reading

Garant, Philias R., author.
The long climb : from barber-surgeons to doctors of dental surgery / Philias R. Garant.
p. ; cm.
Includes bibliographical references.
ISBN 978-0-86715-649-2 (hardcover) I. Title.
[DNLM: 1. History of Dentistry. WU 11.1]
RD533
617.009--dc23
2013033497

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As a dental educator and scientist, I found special pleasure in studying the history of medicine and dentistry. From my readings (often at the expense of more pressing issues), I obtained a better sense of how dentistry evolved and how it became separated from medical practice. Throughout this journey, I have been inspired by the courage and determination of dentistry’s pioneers. From Pierre Fauchard to G. V. Black, there is much to appreciate. On the other hand, there have been episodes of weakness and dishonesty that tarnished the image of the dentist. From consideration of both the good and the bad, we form a true picture of who we are.

There are excellent general histories of dentistry and several recent books on specific periods in the development of dentistry, so why publish another book of this nature? It was my belief that a new narrative, highlighting some of the personalities and the controversies particularly related to developments in the United States, would be instructional as well as enriching for dentists and dental students who might otherwise find a void in their education when it comes to understanding the history of their profession.

The obscure beginnings of dentistry are uncovered in the work of barber-surgeons and surgeons during the Middle Ages and Renaissance. Italian surgeons are credited with early attempts to restore teeth with gold fillings. Following two centuries of slow progress, the dawn of a new era was marked by the apparent sudden arrival of the surgeon-dentist, epitomized by Pierre Fauchard. The rapid growth of dental practice and dental science in Europe and England during the 18th century provided a foundation for the development of an independent dental profession in the American colonies.

This book relates the events that led to the formation of dental schools and dental societies in the United States with the role that these institutions played in promoting laws to regulate dental practice. The pioneering practitioners who led the professionalization of dental practice and the growth of dental science receive special focus. Controversies such as the use of gold versus amalgam filling materials, operative versus mechanical dentistry, the relationship between medicine and dentistry, and the restriction of practice imposed by patents give the story life. Attention is given to how, in the face of growing commercialism, the new dental profession sought to improve its image by adopting a code of ethics. The riveting and tragic story of the discovery of inhalation anesthesia is presented as a tale of ambition, greed, and deceit.

The beginnings of dental research, mostly in microscopic anatomy and microbiology, gave rise to controversy, rivalry, and a brief adherence to vitalism long after it had been dismissed by mainstream science. Recognition of the need for a standardized dental curriculum and the correction of deficiencies in equipment, standards, and research, mainly in the proprietary schools, engendered the Gies Report, a widespread study of dental education resulting in numerous recommendations for change. Implementation of the Gies Report elevated dentistry to its legitimate position within the modern university, alongside medicine, and within the scientific community at the national level by the formation of the National Institute of Dental Research. We end our peregrination through times past with dentistry’s acceptance as a legitimate university discipline.

Dental diseases have been a part of human existence since the days of earliest man. Paleolithic human remains contain evidence of advanced dental attrition and periodontal disease.¹ Ancient Egyptian skulls contain evidence of dental caries and bone destruction from periodontal infection.¹ Toothache is among the common ailments described in the earliest known textbooks of medicine. How did man cope with the excruciating pain of toothache and how did he accommodate to the loss of teeth? How did the practice of dentistry develop and flourish as a separate profession from medicine? To answer these questions and uncover the origins of dentistry, we must examine the records of ancient civilizations.

The Egyptians created numerous tomb inscriptions and papyri that have allowed us to form a vision of their way of life, including their approach to maintaining health and dealing with disease. The healing arts were closely integrated with their religious beliefs, and practitioners of medicine were members of the priesthood. Tomb inscriptions and early histories have suggested that Egyptian medicine may have been diversified. Herodotus, the Greek historian who traveled through Egypt, described the country as rich with practitioners, some specializing in diseases of the eyes, some for the heart, some for the gut, and some for the teeth.² Egyptian tomb inscriptions have revealed that approximately 150 individuals practiced medicine; at least three of them, and perhaps as many as nine, appeared to have treated dental problems.³^,⁴ The earliest dentist, Hesyre, is depicted on carved wooden panels recovered from excavations at Saqqara near Cairo (Fig 1-1). The panel inscription shows that he held the titles of both physician and dentist.⁴

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Fig 1-1 Wooden panel recovered from an Egyptian burial chamber depicting Hesyre and identifying him as a physician and a dentist.

Egyptian medical practice was dominated by the use of herbal remedies concocted in the form of emetics, diuretics, purgatives, and palliative dressings.⁵ The Egyptian pharmacopeia consisted of mineral, plant, and animal products, often in the form of powders or salves. Egyptian surgeons were adept in the use of the knife and cautery for excision or ablation of diseased tissues.

