The Australian dental mirror. [Vol. 2, no. 2]
Australian Dental Association. Queensland Branch.

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Page  1 THE A USTR1ALIAN 'DENTAL MIRROR INCORPORATING THE QUEENSLAND DENTAL MAGAZINE The Official Organ of the.Australiam Dental Association (Queensland Branch) Editor: C. L. Thompson, B.D.Sc. (Melb.), L.D.S. (Vic.), Griffiths House, Queen Street, Brisbane. Brisbane Representative: W. J. SANDILANDS. Address: 89-91 Elizabeth Street, Brisbane. Sydney Representative: Advertising Rates: G. McKINNOAvailable on application to the Manager. G. McKINNON,. Address: 89-91 Elizabeth Street, Brisbane. McDonnell House, 321 Pitt Street. Subscription: 'Phone: NI 6281. Subscription: 'hone: M 61. Within the Commonwealth, 10/6 per anMelbourne Representative: num; Single Copies, 1/- each. Original communications, Sub-Branch F. BRANGHAM, Reports, Incidents of Practice, Personal SMiller House, 357-9 Little Collins Street. Pars, and other correspondence should Phone: M 5427. be addressed to the Editor.:Vol. 2.-New Series FFBRUARY, 1937 No. 2 EDITORIAL. In the January number of the "Australian Dental Mirror", there was printed under the heading of the Dental Board of Queensland, a By-law recently approved by the Governor-in-Council. This By-law is very sweeping in its provision, and so loosely worded that it gives power to the Dental Board, or rather makes it incumbent on the Dental Board, to register any degree, diploma, or title which may, oir has been granted, by any authority competent or otherwise. The exact purpose of this By-law is a little difficult to understand, but it would appear to raise a grave danger of so cheapening diplomas, degrees, etc., that the registration thereof will be of no value either from the point of view of the profession or of the public. While this may not be the intent, it is at least possible under the new By-law, and this Journal can only look with disapproval and alarm on such a regulation. No better service could be given to the public than to make it possible to register only degrees granted by recognised universities whose standing and competency to grant such degrees is unquestionable.

Page  2 * Literary Amalgamation THE DENTAL COSMOS AND THE JOURNAL OF THE AMERICAN DENTAL ASSOCIATION COMBINE. In deference to the desire of the dental profession to control its literature, the S. S. White Dental Manufacturing Company offered "The Dental Cosmos" as a gift to the Trustees of the American Dental Association at their annual meeting in July, 1936, on one principal condition: that the name be perpetuated as a periodical under professional auspices. The House of Delegates of the A.D.A. authorised the Trustees to make the necessary arrangements to combine the two journals. These arrangements have been completed and the title will be "The Journal of the American Dental Association and The Dental Cosmos." The first issue under the new title will be the January, 1937, edition. Dr. L. Pierce Anthony, present Editor of "The Dental Cosmos," will assume the duties of Associate Editor with Dr. C. N. Johnson as Editor of the combined publications. No further subscriptions for "The Dental Cosmos" will be accepted. However, subscribers whose present subscriptions extend beyond December, 1936, will receive copies of the combined journals to complete the subscription period. A subscriber who is already receiving the journal of the American Dental Association, may apply for a refund for the amount remaining on the Cosmos subscription. The subscription for the new combined journal is five dollars a year. The publishing office of the magazine is located at 212 East Superior Street, Chicago, Illinois, U.S.A., but subscriptions may be forwarded through any recognised dental supply house. NOTICE. The initial meeting of the A.D.A. for 1937 will be held at the Empire Chambers, corner Queen and Wharf Streets, Brisbane, on Thursday evening, February 25th, at 8 p.m. Lecturer: HECTOR G. JONES, Esq., M.A., B.D.S. (President, Toowoomba Sub-Branch, A.D.A.) Subject: "The Evidence of the Teeth and Associated Structures in Prehistoric Man with regard to the Theory of Evolution." Your presence will make the meeting a memorable one. 2

Page  3 AUSTRALIAN DENTAL ASSOCIATION. NOMINEES FOR BOARD. Result of Pre-Selection Ballot. The term of office of the present members of the Dentat Board expires on February 28. Following a request from the Department of Health and Home Affairs that it nominate three persons for appointment to the Board for the 1937-4( period, the Australian Dental Association (Queensland branch) held a pre-selection ballot. As a result of the ballot, the following dentists were elected:-- Clifton Leonard Thompson Andrew Robertson Walker Robert Lowery Donnan The A.D.A. therefore has nominated Messrs. Donnan and Thompson and Dr. Walker for appointment to the Dental Board. The Ninth Australian Dental Congress "SYDNEY, AUGUST 16TH-20TH, 1937. The University of Sydney has been chosen as the centre for Congress proceedings. Full particulars will be sent from all State Branches. Mark off this week in your Appointment Books. JOIN PROFIT WITH PLEASURE. 3

Page  4 WNV4O SA'AY$ 1'Hwr SANTA kCLAV.,~ IS A M rs oFp EEXT 1Z.C T tON'S FREE WN FN T PERMA44FENT EX~AMIN AT tC S rzr5 I FREE VE KT* ýCr K 2 E'6 XF a j 4

Page  5 * Can't we make this a coronation year for dentistry, too? (By Reginald S. Boys, L.D.S.) (Read before the Toowoomba Sub-Branch, A.D.A., It is fairly obvious that a very large percentage of the members of the A.D.A. in Queensland are not anxious to become kings in their profession, otherwise they would not be content with half a CROWN. Half a loaf may be better than no bread, but it can be very unwise to apply this rule universally; and half the fair price for any commodity will not carry on a business. I would like to suggest that if the A.D.A. is to be made of obvious value and pep attractive to the young practitioner (and also to older p ts who have not yet joined up) the ideal of the "crown" ajould be substituted for the half-crown, which seems to Bold sway at present. Competition is now such that the young graduate comes into the field, with the public educated (by the dentists, too!), to the idea that the cbirect fee for an average operation of extracting one tooth-or as a minimum fee; and also that advice is not worth paying for! And this is because possibly 80 or 90 per cent. (correct me if I am wrong) of the present members of the A.D.A., and also most of the experienced non-members, have practically anaesthetised themselves into mechanically accepting this valuation. And we (or many of us) are prepared to remove a tooth-difficult or otherwise-(which is a surgical operation if properly done and a reproach to the dentist if it is not)-and when the patient asks the fee, we reply, "Oh, half-a-crown", and generally feel rather shamefaced about it. Later, as may easily happen, with modern constitutions, if the patient requires "after treatment", we mostly do it and charge-nothing-as if it were our fault! Now we know that if this same patient takes his radio (which ministers to his amusement) to an expert for a small adjustment, which may take about ten minutes, he will cheerfully pay five shillings, if asked. But he has been led to believe that it is only worth half that amount, to tinker with his own "condensers." I say "we", but personally, I have for a long time now, been trying to get away from, this manifest absurdity, and mostly getting a minimum of five shillings for all adult extractions--and, of course, not without some resistance now and then. For, I am swimming against a very strong tide, when FELLOW MEMBERS OF THE A.D.A.-men for whom I have the greatest esteem otherwise, and who, at meetings, are strong for the Association, and who would be the first to admit, when put to them, 5

