The Secrets of Specialists/Chapter 30

Whoever procures exemption from physical suffering may be considered a public benefactor and in no other field of labor has there been a better chance of earning such a title than in that of extracting teeth, as the painless operator is the one whom people praise and patronize, but as a general rule a large percentage of operators have made a failure of local anæsthetics, (nostrums) and have discarded them altogether, as being worthless. They do not understand why some can make a success of their use and others can not. While this chapter will not be an exhaustive treatise on the subject, I will endeavor to make it as plain and practical as possible, and give all the information that will be required to handle local anesthetics successfully. What will be said has been taken from the experience of myself and other operators under my observation, who have used this method successfully in over sixty thousand different operations; and I believe that every operator of ordinary skill and intelligence, who will faithfully follow the directions given will be equally successful.

A local anesthetic to be used in dental surgery, there are several objects to be obtained, viz.:

First—To have one that will be safe at all times.

Second—One that can be used in all pathological condition of the gums.

​Third—One that will have no bad after effects.

Fourth—One that will not decompose, within a reasonable length of time.

In the formulas given in the chapter on local anesthesia to which you are referred, I think we have overcome all these obstacles and have an anæsthetic that is safe and can by used in all pathological conditions of the gums without any bad after effects, if used with antiseptic precautions and ordinary skill.

The syringe for this kind of work should have a strong broad cross bar, or finger brace, also a large flat pistol head so that by continual use it will not make the fingers sore. The piston stem should have a minim graduate, or scale, and an easily working nut on the same (for we can best regulate the use of our medicine with this nut). The diameter of the glass cylinder should be quite small, so that you may run up a high pressure when required. Never use a syringe that holds over thirty minims, as larger ones take up too much room when operating. The metal frame work holding the glass cylinder should be open on both sides so that you can have a clear view of the contents of the syringe, and know that it contains no air or floating matter when operating.

The needle should be of medium size, about twenty-two, twenty-three or twenty-four standard wire gage is the proper size. When the syringe is not in use, put a wire previously dipped in olive oil through the needle, and screw the cap on the syringe tight; this keeps the needle from rusting and getting stopped up and the packing of the syringe from drying out. If you are not using the syringe continually you should oil the cylinder occasionally and always keep it in working order, and ready for use. Before using the syringe again be sure that it has been disinfected and is in a thoroughly antiseptic condition. Never use a rusty needle, or one that ​has a blunt, or rough edge. They always cause more or less irritation. One of the best things to sharpen a needle on is a common honing stone.

The accompanying cut represents the kind of syringe to be used when operating with local anæsthetics: 1. Piston head. 2. A 30 minim graduated piston stem with scale. 3. Nut which is set for about two minims, sufficient to inject one side of a molar. 4. Finger brace. 5. Metal frame work supporting glass cylinder. 6. Glass cylinder. 7. Plunger with oil chamber. 8. Needle. 9. Cap to be applied when syringe is not in use. If your needle should get stopped up, so that you cannot get a wire through, but can force water through, put a drop of sulphuric or hydrochloric acid in the funnel ​end of the needle, and blow until it shows at the point; allow it to remain this way a little while, then try to get the wire through; should you fail, try the acid preparation again until you succeed and then rinse the needle and syringe thoroughly.

With the medicine screw the needle on tightly (never remove the needle to fill the syringe). Insert the needle in the anesthetic until it has been thoroughly immersed, then slowly draw the piston back until you get all the medicine you can in the syringe. Adjust the needle upwards and make sufficient pressure on the piston to force all the air out of the syringe and needle; in this way you obviate the danger of injecting air into the tissues. Before operating make a

swab by winding some absorbent cotton around the point of a pair of pliers. (See cut.) Dip this into an antiseptic solution of which listerine is one of the best for this purpose, and bathe the gums thoroughly around the teeth to be operated on. This makes the operation thoroughly antiseptic, providing you have kept your syringe aseptic.

To be operated on by the use of local anesthetics can be divided into three classes, viz.: Firm, spongy and diseased. The firm gums are the most favorable of all for the use of local anesthetics, inasmuch as they retain the medicine in place a greater length of time, and lessen the constitutional absorption. You will find it requires a greater degree of pressure to force the medicine in firm gums than it does where they are spongy, and generally a sac will form where the medicine has been injected, which should always be spread by ​the antiseptic swab. Spongy gums are much more treacherous than firm gums, and if you do not watch them carefully after withdrawing the needle the medicine will escape, and you will not get the desired effect. Hence, after withdrawing

the needle, apply the antiseptic swab and scatter the medicine immediately. Ulcerated and diseased gums are almost invariably spongy and should always be treated as such, and carry out the antiseptic method of treatment more thoroughly by using listerine freely. Should there be an abscess I always open it freely and inject peroxide of hydrogen.

Swelling of the gums will follow the use of local anæsthetics in a certain per cent. of operations, which seems unavoidable, especially if the gums are diseased. The difficulty subsides in a few days, and leaves the gums in a perfectly healthy condition.

