Ancient Evidence Of Periodontal Disease And Its Treatment

Anthropologic expeditions to Mesopotamian sites in Iraq found relics used for dental care in gold vanity sets and cases, including ear scoops, tweezers, and toothpicks. One set found in the Nigel Temple at Ur is estimated to have been used about 3000 BCE.

The oldest written documents related to teeth are from about the same era and were found in the excavations of the Sumerian civilization in the Middle East. These are pictographic and cuneiform tablets and contain descriptions such as this:

Hippocrates (460-377 BCE), a Greek physician, was the first person known to prescribe a dentifrice. His cure was not something we would use today because it was a complex solution, including the head of a hare and three mice to be sieved and soaked in honey and white wine and then rubbed on the gums.³ A twentieth century study of periodontoclasia, an early term for any destructive or degenerative disease of the periodontium, suggested that Hippocrates may have provided relatively effective periodontal treatment long before modern times.⁴ Aristotle, who was born after Hippocrates (348-322 BCE), described “scrapers” used for teeth cleaning. Surviving examples show that these instruments were similar to modern scalers. Interestingly, Aristotle did not think that women had as many teeth as men.¹

Fiber sticks were the earliest known toothbrushes. They were the size of pencils and were hammered or flattened on one end to separate the fibers. Such sticks were recorded in Babylonian, Chinese, Greek, and Roman literature. All were made from trees or bushes with bark containing a cleansing substance plus aromatic fumes that acted as an astringent, like a kind of dentifrice. Early Mohammedans called their sticks “siwaks,” which were made of arrak (Salvadora persica, the toothbrush tree).⁵ In Greece and Italy, sticks came from the mastic tree (Pistacia lentiscus, the toothpick tree). In Saudi Arabia, the sticks are called “miswaks” (Figure 1-1).

The Middle Ages

An early written record of dental calculus, still commonly called tartar, is from Albucasis (936-1013 CE), a Moorish surgeon from Spain. His treatise, De Chirurgia, described removing foreign substances from teeth using a set of 14 scrapers he designed. He recognized the relationship between calculus and tooth loss, writing, “sometimes on the surface of the teeth, both inside and outside, as well as under the gums, are deposited rough scales of ugly appearance and black, green or yellowish in color; thus corruption is communicated to the gums and so the teeth are in process of time denuded.”⁶

The writings of Johannes Aranculus (1412-1484) related diet to oral health and disease. He defined rules for oral hygiene, including avoiding desserts and sweets such as honey, not biting on hard things, and avoiding “substances that can set the teeth on edge.” He also warned against eating onions but with no particular explanation. Teeth were to be cleaned using a thin piece of wood, followed by rinsing with wine.¹

The Development Of Modern Dentistry

The era of modern dentistry began in Europe. Dentists were trained by apprenticeship, learning by watching and assisting an established dentist. Ambroise Paré (1517-1590) was the first apprentice permitted to take an examination and apply for membership in the prestigious College of Surgeons in Paris, a privilege reserved for physicians. He extracted teeth, opened dental abscesses, set fractured jaws, and was recognized by medical colleagues for his professional work.⁷

Andreas Vesalius (1514-1564), a Flemish anatomist, and Bartolommeo Eustachio (1520-1574), an Italian anatomist, were responsible for early anatomic studies of the teeth. In the following century, Anton van Leeuwenhoek (1632-1723), a Dutch naturalist, discovered dentinal tubules when looking through his invention, the microscope. He also examined tartar scrapings from teeth and identified microorganisms in the mouth.⁷

Pierre Fauchard (1678-1761) is called the father of dentistry because of his powerful influence on progress in the profession. He was self-educated but developed systematic methods for dental practice. His classic text, Le Chiurgien Dentiste, was first published in 1728. Fauchard recognized the importance of oral health and described cleaning by “rubbing the teeth from below upwards and from above downwards outside and inside with a little sponge” dipped in warm water and brandy, followed by use of toothpick between the teeth.⁸ Dentistry was touted as an important part of surgical practice by John Hunter (1728-1793), a surgeon and anatomist in London. He recognized that dental caries were initiated on the outside of the tooth on surfaces where food collected.⁷

The Pilgrims brought physicians, an apothecary, and three barber-surgeons to America in 1638. The barber-surgeons provided bloodletting and tooth extraction services along with shaving and hair treatments. It is not clear who was the first dentist to practice in the American colonies. Men such as Woofendale, Mills, Baker, Flagg, Greenwood, and Paul Revere were among the early dentists. However, their methods were only slightly removed from those of the barber-surgeons.⁷

Establishing Formal Dental Education: 1800 to 1900

During the early 1800s, dentists began to understand that knowledge of anatomy, pathology, and physiology was required for practice. They further believed that the apprentice method (working and learning in the office of a preceptor, a clinician-teacher) was inadequate because no one person was competent to teach all scientific and technical subjects required of dentistry. Medicine was already firmly established as a healing profession, and many believed that dentistry should be a branch of medicine. So, the establishment of dentistry as an independent profession faced great challenges both from the apprentice-trained dentists and the better established medical practitioners.⁹

In 1939, Stillman reflected that to be a profession, dentistry had to combine science and technological arts, not merely create “prostheses.”¹⁰ When the first dental school was established, the faculty had little medical education and faced this challenge. There was also dissention among dentists of the time; those dealing with caries and fillings tended to view dentistry as a trade, and those who focused on periodontal tissues described dentistry as a healing profession.¹⁰

The first dental school was officially opened in 1840 as the Baltimore College of Dental Surgery with five students in the first class. The lack of respect for dentistry within the medical profession was slowly overcome and, in 1867, Harvard University established a dental department. At Harvard’s first dental school graduation, its president, Oliver Wendell Holmes, referred to dentistry as a “branch of the medical profession to which this graduating class has devoted itself . . . yours is now an accepted province of this great and beneficent calling . . . medicine.”⁷ Between 1840 and 1867, 13 more dental schools were established. Some were short-lived, but others eventually affiliated with universities.

