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Dental Science and the Separation of Medicine from Religion
The city of Alexandria, Egypt was founded by Alexander the Great in 332 B.C. and for centuries it was an outstanding center of Greek science. One of the earliest institutions in the city was an excellent medical school. Human dissection was initiated there, but unfortunately most of the descriptions were lost when the main library and a subsidiary library were destroyed by fires in the 3rd, 4th and 7th centuries A.D. Subsequent cultures in Western Civilization forbade human dissection for nearly 2,000 years. Consequently, anatomic sciences were retarded until the time of Vesalius and da Vinci in the 16th century A.D.

However, during this early period of Greek science, Aristotle (384-322 B.C.) laid the foundations of Natural History and Comparative Anatomy (including Dental Anatomy). One of his books, On Different Parts of Animals, has a chapter devoted to the study of teeth. In his book, History of Animals, he compares the dental systems of different animals. In describing the functions of different classes of teeth he was quite accurate.

It seems quite amazing that the brilliant Greek Scientist-Philosophers did not see the need either for experimentation or comparing and recording a great number of observations before drawing conclusions. Thus errors such as Aristotle's statement that men have more teeth than women were accepted and perpetuated for eighteen centuries.

Credit should also be given to Aristotle for some very astute observations and conclusions. He observed, for instance, that some of the veins in the head terminate with very slender branches inside the teeth. In a book entitled Problems he queried "Why do figs, when they are soft and sweet, produce damage to the teeth?" He went on then to speculate that perhaps small particles of the figs insinuate themselves into the inter-proximal areas and become the cause of the putrification process. This concept, however, was not prevalent and for centuries no other medical writers made note of any strong connection between such sweet fruits and caries.

One of the greatest and most famous physicians in history is Hippocrates of Cos, known from ancient times as Hippocrates The Great. The exact times of his birth and death are uncertain, but he lived from approximately 460 B.C. to 377 B.C., contemporary with Plato and a little before Aristotle. He was apparently the son of a physician (Asclepiad) and trained as a physician himself. His writing was extensive, including many dental topics.

Among HippocratesÕ contributions, which earned him the title "The Father of MedicineÓ:

Hippocrates was much more fond of the practice of medicine than surgery and preferred to leave the use of the knife to people more skillful in its use than he was. Beginning about this time there occurred a separation between medicine and surgery which persisted for many centuries and still exists in some countries such as England where physicians and surgeons go to different schools, receive different degrees and have completely separate licensing and practice privileges.

Hippocrates was also largely responsible for establishing the humoral theory of pathology. The theory had been formulated previously by Empedocles (490-430 B.C.) and other Greek philosophers. Basically, the theory held that the body's state of health or illness was determined by the balance of four fluids or humors. These humors were blood, yellow bile, black bile and phlegm. If the body or the diseased area was hot and moist, the fluid in excess was blood and the treatment would be some method of reducing or moving the blood; if the body was hot and dry, there was an excess of yellow bile; cold and moist indicated excess phlegm, and cold and dry was a sign of excess black bile. The theory was by no means universally accepted prior to Hippocrates, but Hippocrates' acceptance of and support for the theory did much to establish it firmly.

 The Romans gradually conquered and annexed all of the Greek states between 197 and 30 B.C. There was so much cultural exchange before, during, and after the conquests that in medical- dental history these two great cultures can in many ways be considered as one, the Greco-Roman culture.

Claudius Galen (c. 130-200 A.D.), a Greek physician who practiced in Rome, has for centuries been considered the greatest physician of antiquity next to Hippocrates. Galen supported the humoral theory and popularized many treatments based on the theory. The humoral theory was virtually unquestioned until the mid 1800s. As late as 1910 one dental textbook explained the variations in tooth form as a consequence of the particular humoral balance of the individual, and such terms as being in a "good humor" or a "bad humors'' are part of today's common speech. In the realm of dental science, Galen was the first to identify the nerves in teeth and postulate that the sensations of teeth arose in the pulp.

Galen proposed that caries was caused by the internal action of acrid and corroding humors. In the same way he believed cutaneous ulcers were caused by internal acrid humors without any external cause. The cure must consist of astringent and tonic remedies, either locally applied or taken internally to strengthen the basic substance of the teeth. Toothache was thought to be caused by an inflammation in the teeth which caused an excess nutrition and excess of hot humors. These humors should be reduced by counteracting humors such as astringents, or more generally by laxatives or blood letting or cupping.