Insert the needle about one-tenth of an inch above or below the gum margin, as the case may be. Do not try to ​insert the needle between the gum and the tooth at its margin (a mistake made by many operators,) as you are quite sure to insert some debris which generally accumulates at the margin, along with the needle, which always causes more or less irritation. To insert the needle with but little pain, put the flat side of the needle on the gums and just make sufficient pressure to catch the needle under the gum tissue, and as you push the needle in on a line with the roots, force the medicine ahead of the needle until you have reached a depth corresponding

with the length of the roots; withdraw the needle and make sufficient pressure on the outside surface with the antiseptic swab to scatter the medicine and hasten its absorption by the alveolus. A similar treatment should then be made on the opposite side of the tooth and extract immediately. I never exceed waiting over one minute after rubbing the gums with the antiseptic swab. In this way you liberate a large portion of the medicine, hence more can be used for this purpose than where it gets access to the general circulation. Regulate the amount of medicine used at each injection by the nut on the graduated piston stem. In this way you do not have to watch the syringe to see how much medicine you are using at each injection, but you know when the nut ​on the piston stem comes in contact with the syringe, just how much medicine has been used.

In preparing teeth varies according to the teeth being prepared for operation. Molars and canines require more medicine than incisors and bicuspids. It also requires more medicine to prepare a single tooth than it would a number located together. For instance, if I were to prepare a single molar I would use from two to two and one-half minims on each side of the tooth, where if I was to prepare a number of molars located together I would use from one and one-half to two minims on each side. In preparing the four incisors at once, I make five injections, two on the lingual and three on the labial side, using about one and one-half or two minims at each injection. In preparing any single tooth, all molars and canines always inject on each side of the tooth. The reason it does not take as many injections on the lingual side as it does on the labial is, the space is more compact and the tissues more dense, and you can spread the medicine at your will with an antiseptic swab, which I always hold in my left hand when preparing the teeth. The accompanying cut will show about where to insert the medicine for a complete operation. The dots representing about where the needle should be inserted. It will require a little experience to become skilled in manipulating the syringe and needle, and the more you operate, the less medicine you will use, as it requires a little practice to learn where the medicine will do the most good. While I claim that the use of these anesthetics when carefully administered are perfectly harmless, at the same time I insist that they be properly used. Dentists generally think if they cannot inject a whole mouth full of a local anesthetic into a patient's gums at once, the anasthetic is at fault. Experience with the use of these formula in over sixty thousand different operations by myself and others under my observation, convinces me, that they are the safest ​and best in use, and, if handled with one-fourth the skill other anæsthetics are, you would never hear of any bad effects resulting from their use. It is not the use of a medicine but the abuse of it, that makes people condemn it. In carefully looking up the records of the use of local anesthetics, I am not able to report a single death caused by their use. If a patient presented himself for you to administer chloroform, you wouldn't commence by pouring one or two ounces of the drug on a napkin for inhalation, but would begin gradually, the same method should be observed in using local anesthetics. Instead of injecting a patient's gum full of the anæsthetic the first thing, carefully prepare one or two teeth, and operate in this way. If the operation is painless and successful, you get the patient's confidence, and he loses all fear of proceeding farther. Always allow a few minutes (from five to fifteen) after each operation for the patient to rinse his mouth and the gums, to stop bleeding. Then prepare three or four more, allowing sufficient time after each operation for the patient to rinse his mouth, and his gums stop bleeding. If your patient gets impatient, tell him you cannot operate while his gums are bleeding; for the secret of safety and success is to allow sufficient time to intervene after each operation. I will admit I am a hundred times more reckless than the instructions given above, as I frequently prepare from ten to sixteen teeth at a time, but I am so accustomed to its use, and can judge the temperament of a patient so well that I am perfectly safe in doing so. and the above instructions are laid down for operators with less experience and it is always best to be on the safe side.

Should you ever make such a mistake as to inject the gums full of the medicine at once and the patient should complain of feeling faint, sick at his stomach, etc., extract immediately, and this will liberate a large portion of the anæsthetic, also give the patient a liberal supply of good liquor (preferably brandy), and they will generally feel all right in a few minutes; but do not continue the operation until the patient tells you he feels better and is ready to proceed.

​If stronger stimulants are required, aromatic spirits of ammonia and amyl nitrate may be used to good advantage.

There has been much said of late in current literature regarding sloughing gums and disastrous after effects following the use of local anesthetics, and they do not understand why one dentist can handle a local anesthetic successfully and another cannot. Many dentists will secure some nostrum, allow it to stand around the office for three or four months, exposed to the heat and light until it decomposes and loses its strength, throw their syringe into a box, allow it to corrode, dry up, and the needle get rusty, and when a patient presents himself he gets the benefit by having some decomposed medicine injected in his gums through a corroded and rusty syringe and needle. The patient complains that the operation has been painful (and he ought to). He will probably return in a few days with his face swollen badly and you might find an abscess where the needle was inserted to add to the patient's misery.

There is always a right and a wrong way for everything, and if the operator will follow the instructions given and observe the following "pointers" I will assure him that he will be successful while his competitors are not: First—Always operate under antiseptic precautions by using listerine or some other antiseptic freely. Second—Never allow your syringe and needle to corrode, dry up and become rusty, but always keep it aseptic and in working order. Third—Never get in a hurry, but give the patient plenty of time to rinse his mouth, etc. Fourth—Always operate more slowly on weak, nervous and sickly people than you would on the robust. Fifth—Be sure that the medicine has been inserted in the gum and not squirted in the mouth, as the medicine that gets into the mouth is what causes the patient to complain of sore throat, stiff tongue, faint, sick at stomach, etc. Never operate without having liquor at hand that no needed stimulation may be delayed.