Page  6 that our work calls for a high degree of skill (I nearly wrote skull!), and aseptic care-still take the line of least resistance, and charge half-a-crown as their average minimum fee. If you were to ask them why, they would probably say they are obliged to do it, on account of competition-both that of their own fellow members on the one hand, and of non-members on the other. They are certainly making it very difficult for their fellow associates, who try to do otherwise, and if the A.D.A. is to be of real value to the average member, it surely should be able to arrange for a fairer minimum fee to be general amongst its members, even though it cannot control the outsiders, who, however, should gradually fade out in time. Now, I am not suggesting that the public should be "held up" to exorbitant charges-far from it-and with regard to most fees for other and conservative work, these are reasonable for time and expense involved -though, of course, they vary to some extent, with different practitioners. But as, to-day, it is realised that evein an extraction should be done with meticulous care, a minimum fee, which really enables a dentist to do his work in a proper manner, should be the only one tolerated. And I feel sure that I am safe in saying that the majority of those accepting half-a-crown, are rather ashamed of it every time they do so, and that they must know that it is inadequate if they are to do their work properly. The result is that, while a few MAY continue to operate conscientiously for this fee-and thereby lose money on the average, in the cost of their overhead (which they should be able to work out) the majority will feel that it is not possible to carry on on this basis, and that if they can't alter the fee, they will "cut their corners" and sacrifice some of the desirable detail of their work, and so-work down to a price..This is absolutely undesirable, for it is not upholding the ideals of the profession or of the A.D.A., but amounts to sacrificing them at the altar of the gods "Kash" and "Kompa Tishun." With reference to overhead, as our effective chair hours are perhaps about 1500 per annum, and the expenses of a one man practice may easily reach ~750, it follows that it costs about 10/- per chair hour, and as it is only at the chair that we earn our revenue, we should write up about ~1/1/per hour, to make a reasonable annual income, especially as cash takings are always less than work written up. As fifteen minutes are little enough, on the average, for an extraction-even if we can do it in that time-(and we often do not), unless we are what a Germani friend calls a "Bull und Bush Dentist"-(I did not quite "get" him at first, but lie explained that: "Virst you bull der toot, und den der 'arfcrown from der batient's bocket, und den you bush 'im out der door."). We might be quite often better off if we merely undertook to change a pound. 6

Page  7 We have just drifted into this habit, more or less unthinkingly-almost as if we had absorbed some of our own anaesthetic-and probably those who follow this system, have not thought that they are really acting against professional ideals. Possibly also, you may have heard some of them express strong opinions about some members, who are said to have given support to candidates for the section 8 examination, and consider that they acted contrary to the best interests of the profession. But in reality this is what the half-crown man is doing, because of the reasons I have already mentioned. Of course, he has not thought of it in this light, but I ask him here and now-can he do what he feels to be an aseptic minor surgery operation, AS A GENERAL AVERAGE, for this fee, and make it pay? I feel sure he must answer "no." If so, he must either lose money and work on a non-economic basis or else make his methods conform to the fee! This reminds me of an excellent example of what the low fee leads to (which really prompted this paper). An esteemed member, after operating at the low fee, went on a short vacation. As sometimes happens with us all, the patient had some trouble a couple of days after. He called on another dentist whom he knew very well personally, but whose regular patient he was not, and received treatment twice, once on Saturday morning, and again as a special call on Sunday. Subsequently he asked the fee, and Dentist No. 2 was in a quandary. For he had a fair idea of the charges of Dentist No. 1, and he asked me, on a casual meeting, what I thought he ought to charge under the circumstances. Candidly, I could not tell him. For if the first dentist allows his patient to believe that 2/6 is sufficient for the surgical operation itself, what chance has the other man of persuading him to believe that the after-treatment is worth more? For the patient would naturally think the operation more difficult than the after-treatment. So, what was No. 2 to say? If he had asked him to pay 10/6, which would have been little enough, especially for after hours treatment, the patient, making mental comparisons, and knowing nothing of the ethics of the case, would have thought he was being "stung", simply because he did not favour this man with his regular work. If he had supinely asked 2/6, or even 2/6 for each treatment, he would have been guilty of a gross breach of respect for his own work, and of establishing a further precedent for a manifest absurdity. Indeed, the whole position is unethical, to use an old and perhaps overworked term-for if No. 1 had charged a fair fee, and if his confreres were in the habit of charging the same, then we could afford to treat such cases without charge, and refer the patient back to the original operator for his assessment -which would be a truly professional system. But the low fee is unethical on all counts, even if the work be done conscientiously at a loss, for it amounts to setting an imprae

Page  8 ticable precedent, for it is not possible to conduct a practice on fees involving a loss, and what is more, it is not in the interests of the public, to do anything which, in the long run, tends to deprive it of the best service. The truth is, we are supinely allowing the least skilful, the least educated professionally, and the least conscientious amongst the whole of the registered dentists to set the standard for our work and our fees. Of what use is the special education, training and equipment of a large number of dentists, if they can do no better than to follow the lead of those whose main chance of public support is through catchy advertising and low fees? It would seem that they, with all their special professional training, with all that their Academic Degrees should signify, are trainsforming their D.D.S. into "Deeds of pious resignation", their B.D.S. into "Beads of unprofitable perspiration" and their L.D.S. into "Leads on to frustration," and in reality, are throwing away their own pre-eminence, and playing into the hands of those who only respect the degree of ~.S.D. Now all this could be rectified by a little courage to take a stand for what is reasonable according to present day economic conditions. For all things are relative, and our conduct needs to be based on relativity. It is possible that some day our economic system may be modified or superseded (let us hope by peaceful evolution) in such a way that all honest service will bring adequate reward, and all the "plums" will not go to the mere astute schemer, irrespective of whether he fights fairly or otherwise. For our economic system to-day is undoubtedly based on strife (as Alexis Carrel says) and we have to do a certain amount of fighting to get our rights and prevent the less scrupulous from pushing us over the edge. And this is where we should take a stand for a principle which we feel to be right, instead of meekly allowing the incompetent to set the pace and humbly working to their standard. It may mean slow going for a while, but in reality NO SLOWER than that which the A.D.A. imposes on young members, who are just starting to practise, by frowning on their advertising themselves in bold type (and other restrictions; vide Code). In the end, the paying public will surely discern careful work, and be prepared to pay for it, within reason, even while cheap work may be temporarily available from non-A.D.A. men. It only needs the weight of numbers to turn the scale, and the active co-operation of ALL the members. But we just seem to drift on, putting up with conditions, which are far from desirable, as if it were impossible to make them otherwise. Matters of the past twelve months for Dentistry, have indeed been rather depressing, partly on account of our own errors and partly due to causes which were temporarily too strong for us. But the latter will probably work themselves out and it rests with ourselves to 8