Examinations of the skeletal remains recovered from Egyptian burial sites have shown that 10% of teeth had dental decay, and 20% contained evidence of periodontal disease. Dental calculus (tartar) was present on 50% of all teeth.⁶ Radiographs of two royal mummies, Amenhotep III and Ramesses II, revealed extreme tooth abrasion, periodontal disease, and periapical abscesses but no evidence of dental treatment.⁴ From thousands of Egyptian mummies that have been examined, there is no evidence that Egyptians performed any dental operations. Although instruments that may have been used in medical practice have been recovered in burial chambers, none appear to have been specifically designed for use in dental procedures.⁴

In his studies of Egyptian skulls, F. F. Leek concluded that excessive attrition of occlusal surfaces was the greatest cause of death of the dental pulp, leading to abscess formation, osteomyelitis, and the spread of infection into the jaws.¹ Erosion of enamel and dentin was caused by the consumption of coarse bread and fibrous vegetables.⁷ The masticating (grinding) surfaces of the first molars exhibited the most severe wear, with the crowns often eroded to the gum line.

Tooth erosion and dental abscesses affected all classes, including members of the royalty.⁸ Loss of alveolar bone from periodontal disease is a common finding in ancient Egyptian skulls. The cause of the bone loss appears to have been an excessive accumulation of tartar on the roots of the teeth. No toothbrushes or instruments for scraping tartar have ever been found among Egyptian artifacts. Although dental decay was relatively rare in ancient Egypt, it became more prevalent at the time of the construction of the Great Pyramids. Excavation of 500 skeletons of aristocratic families at gravesites of the Giza pyramids revealed that the prevalence of tartar, caries, and dental abscesses were equal to that found among modern Egyptian populations. This decline in dental health may have been the result of changes in the quantity or form of carbohydrate intake. In 1920, paleoanthropologist Sir Armand Ruffer concluded, “Carious human teeth from ancient remains have been discovered in so many places that it is legitimate to doubt whether there was ever an epoch when the human species was not cursed by toothache.”⁷

From the archaeologic record, it appears that Egyptians did not practice operative dentistry.¹ No tooth filled with gold or any other metal has ever been found within Egyptian tombs. Evidence suggests that severely infected and loose teeth were not extracted.⁸ It would seem that a suffering dental patient had nothing but herbal remedies and magical incantations to afford relief from the pain of toothache and infection.

Among the papyri that have been recovered from Egyptian gravesites, the Ebers Papyrus and the Edwin Smith Papyrus are special sources of medical information. The ability to decipher the hieroglyphic script of the papyri and tomb inscriptions was made possible by the discovery of the Rosetta Stone during Napoleon’s illfated expedition to Egypt in 1799. The stone fragment found in the village of Rosetta in the Nile Valley was inscribed with a message written in the three writing systems used in Egypt: the hieroglyphic (or picture form), the hieratic (religious form), and the demotic (used in everyday communication). In 1822, Jean-Francois Champollion, a master of Greek and eastern languages, translated the demotic text into French and thereby was able to decipher the hieroglyphic sign text. Some hieroglyphics suggest that there may have been physicians for the teeth, as depicted by the juxtaposed symbols of an eye (for he who cares for) and a tusk (for teeth). Similarly, the juxtaposition of a bird (signifying the greatest), a tusk (teeth), and an arrow (a medical practitioner) was translated to mean the “greatest of those who deal with teeth” (upper right corner of Fig 1-1). However, not all experts of Egyptian hieroglyphics are in complete agreement on these interpretations.¹

The Ebers Papyrus, dating from around 1500 BC, is significant because of its description of the heart and its blood supply, evidence of the relatively advanced knowledge of the vascular system as well as the major organs of the human body, believed to have been gained in the practice of embalming and mummification. Dental diseases such as gumboils, pulpitis, and alveolar abscesses are described in the Ebers Papyrus and confirmed by the pathologic findings of the skeletal remains.⁹ Recipes for powders and ointments for tooth and mouth ailments are contained among the 700 formulas listed in the Ebers Papyrus.¹

The Papyrus Anastasi is of interest to dental science in that it contains the idea that toothache was caused by worms that had burrowed into the tooth’s interior (Fig 1-2). The earliest version of this myth can be traced to a Mesopotamian clay tablet, dating back to 1800 BC, discovered in the ancient city of Sumer (now Nippur), Iraq.² The myth of the tooth worm continued to be popular well into the late Middle Ages and was accompanied by the prescription that toothache could be treated by fumigating the infected tooth with the fumes from burning henbane seeds.

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Fig 1-2 Ivory carving depicting worms and demons as the cause of toothache.

