurt to the patient. On the contrary, if the patient be subnormal in resistance, the pockets deep and heavily loaded with organisms, then the operation should be continued over a period of weeks involving only two or three teeth at each treatment. There are two reasons for this course. The first is that if the limiting wall of granulation tissue so beautifully shown to be present in all these pockets by the pathological work of Talbot and others, I repeat, if the limiting be broken wall of granulation tissue down rapidly, an enormous inoculation of the patient occurs at once, and this enormous inoculation may result in an acute disturbance, wherein metastatic transfer plays an important part, and result in a myocarditis, endocarditis, joint infection, or acute abscesses, or chronic infection of the kidney.

The author has learned by bitter expe

rience in the treatment of actual cases that haste in the treatment of these subnormal cases is exceedingly dangerous and subversive to the best interests of the patient, as he has noticed acute joint infection and even pneumonia to result in rapid sequence from, as he believes, over-inoculation from the tearing down of the limiting wall of the granulation tissue which must of necessity be broken down in the rapid treatment of these cases. A second reason for slow treatment by easy stages of these pyorrhea cases lies in the fact, that if the dosage of bacteria be gradually increased from

time to time, the ability of the blood stream to overcome the recurring doses of bacteria which of necessity must be forced into the blood stream by the surgical treatment, gradually raises the immunity of the individual so that at the end of a period of a month or six weeks' treatment of a case of this type, the patient's general resistance is steadily raised, appetite, ambition, and general well-being enhanced. In fact, treatment so carried on has all the good advantages of a polyvalent vaccine and none of its disadvantages. The post-operative care of an individual deserves also careful consideration. MASSAGE-WHEN AND WHY ADMINISTERED.

Massage of the gum margins should not be commenced following operative treatment until all outpour of bony callus from the process edge has ceased

After Treatment.

Blood pressure fell from 150 to 120. No treatment and no emetine or other drug was administered, showing clearly that it is possible to bring about great changes in the treatment of Pyorrhea without drugs by efficient surgery only.

suited to the gum tissue. Perhaps the best method of massaging the gums is with the cut end of the short heavy cotton roll. The dry cotton roll clings to the gum tissue and when held in a haemostat of a kuroris is easy of use by the patient. Its advantages are briefly that it expels the stagnant fluid from an oedematous gum margin and permits inflow of fresh arterial blood. The act of massaging the gum margin drives into the circulation any bacteria that may

the gum is caused to grow more firm and dense and resistant, thus fortifying the gum margin from further infection by enhancing a more perfect structure and locking the door to further infection. The weekly use by the patient of the disclosing stain to guide him in his daily mouth hygiene has a double benefit. The solution now used by most men for disclosing purposes is that mentioned in the beginning of the article, and, tho many times published by those who use it, the writer will give its composition once more for the benefit of the younger men who do not happen to be acquainted with it: Iodine, fifty grains, zinc iodide and potassium iodide each fifteen grains, water and glycerine each four drams, making a total liquid bulk of one ounce with a total bulk of eighty grains of solid material incorporated therein. This should be very carefully triturated and may be sponged on the soft tissues and tooth surfaces without harm occasionally. The author believes it is too concentrated for daily use. Its double benefit accrues from the fact that it destroys instantly the vitality of the bacteria with which it comes in contact and also brings into view the fields where they grow in greatest number undisturbed, thus guiding the patient to a more careful effort in the daily hygiene of the mouth.

Daily prophylaxis by the patient is the greatest safeguard against reinfection and the monthly prophylaxis treatment by the dentist is the best guide to the

patient's endeavor. Treatment by the dentist should be very carefully done and not left to careless hands. In this prophylaxis work the injury of the gum should be distinctly avoided as well as injury of the enamel surface and exposed cementum. It is possible to conceive that too vigorous or ill-advised use of the polishing material on either the enamel or dentine surfaces can do these tissues great harm, even destroying or cutting grooves in them, and has given ground for criticism by many conservative men. This phase of treatment is SO well understood that the author deems it unnecessary to discuss it under a special head.

The

There is, however, one more thought regarding this matter which appeals to the writer as a vast importance, and that is the question of so guiding the daily life of a patient in the matter of food and diet that the oral cavity as well as the balance of the body increases its immunity to all types of infection. work of Doctor Pickerel and Professor Gies of Columbia in this direction should be read and understood by every one of us. The work at present being carried forward by one of our Own number, Professor Bunting of the University of Michigan also should bear fruit in this direction. The net result of the work of Professors G. V. Black (*1), Pickerel (*2), and Gies (*3), has been to indicate to us that we can accomplish an enormous amount for our patients by first limiting diet to exactly what we need for our daily regeneration, thus avoiding excessive deposits of calculus, ingesting those foods which tend to produce a salivary fluid inimical to the growth of bacteria, and the use of such fluids and mouth washes which will promote a normal salivary outpour. This to the mind, of the writer is an enor

*1- Black, in Dental Review 1913. *2--Pickerel on Decay.

*3-Gies' research report, Journal of Allied Societies.