Page  9 take what steps we canf to remedy any inequalities which are within our own control. From a practical point of view, compared with other professional organisations, the A.D.A. is rather ineffective. We certainly have our meetings and our branch meetings! We "pat" each other on the backor some part of it-perhaps; we exchange educational and specialised knowledge-all to the good! But the moment the meeting disbands, each individual member goes back to his own devices and feels that he really is getting no genuine support from the Association in the matter of safeguarding his right to a fair return for his services to the public. The Association has certain rules and by-laws. But if you analyse the new code of ethics, for instance, you will find that it is mostly RITUALISTIC, and its effect is mostly to prevent the newcomer and young member, from "bobbing up" too serenely, to the detriment of the older established men, and that there is really nothing vital to affect the true ideals of dentistry. Please understand, I am not condemning the code, for it is right enough so far as it goes, but merely suggesting that it is only half complete. For there is nothing in it to safeguard an adequate return from the public, for EVERY MEMBER, young or old, for services rendered. To effect this, it is necessary to officially frown upon anyone working for a minimum fee which is suicidal, piffling, and.absolutely inadequate on present day ideals of surgical procedure. If a medical practitioner can get half-a-guinea as a readily recognised fee for advice only, and more for a minor surgical operation, surely our half-crown for extraction is a joke, and so long as we will continue with this absurdity, we will forfeit the true respect of that very public, which pays us this inadequate amount, for our services to them. Professor Helmore, ini his comprehensive address, published in the January issue of the "Mirror", took exception to a medical man saying that dentistry is a "narrow specialty." But we make it appear narrow, by the value we place on it ourselves. We glorify the least valuable, perhaps, and the most mechanical services, thereby endorsing the qualification of candidates under Section 8 (and making it appear to the world at large, that dentistry IS mechanics), and we discount those requiring greater skill and knowledge, which we raised as arguments against Section 8 admissions! We get mostly adequate fees for filling and plate work, and ask a piffling fee for skilled surgery, and advice based on years of special knowledge, and which is our main claim to a professional status. If we are not prepared to value our work in proper perspective, how can we expect outsiders to do so and to credit us with a broad outlook? How can we expect them to show respect for our better efforts, when we go through life accepting crumbs so humbly for services which we should know

Page  10 -------!n.n.................., GET THE WILCLA HABIT! Telegrams: "Wilcla," Brisbane 'Phone: B 6303. PROMPT AND EFFICIENT SERVICE. ANNOUNCING That the WILCA DENTAL CO. have taken over the entire DENTAL STOCK and DENTAL Agencies of THE NORTHERN DENTAL CO. ALL DENTAL GOODS previously handled by this Company are now procurable from WILCA, including ORTHOFORM and NUFORM TEETH, ORALITE BLOCKS and BEDECO CEMENTS, for which we are now Sole Queensland Agents. The Wilcla Dental Company Ltd. 71 ADELAIDE STREET:: BRISBANE P.O. Box 1022 N. I 10

Page  11 are worthy of better recognition. For there is little doubt that, unless he descends to commercial methods and abandons desirable ideals of service, an average practitioner has small chance of making a fair income, on a professional basis. Indeed, that same medical man might have been nearer the truth if he had called dentistry a "Pseudo Profession", for at present, that is what it seems to be, and will be so long as the only ones who have a fair chance of really making money, are the ones who still follow the ideas of thirty or forty years ago, and shut their eyes to the effects of much of this work on the health of their patients to-day. So let us insist on getting paid adequately for the kind of work which we are obliged to de, in 1he light of modern knowledge and experience. Toowoomba, Q'ld., Jan. 31, 1937. (When we close the office door, with a "pang.") FIFI (or fie fie). She walked into his surgery and said: "It's this one here!" "And please extract it painlessly, for T'm nearly dead with fear!" Well, Bill was a "Painless Dentist," as his advertisements loudly said, But while Bill might have been painless himself, his patients were not without dread! He told me it broke.. "a very tough job".. and I said, "How much did you get?" "I only got half-a-crown," he said. "Half THE crown," said I, "I'll bet!" "And didn't you get the root?" I asked,.. and Bill, he blushed and looked funny! "'Well, no... well.. oh, I suppose," he said, " 'Twas a shame to take the money!" Knock, knock! Who's there? Fees! What fees? 'Fece's any good, it'll be five bob! 2 and 6 are the making of 8-section 8? (Minnie Mum.) 11

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Page  13 * The Healing of Wounds in the Mouth (By A. W. L. Row, B.M.Bch. (Oxon), F.R.C.S. (Eng.). (Read before the Toowoomba Sub-Branch, A.D.A., September, 1936.') 1. Anatomy and physiology of the mouth. 2. Dental wounds, amongst buccal wounds. 3. Disinfectants. 4. Local Anaesthesia.. IHaemorrhage. 6. Pain. 7. Local infections. 8. Constitutional diseases. 1. The normal mouth is a perpetually wet cavity, coptaminated by many species of organisms, both pathological and non-pathological. It is subjected to trauma very irequently in the chewing of food, and yet we find that its wounds very seldom fail to heal promptly and without much inflammation. It owes its great powers of resistance to infection not merely to its tliick pliable epithelium, but also to the fact that its surface is kept wet with mucus and saliva, rendering it slippery to sharp objects as well as securing a continuous outpouring of lymph from any injured spot on its surface, and also to its copious blood supply. Unlike the skin, the mouth's epithelium has no hair follicles or sweat glands or sebaceous glands to harbour organisms; on the other hand, it has mucus glands, the ducts of the salivary glands, the sulci around the teeth and the crypts in the lymphoid tissue in the tonsillar and adenoid area. The mucous membrane, not possessing any horny outer layer like the skin, cannot long tolerate being dry, as its shrinkage and loss of pliability causes cracking, and so opens up a raw surface for infection. As it is, kept normally wet, it allows of a free and continuous outpouring of lymph from any raw area, and this helps to wash away from the surface any contaminating organisms, since they cannot swim against the stream. If a spot in such a condition be allowed to dry even for a few hours, a severe infection is likely to result, for the lymph flow in the tissue spaces will then tend to carry the adhering organisms deeper beneath the surface and into the lympihatic vessels, while a few may even penetrate the blood vessels which are torn open by the wound. After the first outflow of blood and lymph following the infliction of the woulnd, a layer of fibrin coagulates on the raw surface, and acts as a protective covering beneath which the epithelial repair takes place. This fibrin must be clearly distinguished 13