The Edwin Smith Papyrus, an even older text dating back to 2700 BC, contains 48 medical case histories of Egyptian medical practices for dealing with various injuries, including a description for reducing fractures of the mandible.² The level of anatomical and physiologic knowledge contained in the Edwin Smith Papyrus is superior to other known papyri. Its emphasis on surgical technique suggests less reliance on the healing power of magic and religious incantation. However, with the exception of the mandibular fracture description, there are no other references to oral diseases in the Edwin Smith Papyrus.¹

Based on research and critical examination of the literature, Thomas Nickol concluded that there was no evidence of any prosthetic work being carried out on the dentition or of any surgical treatment of teeth by medical practitioners in ancient Egypt.¹⁰ The only treatment of dental disease and mouth ailments was by herbal preparations applied to the problematic sites by either physicians or, more likely, artisans of a lower, nonpriestly class. According to Guerini, there is no proof that any fillings or artificial teeth were ever found in mummies.¹¹ In the thousands of Egyptian skulls excavated at burial sites, there are only two examples of attempts to secure loose teeth with gold wire. These were recovered from a burial chamber at Giza in 1914.²

Guerini wondered why the Egyptians, talented in the craftsmanship of gold and other plastic arts and fond of beautifying the human body, did not undertake dental restorative work.¹¹ The artisans who fabricated the exquisite burial masks and other ornamental objects recovered from the pyramids had the necessary talent for making dental restorations. Why there is no evidence of such work remains a mystery.

The first evidence of the replacement of missing teeth was discovered in the Phoenician city of Sidon, now part of Lebanon.¹² A dental segment consisting of two canines and four incisors, wired together with gold wire, was recovered from a burial chamber dating back to the 5th or 4th century BC. Two of the incisors had been sectioned to remove the apical end, thereby creating a flat surface for vertical wiring of these teeth to the main horizontal wire network²^,¹² (Fig 1-3). These teeth were part of the skeletal remains of a man of high rank judging by his gold ring, linen wrappings, and the marble anthropoid sarcophagus that contained his body (Fig 1-4). Bone resorption of the jaws indicated that the individual suffered from advanced periodontal disease and that he had undoubtedly sought dental treatment for loose teeth. This gold wiring method allowed for replacement of two teeth and stabilization of all six. This artifact is believed to be the first partial denture ever discovered. Despite its primitiveness, it is ingenious in its design of incorporating the two canines for stability and in the method of attaching the two replacement teeth.

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Fig 1-3 Primitive dental prosthesis recovered in the Phoenician city of Sidon.

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Fig 1-4 Anthropoid sarcophagi from Sidon.

A second sarcophagus within the same burial chamber contained the body of a woman believed to be the man’s wife (see Fig 1-4). The sarcophagi were of Parian marble and thought to be the workmanship of Greek sculptors. Burial vaults of this type were contracted during life only by the wealthiest citizens of Phoenicia. Sidon was reputed to have numerous skilled metal workers who fabricated a variety of art objects. It would seem that among them were artisans who found the courage to venture into the care of ailing dental patients.

Knowledge of medical and dental diseases and their treatment in ancient Israel are contained in the Bible and the Talmud.¹³ Although it is suggested that oral diseases were treated by herbal regimens, as in adjacent cultures, and that gold teeth may have been fabricated, there is no paleoanthropologic evidence for such activity. But judging from the skills in metallurgy of the contemporaneous Phoenicians, one cannot rule out that such dental craftsmanship existed. The single most important medical contribution of the Israelites was the set of laws put forth by Moses for maintaining the public health through improved sanitation.¹³

The records of ancient civilizations of Sumeria, Assyria, and Babylonia, located in the land of the Tigris and Euphrates Rivers (Mesopotamia), provide another source of information on the origins of medical practice.¹⁴ Evidence points again to the priestly class as the guardians of magical and herbal remedies for all types of ailments, including toothache and other diseases of the mouth. Knowledge of their medical culture has been retrieved from clay tablets and votives recovered from archaeologic sites.¹³ More than 800 medical tablets (some in fragments) have been partially translated from their cuneiform language. Tablets now preserved in the British Museum describe incantations and herbal remedies for toothache. The overriding belief in Babylonian medicine was that diseases were the result of possession by demons (each disease its own demon).¹⁵ Incantations and magic as means of driving demons out of the body were major elements in the cure of diseases.¹⁴ One tablet, now held in the British Museum, contains the myth of tooth worms as the agent of toothache (see Fig 1-2), along with incantations for their expulsion. The most extensive Babylonian medical text, the Diagnostic Handbook, written by the physician Esagil-kin-apli during the reign of the Babylonian King Adad-apla-iddina (1069–1046 BC), contains a list of medical symptoms and empiric observations with logical rules to be used in making a diagnosis and prognosis. A major contribution of this civilization was the civil Code of Hammurabi (King of Babylonia, 3123–2081 BC). Among its laws were rules for the practice of medicine, including the setting of fees and penalties for malpractice, such as loss of a hand for a botched surgery.¹⁴

It was not until the development of the Greek civilization that rational remedies began to replace the reign of superstition in medical and dental practice. Nevertheless, the oldest Greek medicine continued to be based on religious superstition and was administered by priests in health temples or spas (asclepiads). An excellent description of these extensive health temples, and the curious rites that took place within, are described by Richard Caton.¹⁶ Cures were mainly the result of the combined effects of suggestion, empiric remedies, and minor surgeries. Medical knowledge was passed on, generally from father to son, within families over many generations.