Interrelationship of Early Periodontics to Dental Hygiene

Periodontal diseases are as old as human civilization. Descriptions of early attempts at treating them were recorded, but in general, periodontal diseases were assumed to be incurable. In 1845 John M. Riggs first publicly called attention to this disease in the United States. He asserted that it was a curable disease and that with proper surgical treatment (by this he meant cleaning of the periodontal pockets), 90% of the cases could be cured. His opinion became widely accepted and periodontal disease became known as Riggs’ disease. Curettage beyond the confines of the periodontal pocket to “stir up a healing reaction” was his original contribution to therapy.¹¹

Leonard Koecker, a nineteenth century surgeon-dentist in London, was acknowledged to have successfully treated advanced cases of periodontal disease with conservative techniques. He is considered the first periodontist. His treatment to cure periodontoclasia, as it was called at the time, was very controversial. However, Riggs adopted these techniques and demonstrated them in public clinics. When dentists saw the results, these treatments became accepted.⁴

F.H. Rehwinkel renamed periodontoclasia pyorrhea alveolaris in a report he presented to the American Dental Association (ADA) in 1877. This name was never totally accepted because it was descriptive of only one aspect of pathology, bone loss. However, pyorrhea became a commonly used term that is still used today.⁴

Development of the Profession of Dental Hygiene

Late in the 1800s, dental journals began to include articles about disease prevention and patient education. D.D. Smith of Philadelphia emphasized systematic change in the oral environment surrounding the teeth to prevent disease and demonstrated these techniques to colleagues. Smith had a profound influence on Alfred C. Fones, the founder of the role of the dental hygienist. Fones attended a meeting of the Northeastern Dental Society in 1898 at which Smith described his system of periodic oral prophylaxis (cleaning of the teeth). The treatment required patients to return at intervals of a few weeks for office treatment and to perform daily home care as they were instructed. Fones visited Smith’s office three times to observe the practice. He then implemented this system in his own office for 5 years. Fones recognized that the procedures took an inordinate amount of his practice time. Smith believed that prophylaxis was too important to be delegated, but Fones disagreed and sought to develop an assistant to provide this care.¹²

First Dental Hygiene Schools

Fones went on to establish the first school for dental hygienists in Bridgeport, Connecticut, in 1913. His school graduated hygienists for 3 years before colleges and universities began to train dental hygienists in 1916 (Figure 1-2).

Clinical Note 1-6

Dental hygiene began as a profession in 1913.

Robin Adair of Atlanta, an oral surgeon with both medical and dental degrees, presented “The Introduction of Oral Prophylaxis into Dental Practice” to the Florida State Dental Society in June 1911. He described his system of regular dental cleanings for patients in his practice in which he first provided the treatment himself and then employed a “dental nurse.” He interviewed 150 applicants before selecting an experienced nurse to train for the position. He required that she assist him at the chair, read everything published on preventive dentistry, and practice on her family and friends before treating office patients. Adair performed the initial treatment and had the dental nurse finish. He reported that his patients were delighted and even sent out cards notifying his patients of the dental nurse and her skills.

Adair opened the fourth dental hygiene program in 1917 in Atlanta but graduated only 17 students. His untimely death in an automobile accident, which resulted in closure of the school, was a great loss to the development of dental hygiene.¹³

School Programs For Children

It was the general consensus during the period from 1900 to 1930 that a clean tooth would not decay. Because of this philosophy, many school dental health education programs were established to teach toothbrushing and promote prevention. Some of these community programs had benefactors who financed clinics for the dental treatment of children. Three of these programs also educated dental hygienists in their clinics: Guggenheim and Eastman, in New York State, and Forsyth, in Boston (Figure 1-3). Dental hygienist graduates from these programs had little experience treating adult patients. In contrast, Fones’ original educational program included instruction about permanent teeth and pyorrhea alveolaris, described as a curable disease requiring an exacting and painstaking treatment technique.¹¹

Many public elementary school dental hygiene programs were initiated in the first half of the twentieth century because the greatest cause of student absence was recognized to be toothache. New York State had the most highly developed programs and required dental hygienists to have teaching credentials for the public schools. Boston also had many school dental clinics located throughout the city. School clinics were located directly in school buildings in Flint, Michigan. It was well into the 1930s before techniques for restoring primary teeth were generally taught and practiced by dentists, so these school clinics, staffed by dentists and hygienists, mostly extracted primary teeth, restored erupted permanent first molars, and cleaned children’s teeth.¹³