Page  14 ""zczjYf 4/l7yto C ome to t/e RIGHT F LACE " FURNITURE FURNISHINGS RADIO - CARPETS LINOLEUM ad CHINA iT&ITTO NS Complete Home Furnishers 254-262 George St., BRISBANE from the "membrane" of necrotic mucous membrane found in certain severe infections of the mouth and fauces (as distinct from mere injuries) as in cases of diphtheria, cancrum oris in children, and even severe staphylococcal or pneumococcal infections. Some fibrinous membranes, be it noted, may be very adherent and may cause bleeding when removed, though the underlying mucous membrane is not necrotic; one may see such a "pseudo-membrane" in severe acute cases of Vincent's Angina. The fibrin layer's utility as a protection, however, may be offset in some cases by its affording in it and beneath it a harbourage for pathogenic organisms, and in such cases it needs to be removed. By no practical means can the oral cavity be kept continuously free of pathogenic organisms, and consequently our reliance must be placed upon keeping its surface normally wet with mucous and saliva, upon maintaining the blood supply of the injured area, and upon discouraging bacterial growth by cleansing mouth-washes with some non-irritating disinfectant, being especially careful to avoid dry or sticky mucous and surface blood clot (as distinct from the clot inside the end of torn vessels). Under such conditions, the mouth shows an astonishing resistance to acute infections, 14

Page  15 provided that the general health be good, for upon the latter fact largely depends the prompt destruction of any organisms which have invaded beneath the surface of the wound and are attempting to multiply there. Lymph, mucous, and saliva are the natural and best fluids to bathe the injured area, and mouth washes are only to be used to enhance the flow of these natural fluids and discourage bacterial growth, and not by any means as a substitute for them or a means for their removal. A mild alkaline mouthwash like 2% sodium bicarbonate in water is a fine liquefier of sticky or dry mucous, or of surface clot, and is not likely to start haemorrhagic oozing if used gently, as hydrogen peroxide may easily do in recent wounds by its mechanical action on the clot. 2. Dental wounds are in the nature of deep pits, with a relatively narrow opening. In the healing of such a cavity, bathed as it is with pathogenic organisms, a serious disadvantage lies in the fact that the depths of the pit lie not only in bone which heals relatively slowly, but also in infected and sometimes fractured bone, with an impoverished blood supply. The tendency of the overlying gum to heal more rapidly than the bone predisposes to a blockage of free drainage of the cavity, and thus to sinus formation, or, if the infection be less virulent, to the total inclusion of a septic focus under an apparently healthy healing of the gum; such a focus may remain absolutely unnoticed for years, although causing by absorption from it very severe general symptoms, e.g., in respiratory or alimentary tract, or in joints, etc. (one such case seen recently showed a tender swelling resembling a submaxillary salivary gland abscess, which was only truly diagnosed when a small piece of necrotic bone pierced the inner aspect of the alveolar mucus membrane; previously there had been no sign of sepsis during the 4 years following the extraction of the tooth, the gum having healed promptly and painlessly). Also, if the patient's resistance be lowered, e.g., by sepsis elsewhere, or fatigue, the focus may flare up and cause an acute osteomyelitis or even a septicaemia, with possibly disastrous results. In such a case of residual infection, a persistent sinus is to be regarded as a safety valve, but it is not safe enough, unless kept large and prevented from closing periodically as many such sinuses tend to do; often it is necessary to widen the opening by excision, and to bevel down the edges to allow of sound healing from the bottom. In the case of a cyst lined by epithelium, whether arising in connection with tooth development or by accidental implantation, the whole of the epithelial lining must be removed before the cavity will fill with healthy granulation and fibrous tissue; also if the cavity be a deep and wide one. it may be necessary to bevel down its bony edges as much as possible to reduce its depth, and so 15

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Page  17 allow the buccal epithelium to grow across its floor, in such cases, epithelial grafts to line a large cavity are most difficult to keep applied and very uncertain in results. Bony fragments from the alveolar margins are inevitable in some extractions; for their survival they need to be firmly attached to their blood supply through the periosteum; otherwise, they are bound to die and form infected sequestra, a most persistant and dangerous form of focal sepsis. Such sequestra on the lower jaw particularly can occur of course without actual fracture, by a combination of devascularisation and infection (the former occurring for example by the injudicious use of elevators, which may strip off the periosteal covering). In such cases, the sequestrum tends to take a long time, perhaps a year or more, to become sufficiently separated from the living bone to allow of surgical removal, free drainage during this period being necessary, but often difficult to maintain. The inquisitive tongue is a very real enemy to prompt haemostasis of the socket, and to the absolute rest of the lacerated gum which is so desirable during the first day or two especially, whilst the leucocytic barrier to invasion is being erected. Also, the fact that the tongue is poking about points to emotional restlessness, and this keeps the blood pressure raised and so increases bleeding, as well as causing mental stress and fatigue. On the other hand, the tongue does seek out any unnaturally dry spot, and moisten it to its advantage, an advantage fully appreciated by any surgeon who has had to deal with a patient whose tongue has been removed, e.g., for cancer. 3. Disinfectants. As our knowledge of the natural mechanisms of defence increases, more and more are we relying upon them to prevent infection of surgical wounds, though antiseptics are definitely of great use in killing bacteria or discouraging their growth on the surface, especially during the first few hours (4 to 6), following the trauma which intervene before the contaminating organisms actually invade the injured tissues. It is realised that our present antiseptics act only on the surface or very close to it, though they certainly are very effective in cleaning such a surface temporarily, e.g., before any surgical -procedure. A most important essential in a disinfectant is that it shall not irritate the tissues, and so delay their rate of healing as well as lower their resistance to subsequent infection, when the disinfectant is no longer there. Now the disinfection of the skin for major surgery lias been investigated very closely, and with excellent results, but it would be a mistake to apply all the findings to the disinfection of mucous membrane. For example, for skin disinfection, a solvent for the disinfectant has to be used which will penetrate not only the horny layer, but also to 17

Page  18 the sweat and grease glands in order to deal with most of the organisms swarming there; also, a dehydrating solvent is a great advantage as it hardens the surface of the skin and tends temporarily to seal the openings of these glands and hair follicles, so as to prevent subsequent contamination during operation of the adjoining wound. A mixture of alcohol, acetone and water (a little) has been found to be the best solvent, being a liquid of low surface tension, which will mix with grease and also dehydrate the surface of the skin. A mucous membrane, however, provides both different conditions and different requirements! it has no grease glands, it is wet and must not be dried for more than a few minutes, and it is much more easily irritated; on the other hand, most of its surface is much more easily cleaned. A fact often overlooked is that a disinfectant in a nonirritating concentration takes several minutes to kill any organisms with which, it is actually in close contact. It is so very easy, especially with a highly coloured antiseptic, to delude oneself into believing that the mere application of the colour secures immediate disinfection (even if the organisms could appreciate the vividness of the colour, they would possibly be able to endure it for a few minutes, however distressed). Also, we must remember how very effective mere mechanical cleansing is by itslf; for example, in much I I k-UZ666mm F? V V PAM' WNUOU SUMMM, V? MAR For Your High Grade Jobs Use High Grade Plaster TOP DOG DENTAL PLASTER HAS PROVED ITSELF. Packed in llb., 71b., 141b., 281b., 501b. tins, 1501b. bags, and 2001b. casks. Order all supplies from your Dental House. Sole Agents-Wholesale Only: BARKER & CO., LTD., 87 EAGLN STREET, BRISBANE. I 119.~o~WPP~p~pp~ppq~pp 18