Asclepius, a mythologic Greek physician believed to have existed around 1200 BC, became the central figure of a religious cult of medicine practiced by priests at temples²^,¹⁴ (Fig 1-5). An Asclepian cure was obtained by overnight rest in a spalike setting where treatments were often made when the patient was in a semihypnotized state. The patient’s complaint and the method whereby a cure was made were recorded on clay votive tablets and kept within the temple. At the ruins of the asclepiad of Epidaurus, votive tablets of teeth and jaws were discovered. Evidence that tooth extraction was performed in ancient Greece is also supported by the discovery of a pair of forceps (odontagra) in the ruins of an asclepiad. Aristotle described the use of this instrument for extracting teeth.¹¹

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Fig 1-5 Asclepius.

Greek philosophers developed the theory of the four elements— fire, air, water, and earth—and associated them to the four qualities that formed the earliest idea of a chemical universe (hot with fire, cold with air, moist with water, and dry with earth). The humoral theory of health and disease was developed by Empedocles, the founder of a Greek medical school in Sicily in the 5th century BC. Empedocles believed that health was the result of a balance of the elements and that imbalance led to disease. This theory of the four elements became the standard dogma for nearly 2,000 years.

Hippocrates, born in 460 BC on the Greek island of Cos, became the leader of the rational school of Greek medicine, a system based on careful observation of the patient and treatment of the observable problems (Fig 1-6). His clinical medicine was based on centuries of accumulated knowledge gained in the temple medicine of Asclepius.¹⁷ But Hippocratic medicine was less reliant on magic or religion and more nature based, advocating herbal and dietary approaches to better health.¹⁸ Hippocrates extended the ideas of Empedocles by postulating the existence of four principal fluids (the cardinal humors: blood, phlegm, black bile, and yellow bile) to correspond with the four chemical elements (hot, cold, moist, and dry). In addition, there were four corresponding temperaments: hematic (excitable), phlegmatic, melancholic, and bilious. For the followers of Hippocrates, health existed when these four humors and elemental conditions were in balance.⁵ Disruption of the balance was the cause of disease. His writings (and those of his associates and pupils) became known as the “Corpus Hippocraticus.”¹⁸

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Fig 1-6 Hippocrates.

Guerini described the many references to dental and oral diseases that are scattered within the Corpus Hippocraticus.¹¹ For example:

In cases of toothache, if the tooth is decayed and loose it must be extracted. If it is neither decayed nor loose, but still painful, it is necessary to desiccate it by cauterizing. Masticatories also do good, as the pain derives from pituita (phlegm) insinuating itself under the roots of the teeth. Teeth are eroded and become decayed partly by pituita, and partly by food, when they are by nature weak and badly fixed in the gums.

Large tubercles, of the size of grapes, had formed on the gums close to the teeth, black and livid, but not painful, except when the patient took food. For the mouth, incense powder mixed with some other ingredients proved useful. The internal use of the decoction of lentils also did good to the ulcers of the mouth.

According to Hippocrates, the extraction of firmly embedded teeth was fraught with danger; therefore, he advocated the extraction of loose teeth only and the use of leaden forceps to minimize fracturing the crown from the roots.⁹ Brief discussions of gingival overgrowth, dental abscess, caries, and jaw luxation are found in the Hippocratic writings.²

Examination of 1,500 teeth recovered from Greek cemeteries established around 1500 BC revealed similar dental diseases as those found at Egyptian sites, namely extensive dental attrition, periodontal bone loss (28%), and a relatively low level of caries (9%).¹⁹ In the Hippocratic writings, toothache was thought to arise by accumulation of phlegm draining down from above for the maxillary teeth and up from the internal organs for the mandibular teeth. Treatment consisted of bloodletting, purging, and application of various herbal remedies. Teeth were extracted only if these remedies were unsuccessful. It was the practice to extract only loose teeth. Various dressings were applied to teeth and gums to degrade the periodontal tissues and loosen the teeth in advance of the extraction. As a precautionary step, cavities were filled with lint and lead to strengthen the crown before applying the forceps in order to minimize the chance of breaking the crown from the root. This practice persisted into the Middle Ages in Europe.

Hippocrates believed that doctors should possess social responsibility and high ethics.²⁰ They must avoid unkindness and offer their services free when necessary. Greek practitioners who embraced the Hippocratic method held themselves to a higher social responsibility and pledged to avoid all unkindness and to offer their services free when necessary. The Hippocratic Oath, taken by all who entered the medical profession, may be summarized by the dictum “help the patient and do no harm.”²¹ The oath directs the physician to respect the patient’s personal information and to avoid taking advantage of the patient’s dependence and vulnerability. The admonition in the oath that “I shall not use the knife even upon sufferers from stone, but will leave the operation to the technicians” has special meaning for understanding how the manual practices of surgery and dentistry developed in separation from the intellectual exercises of diagnosis, prognosis, and prescription, responsibilities of the physician class. Over the ensuing centuries, this led to the unfortunate separation of surgery and dentistry from medicine, with physicians in a supreme position by virtue of their knowledge of Latin and their university education.