Page  19 plastic surgery, a careful wiping of the surface with ether is often the only "disinfection" attempted or required, for non-irritation of the skin or mucous membrane is a thing highly to be prized where prompt and clean healing is needed to keel) scar formation as inconspicuous as possible, by such a method, most of the organisms are removed. For mucous membranes, then, we need to use a nonirritating, non-dehydrating antiseptic, and to allow it sufficient time to act. Another very important point lies in the influence of the presence of blood or serum on the potency of the particular antiseptic used. The potency of most antiseptics is very greatly reduced by its presence, but that of a few, especially certain dyes, is definitely increased; this influence is exerted not only over the killing power of the disinfectant (its "bactericidal" power), but also over its power to check growth of bacteria (its "bacteriostatic" power) in most cases. The dye disinfectants whose potency is increased by the presence of blood or serum include brilliant green and crystal (methyl) violet, while that of flavine is not greaty reduced bactericidally, and not at all bacteriostatically. The presence of blood or serum, however, enormously reduces the potency of iodine, potassium permanganate or eusol, while hydrogen peroxide even at full strength loses all bactericidal power against streptococcus pyogenes, for example, when 5% of blood is present. A new antiseptic whose bactericidal power is very great and whose staining properties are negligible is Metaphen; it is almost non-irritating, keeps indefinitely, does not harm instruments or rubber when immersed for a few hours, and seems to be definitely the most potent antiseptic for surface disinfection. At present, however, its price is a strong deterrent. A fact not realised as widely as it should be is that aqueous solutions of disinfectant are, where sufficient solubility is present, enormously more potent than alcoholic solutions; the idea of using alcohol and acetone is merely to ensure penetration of a greasy layer, and some water as well must be present to allow the antiseptic to exert its action strongly. On a mucous membrane, which is non-greasy and wet, no grease solvent is necessary, and the omission of alcohol or acetone prevents dedydration and irritation. (It is convenient in some cases, however, to keep a strong alcoholic solution for stock, and dilute it with many volumes of water for use.) For example, streptococcus pyogenes is killed in vitro in 15 minutes by a 1/120,000 aqueous solution of iodine (or a 1/2000 solution if 5% of blood be present); a solution of iodine in absolute alcohol, however, is not at all effective, though equal parts of water and alcohol without any iodine will kill them in 15 minutes, and one part of water and two of alcohol in slightly less time. 19

Page  20 Long after the disinfectant lhas been washed away, any irritated or necrosed tissue is left as an easy prey to new hordes of organisms. It is very important to realise, however, that a disinfectant is most useful even if it does not actually kill the:organisms, plrovided that it prevents their multiplication, and for this purpose much greater dilutions are effective; for example, a 1/5000 aqueous solution of iodine should be a very effective and slightly astringent mouth wash, rmeembering, however, that its action would be neutralised by any alkalis present; a chlorine mouth wash (1 in 800) is definitely potent, but hopelessly unpleasant to taste and smell. For any given antiseptic, different types of organism have vastly different powers of resistance, so we need to choose an antiseptic which has been found to be particularly potent against the organism with which we are dealing, as well as non-toxic and non-irritating both to the patient's issues locally and to his whole body if absorbed, whether locally or after swallowing. For example, hydrogen peroxide has been found very potent against the organisms of Vincent's Angina. 4. Local Anaesthesia. Nowadays we have a host of safe local anaesthetics for injection, and a few really good ones for surface anaesthesia, the latter including percain and pantocain as well as cocain. lTnfortunately, however, cocain alone of these can cause a simultaneous local vaso-constriction, a most desirable property, since it not only intensifies local action, but also greatly reduces the rate of absorption into the circulation and hence the general toxicity of the drug. Cocain's very dangerous toxicity for those susceptible to it is its only drawback, though a great one, and sufficient to rule it out as far as injection anaesthesia is concerned, save in the hands of very few people. With the other anaesthetics, then, in order to secure the requisite vasoconstriction, adrenalin, either natural or synthetic, is added to the anaesthetic solution, with great immediate benefit, If you are in doubt as to which Sof the plastic denture m aterials to use ask your dental depot manager or salesman as to the largest sales and the least complaints of the thermoplastics. inserted by and in the interests of the NATUDENT CORPORATION 20

Page  21 but its after results may occasionally be anything from inconvenient to disastrous, according to the amount used and the particular patient's tolerance for it. For general surgery nowaday, the experts are advising much smaller amounts than were used previously, viz., not mere than 10 drops of a 1/1000 solution of adrenalin per 100 c.e. of solution, i.e., a dilution of at least 1/150,000. Greater quantities certainly hasten haemostasis, but are liable to cause reactionary haemorrhage a few hours later, when both patient and dentist hope to be sleeping peacefully; also, in an occasional case, it can cause severe sloughing, especially if the tissues be already infected by a virulent organism; this in turn will predispose to secondary haemorrhage some days later when the sloughs separate, and, most seriously, to necrosis of bone which has been devascularised too completely and too long to avoid infection by contaminating organisms. In a few cases, general symptoms of adrenalin intolerance may be met with, with a transient rise in blood pressure which may be serious to a weak heart, while other sympathetic over-stimulation in the form of palpitations and sweating and restlessness is bound to make the dentist unpopular. Tn the low concentrations mentioned, however, it is very unlikely to cause much trouble, and the effect will be found quite adequate provided the operator gives the solution the requisite time to act, since vasoconstriction as well as anaesthesia only reaches its full effect after several minutes. It is worth noting that a synthetic substitute for adrenalin is now being marketed, under the name "Neosynephrin", which is claimed to have fewer disabilities; it should be worth investigating. Ephedrine is definitely less active than adrenalin, though longer acting. Synthetic adrenalin, when stale, is said to develop toxic properties as well as to lose its potency, whereas the natural gland extract is merely inert in this condition. Novutox is a combination of novocain, quinine, and adrenalin, which is claimed to be safe for injection even into badly infected tissues. It is said even to promote healing. Also, it keeps sterile after opening the bottle, which is a. great convenience, and remains potent indefinitely. I can personally vouch for its excellence as an anaesthetic, and its safety in infected tissues, especially gums. At present, its price is a strong deterrent. Not only isotonicity but also hydrogen ion concentration are to be regarded as important from the point of view of tissue damage, and also as regard haemorrhage, for tissue acidosis, either general or merely local, predisposes to haemorrhage. 21

Page  22 PROFESSIONAL BRASS PLATES (For Dentists, Doctors, Etc.) Memorial Tablets (Engraved or Cast Bronze). Trophy Shields, Stencil Plates. All classes of Engraving done. Surgical Instruments, Trophy Cups, Medals, Presentations, Etc. JAMES STEWART, GENERAL ENGRAVER & ART METAL WORKER (Over 30 years' practical experience) EWING HOUSE (1st Floor), 130 ADELAIDE ST. (opp. Finney's), BRISBANE. 'Phone: B 8473. DENTAL SUITE TO LET. Four good rooms, with exclusive stair, overlooking first section tram stop from city. Occupied last 17 years by dentists. Closely settled suburb. Moderate rent. SIDNEY D. FLETCHER, GRIFFITHS HOUSE, QUEEN STREET, BRISBANE. BOX 1052N, G.P.O. 'PHONE: B 5910..1WD

Page  23 5. Haemorrhage. Prompt arrest of haemorrhage aids prompt healing, provided that free drainage of lymph and serum is not interfered with in the achieving of the haemo'stasis, e.g., by prolonged plugging, and also that the tissues are not devascularised too long, or too severely. Haemostasis is effected naturally by two mechanisms: (a) contraction and retraction of cut or torn ends of vessel; and (b) clotting of the blood. As regards (a), the contraction and retraction of the vessel ends is accompanied by an increase in stickiness of their inner lining, allowing platelets and leucocytes to stick to them and so still further diminish the size of the lumen; this in turn leads to a slowing down of the blood flow, which not only decreases the total amount of blood lost, but it gives it time to clot in the ends of the ruptured vessels, aided by the breakdown of platelets; also, the clot is given a better chance of becoming firmly adherent to the vessel's wall, and so effectually sealing the opening; a most important aid to haemostasis lies in keeping the general blood pressure low, by avoiding emotional disturbance in the patient as much as possible. (This is shown very clearly by the marvellous effect of an injection of morphia when used to lessen haemorrhage from a point where pressure cannot easily be exerted, e.g., in the stomach or nose). "Reactionary" haemorrhage is caused (a few hours later) by the vessels failing to maintain this contraction and retraclion, so that the clot is no longer a tight fit in the vessel ends, and as it has not yet had sufficient time to become securely attached to the walls by strands of fibrin, it is swept away by the increased rate of blood flow, and haemostasis has to be secured all over again. As regards (b) the clotting of the blood, the rate of clotting and firmness of the clot varies with a host of conditions; also, the maintenance of firmness of the clot depends upon its not being grossly infected and so liquefied; such an occurrence would lead to a "secondary" haemorrhage some days later. We must distinguish between the terms "bleeding time" and "clotting time" and note that neither of these estimations refer to the actual conditions in the body; though they do afford us valuable information as to what we may expect to happen when we make a wound. "Bleeding time" is a measurement of the time taken by capillary vessels (only) to cease bleeding after a prick; thus it is a measure of capillary contraction and retraction, and stickiness of walls to some extent. After the prick is made, the oozing blood is wiped off gently with a piece of filter paper every quarter- or half-a-minute until no more exudes; no squeezing is employed. An average time is two to five minutes. 23

Page  24 "Clotting time" measures the time taken by blood to clot in a capillary tube, the average being 4 to 9 minutes. These times are independent of one another, and either or both may be altered in different diseases. (Incidentally a confusion of thought often arises between "bleeders" and "haemophiliacs"; the latter form one rare species of the former, and are practically always males; their blood fails to clot quickly enough to seal the vessel ends, this failure apparently being due to their blood platelets not disintegrating readily enough to yield the requisite amount of thrombokinase for quick clotting; if thrombokinase be added, their blood will clot. "Bleeders", however, belong to a much wider group, including failures not only in clotting but also in contraction and retraction, and yet again in a persistent high blood pressure. For example, consider sufferers from arterio sclerosis, jaundice, great excitement, severe debilitating illness and so on; such cases naturally include females as well as males.) In dental wounds, not only are larger vessels than capillaries torn across, but many of them lie in bone or dense periosteum, where their firm attachment to the walls of the bony canals or fibrous tissue prevents full contraction and retraction in some cases; this tends to allow clotting outside the vessels, on the surface, unless the blood flow is decreased sufficiently by temporary plugging. It is noteworthy that any substance which is "wettable" by the blood promotes clotting, e.g., dry cotton wool, whereas greasy material or already wet material does not, since the blood cannot easily reach the surface of the material. Also, that the greater the surface in contact with the blood the more extensive the clotting; hence the finer the threads the better-cobwebs once were very popular! Again, any substance lessening local tissue acidosis will help clotting, e.g., powdered sodium carbonate or glucose; another aid lies in the local application of extra thrombokinase or calcium, thus a piece of fresh muscle or some haemoplastin on a swab will U.S.A. A.D.A. SPECIFICATION for DENTAL AMALGAM ALLOYS G&G Quick Setting Alloy (Not Modified) was tested at the Metallographical Research Laboratory, University of Melbourne, and found to IV. Detail requirements (1) Chemical composition shall be within the following limits:Silver............ 65% Minimum Tin................. 25% Minimum Copper........ 6% Maximum Zinc...................... 2% Maximum Cc Ca )nform to these specifi- Gold and Platinum will not be reLtions. garded as foreign materials. Obtainable at all Dental Depots-Price 8/6 per oz. GLOVER & GOODE PTY. LTD. DENTAL MANUFACTURERS - MELBOURNE 24