The Etruscans of northern Italy are considered to have produced the earliest examples of prosthetic dentistry. The Etruscan civilization flourished before the Christian era and the establishment of the Roman Empire. The Etruscans spoke a separate language and practiced advanced decorative arts, largely influenced by their extensive cultural and commercial ties with Greece and Egypt. Prosthetic dental appliances constructed with teeth carved from bone, animal teeth, or with human teeth removed from cadavers and fastened with gold bands have been found in Etruscan and Roman gravesites (Fig 1-7). Twenty Etruscan dental appliances have been documented, but only nine survive. All appear to have been used as decorative bands or to support replacements to one or both maxillary central incisors in women from whom healthy teeth may have been removed deliberately.¹¹ This evidence seems to confirm that gold dental appliances were worn only by Etruscan women, suggesting that cosmetic concerns were paramount in their creation.

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Fig 1-7 Etruscan dental prosthesis.

Greek, Egyptian, Phoenician, and Persian civilizations influenced the growth of medical knowledge and technology through the intercourse of commerce in the eastern Mediterranean Sea. The Egyptian city of Alexandria became a center of learning, where a great university and library were developed.⁵ Greek medical lore was translated into Arabic and preserved for centuries before translation to Latin in the Early Middle Ages. The Roman civilization, beginning with the foundation of the city of Rome in 753 BC, absorbed a great deal of what was known from the establishment of Greek communities within its territories. The Greek medical system of health spas (temples) spread its influence among the Romans. The humoral theory of diseases fundamental to Greek medicine was accepted in Rome.

Medicine in the Roman Empire became less philosophic and more practical out of the necessity of maintaining large armies and meeting the demands of an increasingly wealthy urban population. Roman armies spread throughout the Empire were accompanied by surgeons to repair wounded soldiers and physicians who tended to the illnesses common to marching armies and large encampments of men. Although medical remedies were still mostly herbal, there was an increasing place for surgical treatment of wounds. Surgical instruments recovered from Roman graveyards reveal advanced designs and a wide array of implements²² (Fig 1-8). During the Roman Empire, the profession of medicine became very profitable, and soon it became overstocked. This may have led to a subdivision of medical practice, with specialists becoming common in the latter half of the first century of the Christian era.²³

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Fig 1-8 Roman surgical instruments. (Courtesy of Historical Collections & Services, Claude Moore Health Sciences Library, University of Virginia.)

The two giants of Roman medicine were Celsus (25 BC–50 AD) and Galen (129–200 ad). Celsus, independently wealthy after the death of his father, studied Hippocratic medicine in the Greek islands and later at the medical school of Alexandria.²¹ Celsus was a prolific writer, a compiler who assembled most of what was known of Greek medicine into his eight-book De Re Medicina. Book 6 dealt with diseases of the eyes, ears, nose, throat, and mouth. Celsus accepted the four classic signs of inflammation as rubor, tumor, calor, and dolor. His De Re Medicina served as a basic compendium of medical and dental knowledge into the Middle Ages. He was an empiric in his belief that it was not very important to know what caused a disease but only what cured it or alleviated the suffering. According to Celsus, a man was not qualified for his profession by theory but by practice (experience).

Celsus considered toothache to be numbered among the worst of tortures. He recommended the application of poultices, purgatives, and fumigations for the relief of toothache.²⁴^;² Periodontal suppuration and carious teeth were best treated by cauterization with a hot iron and/or boiling oil. The later technique was carried out with small pellets of lint attached to a probe or toothpick and dipped in boiling oil before applying to the tooth. Tooth extraction was considered dangerous, to be performed only as a last resort. A finger technique, used after application of loosening agents, was preferred to the use of forceps. Celsus recommended, as others had before him, to pack the cavity of a carious tooth with lead or linen prior to applying the forceps lest the crown fracture away. All bone and root fragments must be removed to minimize any postsurgical infection. Hoffmann-Axthelm considered the exodontia technique of Celsus to be remarkably modern in concept.²

Celsus advocated the use of files to smooth jagged edges and to remove tartar from teeth. A mixture containing poppies in the form of a paste was recommended for treating the pain of oral ulcers and toothache.¹¹ Another remedy for toothache and oral ulcers consisted of application of papyrus paper impregnated with arsenic and other caustic substances to the diseased area. Dental abscesses were to be lanced and drained. Jaw fractures were treated with tooth banding and jaw bandages to immobilize the bony fragments. Paulus Aegineta, a 7th-century Greek physician and author of an encyclopedic survey of Greek and Roman medicine, gave these instructions for tooth extraction:

Having scarified around the tooth down to the socket, we must by degree shake the teeth with a tooth-extractor, and draw it out. But, if it is carious, we must first plug up the hole with a small tent, that it may not break when compressed by the instrument. After the extraction we may consume the flesh that is left by sprinkling it with finely levigated salts, and afterwards gargles of wine oroxycrate may be used until the completion of the cure.²⁵

In his many commentaries, Aegineta noted that Celsus disapproved of the extraction of teeth except in cases of extreme necessity. Celsus warned of the danger of fracturing the jawbone during tooth extraction, citing cases that led to death of the patient.²⁵

The most famous of all Greek/Roman physicians and teachers was Galen (Fig 1-9). Born in Pergamum in 129 AD, Galen went on to achieve fame second only to Hippocrates. Like Celsus, he studied Greek medicine at Pergamum, Corinth, and Alexandria. Galen practiced medicine in Rome and for a time with the Roman army under Marcus Aurelius. While at Pergamum, he was surgeon to the gladiators. Galen wrote extensively, leaving a body of medical knowledge that controlled the medical curriculum and practice into the 16th century.⁵ In dental medicine, he followed the chief remedies proposed by earlier Greek and Roman physicians. He was the first to recognize that a toothache could be derived from inflammation of the pulp and that dental pain could also arise from an inflammation of the radicular (root) portion of the tooth. Guerini gives us the most complete account of the contributions of Greek and Roman physicians to the treatment of oral and dental diseases. Despite ample references in the medical texts of Greek and Roman physicians to dental and gingival diseases and their surgical and herbal treatment regimens, there is no evidence that any restorative or prosthetic dentistry was actually performed by medical practitioners.¹¹

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Fig 1-9 Galen.

But evidence of a different nature, along with the dental artifacts recovered from Etruscan graves, suggests that there were artisans who carried out dental services for the wealthy classes. Martial, a Roman satirist of the 1st century AD, in writing of daily life makes several references to dental practitioners and false teeth. In speaking of the practitioner Cascellius, Martial writes that he “extracts or repairs an aching tooth.” Elsewhere he notes, “and you, Galla, lay aside your teeth at night, just as you do your silken dress” and, to Leila, “You wear bought teeth, and bought hair.”²⁶

Two notable Roman physicians of the first and second Christian centuries were Archigenes and Adromachus. Archigenes’s notable achievement was his approach to treating toothache by drilling into the pulp with a trephine to allow the escape of morbid substances and his introduction of medicines. Andromachus, physician to Nero, achieved fame with his concocted mixture called theriac. Andromachus claimed that theriac cured all sorts of diseases, including toothache. Its beneficial effect was probably due to its chief component, opium.¹¹

Dioscorides, a Roman herbalist of the 1st century, classified hundreds of plants to be used as remedies for most ailments, including toothaches, oral ulcers, and abscesses.¹³ His book De materia medica was translated into Arabic and later into various European languages. It contained recipes for preparations to be inserted into the cavities of decaying teeth. It also contained formulas for medicines that were reported to loosen teeth and aid in extraction. This book remained in use for about 1,500 years.

The downfall of the Roman Empire was followed by a long decline in the growth of knowledge throughout the Western world. During this period, the Arabian peoples expanded their influence by conquering the Mediterranean and extending their culture into Spain and southern France. In their great cities of Baghdad, Damascus, Seville, Toledo, and Cordova, they established new centers of learning, incorporating the medical knowledge of the Greeks, Romans, and Egyptians through translation into Arabic. Knowledge of Greek and Roman medicine came to the Arabs through Christians who were driven out of the Byzantine Empire. Displaced scholars translated Greek medical manuscripts into Semitic languages and then into Arabic. By adding their own experiences to the Hellenic and Roman corpus of medicine, Arabs developed an Islamic medicine exemplified by its leading practitioners, Rhazes (865–925 AD), Albucasis (936–1013 AD), and Avicenna (980–1037 AD).

Rhazes (Abu Bakr Muhammad ibn Zakariya ar-Razi) was born in northeastern Persia and studied medicine in Baghdad before becoming a court physician and a leading figure in the field of medicine, ranking with Hippocrates and Galen as one of the founders of clinical medicine. The Al-Mansuri, one of Rhazes’s many writings, consisted of ten parts (books) and is an encyclopedic review of contemporary Islamic medicine, used in teaching until long after the Renaissance. As in all previous compendiums of medical knowledge, attention was given to the care of the teeth and to the treatment of dental and oral diseases much in accord with previous ideas of Galen. For the care of teeth, Rhazes recommended cleansing powders combining abrasive and whitening substances such as the ashes of ocean crabs and mussels.² To protect the teeth from caries, he advocated oiling the teeth before going to bed and avoiding sweets. Toothache was treated by filling the cavity with mastic (a resin or gum) and alum (a mineral salt of sulfate of aluminum and potassium).¹¹ If pain persisted, Rhazes recommended entering the tooth with a drill and applying cauterization with a hot iron or boiling oil.² Opium and myrrh were used as topical remedies and in dressings. Extraction, a last resort, was said to be aided by first applying loosening agents such as arsenic paste or the juices of a boiled frog. In general, Arab physicians were cautious about extracting teeth, preferring to firm tissues with astringents, cauterizing and ligating loose teeth to healthier abutment teeth. Diseased gums were treated by scarification and application of leeches. Hoffmann-Axthelm has noted that in 19th-century Baghdad, a metallic substance called tancar, similar to that used by tin smiths and plumbers, was used to fill carious teeth.²