Page  25 often be effective. (One obstinate case was stopped by a piece of muscle from a pigeon, shot for the purpose, when other more formal remedies were lacking-a practitioner with real initiative, as well as ability to hit the pigeon!). Saliva slightly delays clotting, and its contained organisms are very liable to infect the clot; a method now being tried with excellent results, I believe, consists in keeping the saliva away from the socket and it clots until the latter have had time to become firmly set. It is important to remember that a definite interval occurs between the moment when organisms come in contact with a wounded surface ("contamination") and when they manage to penetrate beneath the surface ("infection"), the duration of this interval being about 4-6 hours, the existence of this interval is an invaluable aid both to the body in beginning its defence preparations and to the surgeon in cleansing mechanically and with disinfectants the contaminated surface before infection has taken place. A contaminated surface can undoubtedly be cleaned and disinfected most thoroughly by modern technique, and under such precautionary treatment, the wound will suffer from much less inflammation and pain than if left bathed in organisms during all these important hours. It would be interesting to try light plugging of a socket a few minutes after extraction for a short time only with a non-irritating antiseptic like an aqueous solution of Flavire., Metaphen, Brilliant Green or Methyl Violet; this would kill the surface organisms and also prevent the formation of a large surface clot; even disinfecting and their preventing saliva from reaching the cavity for an hour or so should help greatly. A blood clot on the surface of a wound or forming a lid to a cavity is a menace to rapid healing, as it forms a perfect culture chamber and medium for the included organisms. A clean surface with as few pedunculated tags as possible, and with all its tiny vessels each plugged by its own separate clot and ozzing lymph freely at first from tissue spaces and torn lymphatics, until no longer irritated by organisms or toxins, gives the best chance of healing with a minimum of inflammation; lymph and serum flow ceases ultimately when all these spaces become blocked by a deposit of fibrin, which is merely lymph-clot. It is a good plan, in cases giving a previous history of prolonged bleeding, to alkalise the patient before beginning the extractions; this can be done by giving by mouth drachm doses of sodium bicarbonate in water until the urine is alkaline to litmus; in children, a dose or two will usually effect this but in adults occasionally two or three days' treatment may be necessary. This will ensure that no tissue acidosis is present. Loundes Yates, of London, about 10 years ago showed that this preliminary treatment greatly decreased blood loss in operations on tonsils and adenoids. 25

Page  26 A simple, but very effective, cause of prolonged oozing is the wearing of too tight a collar, including the neck band of the shirt, whose tightness will be overlooked unless a finger be passed down inside the collar itself. The avoidance of excessive laceration also lessens haemSorrhage and moreover, leaves the damaged tissues with a better blood supply for their repair. "Carnivorous" surgery in any part of the body is strongly to, be deprecated; it is due more often to haste than enthusiasm, perhaps, though occasionally an exhibition of dexterity may suggest that the operator has temporarily overlooked the fact that the flesh is still living, and is not mere meat. Any chemical haemostatics are to be used with care, and every effort should be made to see the exact bleeding point and treat it, rather than to plug the area indiscriminately, for all chemical haemostatics are bound to do some tissue damage, and the more localised this is the better. A good headlamp is invaluable in locating such bleeding points. Adrenalin and pituitrin are both powerful vasoconstrictors, the adrenalin acting on the neuro-muscular junction, the pituitrin on the muscle fibre itself. Neither should be I ' " " ',JlI I ORTHOCAINE LOCAL ANAESTHETIC. Procaine 2% Solution. Stabilised with Buffering Salts. STERILE NEUTRALISED ISOTONIC. Manufactured by qualified chemists under personal supervision of Dr. Noel Gutteridge, Bacteriologist, whose professional services have been retained by the manufacturers to ensure the safety and sterility of the product. Distributed by: THE NORTHERN DENTAL & MEDICAL SUPPLIES PTY. LTD. BRISBANE TOWNSVILLE I VP~co~P~~~PQWPPP~~P3 I -- - 26 N

Page  27 applied for long periods, for fear of necrosis. If the vessels show reactionary haemorrhage after adrenalin, whether injected or applied to the surface, it is useless to apply more adrenalin in most cases, for the neuro-muscular junction is too fatigued to respond; in such a case, however, pituitrin applied to the spot, and not merely added to a pool of blood, will cause fresh vasoconstriction. In one such case, more adrenalin caused a sharp increase in haemorrhage, but pituitrin soon checked it. Haemoplastin (Lapenta) which has now replaced haemstatic serum, is a protein free preparation which contains prothrombin and thrombokinase. Its standard requirement is that it shall reduce the clotting time of a normal dog's blood to one third of its previous value, when 2 c.c. are injected intramuscularly or subcutaneously. No anaphylactic phenomena are ever caused by it, sin~ce the setum proteins have all been removed. A normal dose for an adult would be 2 to 5 c.c. and in cases of true haemophilia, it is advised by the makers to give 5 c.c. every four hours for 3 days prior to operation; in other cases of prolonged bleeding, it should be repeated in 5 c.c. doses every 3-4 hours till bleeding ceases. In the case of tooth socket, a greater concentration can be achieved by plugging the socket with gauze soaked in haemoplastin. It can be boiled without loss of potency. (For true haemophiliacs, a small blood transfusion from a normal person will check bleeding). Thromoplastin contains thrombokinase, and is meant for local application only, though it can be injected with less effect however. 6. Pain lowers resistance to infection, and hence, if long continued, delays healing. In dental wounds its cause seems partly at least to be concerned with the type of infecting organism, though an unsuitable local anaesthetic and fractured alveolar margins are undoubtedly other factors involved, In local lesions generally for example, staphylococci seem to cause much pain, e.g., boils, carbuncles, acute osteomyelitis, including mastoid suppuration, inflamed glands, etc. After multiple or difficult extractions under general anaesthesia, it is highly advisable for the doctor to give, as soon as the patient recovers consciousness (but not before lest haemorrhage be concealed through swallowing the blood), a dose of morphia; this secures a few hours' freedom from pain and distress at the time when the blood pressure should be prevented from rising. Later some other analgesic drug can be given when required, by mouth; in this con27

Page  28 nection, a point of great interest to dentists lies in the undoubted association in certain fatal cases which have occurred of the triad of Vincent's angina infection, a predisposition to the blood disease agranulocytosis, and the excitant action on the latent form of this disease of certain amidopyrin derivatives, even when given in small doses (e.g., 5 grains in one or more doses, which has led to an acute exacerbation of the agranulocytosis with serious or fatal results). However, these drugs are not the only exciting cause of agranulocytosis, for flare-ups have also occurred after giving arsenical compounds (e.g., for Vincent's angina or syphilis), and also after gold compounds and dinitrophenol, the latest "slimming" drug in the advertisements. Allan Walker in the Australian Medical Journal of August 3rd, 1935, gives an exhaustive account of our present knowledge of agranulocytosis and the drugs exciting it, while Vincent's ingina and its treatment are well discussed by C. Bowdler Henry in the B.M.J., May 30, 1936. Emotional stress at the prospect of the ordeal tends to raise the blood pressure and so to increase haemorrhage. In obviously emotional patients, it is a great help to the dentist if they are calmed down during the previous 24 hours or so by a sedative, especially the night before, to ensure a good night's rest. JOHN T. JENNINGS LTD. USE-- COE PLASTIC COECAL STONE and COE INVESTMENT for Superior Results The new classic and logical work: "CLINICAL DIAGNOSIS OF DISEASE OF THE MOUTH" Now available-45/-. (Author-Louis V. Hayes, D.D.S.) JENDENT WHITE ALLOY Conforms with the U.S.A. Bureau of Standards; is unexcelled for efficiency, adaptability and plasticity. 8/3 oz.-5 ozs. less 5%: 10 ozs. less 10%. Travelling Representative: Percy A. Hurworth. Brisbane Address: T. & G. Bldg. 'Phone B8777 JOHN T. JENNINGS LTD. BRISBANE 28

Page  29 7. Local infection of the gums and mouth varies greatly not only in severity, but also in its effect upon subseiquent healing. Diphtheria or diptheroid organisms may cause a very obstinate retardation of healing (seen also in skin ulcers occasionally) and their unusual presence may be quite unsuspected in the absence of other symptoms unless a smear be examined; antitoxic serum helps to clear up such art infection. ' Acute or chronic gingivitis due to metallic poisoning, e.g., mercury or bismuth or lead improves rapidly with elimination of the metal from the body. Scorbutic gingivitis is perhaps more frequent than is suspected; vitamin C in oranges, lemons or tomatoes cures it very rapidly. Vincent's angina (fuso-spirillary symbiosis) is reported to be a common infection in Queensland, and is highly contagious, so that every precaution against its spread should be taken by dentist and patient alike. It exists in chronic, subacute and acute forms. C. Bowdler Henry's article, quoted above, should be read, a brief summary being as follows:Remember that the infection is often present in cases of agranulocytosis, and hence get a leucocyte count done before commencing too drastic a treatment; also, if agranulocytosis is present, do not give arsenical treatment for the Vincent's angina, as it may cause a dangerous exacerbation of the agranulocytosis. 1. In the acute stage, very lightly scrape the ulcers to remove the fibrinous membrane, and syringe thoroughly with hydrogen peroxide, or spray with oxygen and a mouthwash; paint the raw surface with an esharotic, e.g., pure carbolic, use a mouth wash of borax in water half hourly. With this treatment, even within 24 hours, the ulcers will be clean and covered with fibrin, and within a few days they will again be covered with eptithelium. After 24 hours, carefully remove the gross tartar, and subsequently gradually remove the remainder with as little trauma as possible. To sum up, cause as little trauma as possible, remove the sloughs, cauterise, scale the teeth, and provide plenty of oxygen. Intravenous arsenical injections help to prevent the spread, but do not help greatly to eradicate the infection from the gum crevices. 2. Chronic stage. Eradication is needed of all pockets and crevices in which the organisms lurk. This necessitates cleansing and stopping of carious cavities, extraction of dead teeth, excision of all gingival pockets, an electro-cauterisation of the gingival sulcus of every tooth, the resulting coagulum being scraped away and oxygen-containing mouth washes and freely until healing has occurred. It is best to 29

Page  30 deal with the whole mouth at one sitting, if practicable, so as to avoid re-infection of treated areas from untouched foci. Tonsils also frequently harbour the organisms, and then need removal. Appearance is an unreliable guide to cure, and microscopic smears should be made repeatedly till negative results are obtained. 8. Constitutional disease can be a most potent cause of delayed healing; amongst the more common of such diseases are severe anaemias, diabetes, tuberculosis, the cachetic stage of malignant disease, purpura, leucaemias, lead or mercury poisoning, vitamin deficiency, especially vitamin C as in scurvy, and occasionally agranulocytosis. In such cases especially, and also in cases where the gums are very spongy and bleed easily, it is vitally important not to cause too much trauma at the first trial; a great improvement can often be effected by a preliminary palliative local treatment in the shape of scaling, cleansing of pockets, and antiseptic mouth washes at frequent intervals even for only a few days before the extractions; such palliation will not only render extractions safer (and healing more rapid), but also much less painful and sickening. Also, if any doubt exists as to the patient's general condition, it is most advisable not to extract more than one tooth at a time, and then to watch carefully for a week at least for any general reaction; if a reaction does occur, it is highly dangerous to extract any more at all until the reaction has completely subsided. The presence of any acute or subacute infection, e.g., a cold, a sore throat, or influenza especially, severely lowers the patient's resistance, and extractions may then be followed by a severe local reaction, a flare-up of the acute infection, or death some weeks later from a subacute bacterial endocarditis; too many such cases have been rceorded, apart from those which have not. l.;AAAAaM<6AJ~w^ CAFFERATA DENTAL PLASTER (SUPERFINE) THE HIGHEST GRADE ENGLISH PLASTER ON MARKET. Packed in I cwt. Paper Lined Bags & 300 lbs. Casks Used by all Leading Dentists and Dental Mechanics. Free Samples supplied on Application. HOSKIN 8 COMPANY 'Phones: B 1941-2. CREEK STREET, CITY. I F 30

Page  31 Certain obvious signs should render the dentist cautious in proceeding with extractions until a doctor's examination has been secured; for example, the pallor and perhaps yellowness of a case of severe anaemia or leucaemia; the persistent shortness of breath even while sitting of a case of heart failure, with or without cyanosis; the honey-smelling breath of a case of severe acidosis; the pallor and oedema of the face of an advanced renal failure of one type; the wheezing of an asthmatic whose heart may be very tired; the protruding eyes, fine hand tremor, flushing and excitability of an exophthalmic goitre (whose thryroid may not be enlarged), the tired look of a patient not yet fully recovered from some acute illness (especially influenza, which is so prone to be followed by a severe secondary infection). For similar reason, the patient should, after extractions, avoid contact with anyone suffering from an acute infection, lest he catch it himself. I glo...-.... ---n~-~~lr~.~~ST 8 The Publication of this Journal is made possible by the SUPPORT OF THE ADVERTISERS Help Those Who Help You By Giving Preference To Those Firms Who Make "THE DENTAL MIRROR" Their Advertising Medium. If ipoppWWPvp3WpppppPPWpPppqpppppppPpDPPp 31

Page  32 S. S. White Equipment Unit 62E and the form fitting Diamond Chair No. 2. Look Successful Be Successful It has been said that there are three factors of prime importance in the success of a dental practice; the first, knowledge, skill, and experience; the second, personality; the third, environment. Knowledge and training should, of course, be the deciding factor for judging a dentist's ability. Unfortunately, however, these are too often judged last by patients. It is a common fa!ling for them to estimate a man's ability first by his surroundings, then by his personality, his skill and training last. Fair or unfair, this is the method of mass approval. If you have delayed renovating your office for the coming of better times, renovate it now. Your old patients will be pleased with the change, new patients will be favourably impressed. Nor need you incur a burdenable overhead in renovating. There is an S. S. White Equipment combination of chair and unit suited to your practice and pocketbook, also a convenient deferred-payment plan. Ask your dealer or write direct. THE S. S. WHITE CO. OF AUSTRALIA LTD. *,,. M4, 9. 41t I Ii T. & G. MUTUAL LIFE BUILDING C/r. PARK AND ELIZABETH STREETS, SYDNEY, N.S.W. Distributors of S. S. White Trade-Marked Products Say you saw it in "Australian Dental Mirror." 32 4*L.W L-S--S-I~TfE* ~, OFF,

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