Albucasis was born in Cordoba, Spain, in 936 AD and is believed to have died after 1009 AD. This university-educated physician wrote an encyclopedic treatise on medicine and surgery called the Al-Tasrif (The Method). It covers the advantages and disadvantages of cautery and the tools for treatment of wounds, venesection (phlebotomy), and cupping, as well as various kinds of needles and threads for stitching wounds, including about 150 depictions and drawings of tools, surgical instruments, droppers, and syringes¹¹ (Fig 1-10). Albucasis, a foremost oral surgeon, warned of breaking crowns and leaving stumps in the jaw, complications that often occurred when untrained practitioners extracted teeth.² For extraction, he advised detaching the gingiva and loosening the tooth before applying the forceps. Like Celsus, he advocated filling the cavity of a carious tooth with linen thread to minimize crushing of the crown. His coverage of dental and oral diseases was rather extensive. He recognized tartar to be the cause of periodontal disease and placed great importance on scaling.² He designed numerous types of scalers and other dental instruments.¹¹ Albucasis advocated ligating loose teeth with silver and gold wires and replacing missing teeth with artificial teeth carved from bone. According to Hoffmann-Axthelm, Albucasis must be considered the most important practitioner of dental medicine up to that time and one that would not be surpassed for several centuries to come.²

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Fig 1-10 Page from Albucasis’s Al-Tasrif depicting instruments for scraping tartar from teeth.

Avicenna, (Ali al-Husayn ibn-Sina), an Iranian physician, is considered to be the most famous and influential of the philosopher-scientists of Islam. He composed the Kitab al-shifa’ (Book of Healing), a vast philosophic and scientific encyclopedia, and The Canon of Medicine, which is among the most famous books in the history of medicine. Avicenna stressed the importance of oral hygiene. He discussed the causes and treatment of toothache and oral ulcerations. According to Avicenna, the proper treatment for relief of throbbing dental pain was to drill the tooth to drain it of its humors and to introduce various palliative medicaments.¹¹ He recommended the application of arsenic for treatment of toothache, ulcers, and fistulas. A section of The Canon dealt with treatment of fractured jaws and the importance of attaining proper occlusion and stabilization with wires and bandages.² Herbal remedies, as in former times, remained the most important aspect of treatment of systemic and dental diseases.

In ancient times, the medical profession considered toothache, gingival disease, and oral ulcerations as ailments to be treated side-by-side with eye, genital, gastrointestinal, heart, and other regional ailments. Indeed, the mouth was connected to the body. From the beginning of written records, it is clear that tooth abrasion, caries, toothache, and dental abscesses formed significant medical needs. Periodontal disease and inflammation of the gums were common problems. Dental calculus (tartar), recognized as a cause of gingival and periodontal inflammation, was removed with special instruments. Treatment was heavily based on local application and or consumption of herbal remedies, sometimes concocted with added “junk” to drive away demons. Textural evidence suggests that dental cavities were “filled” with herbal preparations, often with opium and arsenic as part of the mixture. Cauterization and extractions were performed when herbals remedies proved ineffective. When extraction was necessary, it was advised to loosen the tooth with application of natural medicines before extraction, and it was suggested to leave the actual extraction to one who had experience with the technique. For the rich, loose teeth were splinted to solid ones with gold wires. In a few cases, missing teeth were replaced with teeth carved from bone or with cadaver teeth. But this again was only for the wealthy. In accord with the humoral concept of diseases, bloodletting, cupping, purging, and cauterization were treatments of choice for suppurating infections. Physicians may have prescribed the treatment of oral and dental diseases, but the actual manual service was assigned to a surgeon or subordinate mechanic.

1. Leek FF. The practice of dentistry in ancient Egypt. J Egypt Archaeol 1967; 53:51–58.

3. Ghalioungui P. Did a dental profession exist in Ancient Egypt? Med Hist 1971;15:92–94.

4. Forshaw RJ. The practice of dentistry in ancient Egypt. Br Dent J 2009; 206:481–486.

7. Ruffer A. Study of abnormalities and pathology of ancient Egyptian teeth. Am J Phys Anthropol 1920;3:335–397.

8. Forshaw RJ. Dental health and disease in ancient Egypt. Br Dent J 2009; 206:421–424.

9. Densham A. A review of the progress of dental science and literature from the earliest ages. Proc R Soc Med 1909;2:71–98.

10. Nickol T. An examination of the dental state of an Egyptian mummy by means of computer tomography: A contribution to “dentistry in ancient Egypt.” Bull Hist Dent 1995;43:105–112.

11. Guerini V. A History of Dentistry from the Most Ancient Times Until the End of the Eighteenth Century. Philadelphia: Lea & Febiger, 1909:188–199.

12. Torrey CC. A Phoenician necropolis at Sidon. Ann Am Sch Orient Res Jerusalem 1920;1:1–27.

13. Shklar G, Chernin D. A Sourcebook of Dental Medicine. Waban, MA: Maro, 2002.

14. Libby W. The History of Medicine in Its Salient Features. Boston: Houghton Mifflin, 1922.

15. Jastrow N. The medicine of the Babylonians and Assyrians. Proc R Soc Med 1914;7(Sect Hist Med):109–176.

16. Caton R. Hippocrates and the newly-discovered health temple of Cos. Br Med J 1906;1:571–574.

19. Carr G. Some dental characteristics of the middle Minoans. Man 1960;60: 119–122.

21. Garrison FH. An Introduction to the History of Medicine. Philadelphia: W. B. Saunders, 1913.

22. Milne JS. Surgical Instruments in Greek and Roman Times. Oxford: Claren-don, 1907.

23. Barnes H. On Roman medicine and Roman medical inscriptions found in Britain. Proc R Soc Med 1914;7(Sect Hist Med):71–87.

24. Collier GF. A Translation of the Eight Books of Aul. Corn. Celsus on Medicine. London: Simpkin and Marshall, 1831.

25. Adams F. The Seven Books of Paulus Aegineta. London: Sydenham Society, 1846.

1 Dinosaurs and Pleistocene cave bears show evidence of dental caries and periodontal disease.

2 “IX. In TOOTH-ACHE, which may be justly ranked among the most excruciating affections, wine is most decidedly to be interdicted: even food, at first ought to be denied, and afterwards employed sparingly, choosing such as is tender, that it may not irritate the teeth during mastication; externally the steam of hot water must be applied by means of a sponge, and a cerate prepared with cypress or orris oil, spread on wool, is to be laid over the part, while the head itself ought to be covered. Should the pain become more severe, benefit may accrue from opening the bowels by clyster, laying hot poultices upon the jaw, and retaining in the mouth warm water impregnated with any proper medicines, and repeatedly renewing the liquid. For this purpose cinquefoil root is boiled in diluted wine, and henbane root either in posca or mixed wine, adding to both these liquors a small portion of salt; so also poppy-heads, not too dry, and the root of mandragore. But especial care must be taken lest either of these three be swallowed. A decoction of the bark of the root of the white poplar is also a proper medicine for the same purpose; so also hartshorn shavings in vinegar; and catmint with a fat teda, or with a ripe fig either in mulse or vinegar and honey; after boiling the fig the fluid must be strained; also a probe enveloped in wool is to be immersed in hot oil, and with this the tooth itself is to be fomented. There are certain applications acting upon the tooth itself like a cataplasm: such is the pulp of the rind taken from a sour and dry pomegranate, rubbed up with a like portion of galls and pine-bark, with which minium is mixed; these, after trituration, are beat up with rainwater; or equal portions of panaces, opium, peucedanum and stavesacre without the seeds, are rubbed together; or three parts of galbanum to one of opium. Be the local application to the teeth what it may, one should be equally exact in the use of the cerate for the jaw, covering it, as I said before, with wool. Some also mix together of myrrh, cardamom, of each p. x. I. saffron, pellitory, figs, pepper, of each p. x. IV. mustard p. x. VIII.: having rubbed them together, they smear them on a piece of linen rag, and apply them on the shoulder of that side where the tooth aches; if in the upper jaw on the scapula, if in the lower on the breast. and that alleviates the pain; and after it has produced the proper effect, it is to be immediately removed. Even if the tooth be carious, unless there be urgent occasion, there is no need to be in a burry to extract it; but to each fomentation above mentioned other stronger compositions are to be added, of a nature calculated to allay pain, such as is that of Hera. It contains of opium p. x. I. pepper p. x. II. Sory p. x. x.; these when powdered are formed into a mass with galbanum, and that is applied round the affected tooth.”²⁴

The downfall of the Roman Empire in the 5th century AD led to a generalized decline in the stability and organization of society in the Western world. The invasion of barbarians from the northern territories destroyed the established fabric of law imposed by Roman rule, only to be reversed by the subsequent growth of Christian institutions, the rise of kingship and feudalism, and the eventual emergence of commercialism. Centers of learning created by Christian and Islamic scholars in the newly formed kingdoms of Britain, France, Germany, and Spain served to revive social order. The recovery that followed several centuries of relative poverty was halted temporarily by the disruption of commerce in the Mediterranean during the Islamic conquests of the Iberian Peninsula and southern France and by Viking raids in the North. By the 11th and 12th centuries, resurgence in trade of raw materials and manufactured goods was felt in Europe, especially in major cities along the Northern, Atlantic, and Mediterranean coasts and inland along the major rivers.¹ The rise of a rich merchant class was accompanied by increased numbers of affluent clergymen and municipal administrators. By the 13th century, an increasing percentage of the population was employed, organized in guilds, and better educated than before. The rising number of city-dwelling bourgeoisie created a growing, albeit slow, demand for better health care, including treatment of oral and dental diseases.²^,³

Physicians occupied the top of the health care pyramid in the Middle Ages. They attended university medical schools and upon successful examination earned the right to wear academic robes before entering practice.⁴ Having completed the educational program known as the Articella, they knew Latin and were steeped in the classical medicine of Galen. In some cities, physicians were required to have passed municipal or university licensing examinations. The few surgeons who held medical degrees were considered to be master-surgeons and to belong to the surgeons of the long robe (a result of their right to wear academic robes). However, most surgeons were uneducated, knew no Latin, acquired their trade by apprenticeship, and were considered to be surgeons of the short robe, or lay surgeons.⁵⁶