For ulcerated gums (herpes, aphthous ulcers, gingivostomatitis) Galen recommends, among other things, cauterizing the ulcers with boiling oil carried to the site with a sort of homemade Roman Q-tip.

When a tooth is extruded above the level of the other teeth, Galen would hold the tooth firmly with a small piece of cloth while he filed it with an iron file. When the patient began to feel too much pain, he dismissed the patient to return the next day and continue the treatment. This went on until the tooth was filed even with the other teeth. During the course of the treatment he advised the patient to remain silent and nourish himself with liquid or soft food and take remedies prescribed to strengthen the teeth.

Dental Physicians and Dental Technician
A t approximately the same time as this separation of medicine and surgery, practitioners began to specialize in Greece and Rome as had been the case in ancient Egypt. As with the Egyptians, it appears that the specialization was not hard and fast. If a general practitioner wanted to practice general medicine and surgery and one or more specialties he could do so.

Some aspects of dentistry were practiced in the Roman world by four different groups of practitioners:

Advances in Dental Treatment
Hippocrates made one simple recommendation often overlooked by both physicians and dentists. He advised that when a patient "has an ulcer of long duration on the margin of the tongue, one should examine the teeth on that side to see if some one of them does not, by chance, present a sharp point.Ó Such a point would then be filed with an iron file. Regarding fracture of the lower jaw, Hippocrates discusses separately complete fractures, incomplete, and fractures of the symphysis. He recommended "if the teeth in the proximity of the lesion (fracture) be shaken, one ought, after having reduced the fracture, to bind them one to the other, until the consolidation of bone, using preferably gold wire for the purpose; but if this be wanting, linen thread can be used instead, and not only ought the two teeth next to the site of the fracture to be bound, but several of the others besidesÓ.

He also mentions that if the procedure is done properly, healing is rapid and the teeth occlude and function properly. If it is not done right "the cure is retarded, the fragments unite in bad position, and the teeth are injured and become useless".

Artificial fixed and removable bridges were fairly common among the wealthy classes of Rome. Several writers refer to such appliances. Martial in one place refers to Aegle who "counterfeits reality with teeth of bone and Indian Ivory". In another place he makes reference to a Roman dentist, apparently a physician specializing in dentistry, named Cascellius "who has grown rich like a senator among the great men and fine women, and who cures the dental diseases and can

pull teeth".

Romans apparently suffered from a high incidence of dental disease. For treatment of toothache Scribonius Largus (c. 47 A.D.) says "Nearly everybody says that the forceps is the cure for aching teeth, and yet I know that there are many beneficial procedures less violent than this last resort. So when a tooth is decayed in part, my advice is to not have the tooth out forthwith, but to have the decayed part removed with a surgical knife, which is a painless (?) process, for then the remaining portion will have the appearance and serve all the functions of a tooth. But if the pain becomes too bad, it is to be soothed in various ways, by the mastication of various things, or by the fumigation of the mouth, or by Òlaying of certain things on the tooth."

Aulus Celsus, one of the greatest Roman physicians, stated regarding toothache: "It may be numbered amongst the worst tortures, the patient must abstain entirely from wine, and at first even from food; afterwards, he may partake of soft food but very sparingly, so as not to irritate the teeth by mastication. Meanwhile by means of a sponge he must let the stream of hot water reach the affected part and apply externally, on the side corresponding with the pain, a cerate of cypress or of iris on which he must then place some wool and keep the head well covered up."

Celsus advised (as others did) that extraction only be submitted to when all other methods of cure (of which there were hundreds) had been tried. If extraction did become necessary, he introduced the idea for decayed teeth of first filling the cavity with unraveled linen or with lead to prevent breaking the tooth during extraction. The idea of therapeutic filling to permanently restore the lost structure did not occur until many centuries later.

Archigenes (c. 54 BC to 17 A.D.), a talented Roman general physician (including surgery and dentistry) stated that many cases of toothache (odontalgia) are caused from a disease in the interior of the tooth (pulpitis). In such cases he introduced a technique which has continued

to the present day, perforating the pulp with a drill, known as trephining. He invented a special

drill for this purpose.

Some of the other treatments he recommended for toothache were:

1. Cleaning the caries from the cavity and then placing a mixture of turpentine and iron sulfate into the cavity, then dropping some of the same mixture into the ear on the side where the pain was felt.

4. If the pain is in a broken tooth, Archigenes recommended cauterization with a red-hot iron.

5. For bleeding gums, Archigenes recommended rubbing them with a mixture of very finely pulverized myrtle and then applying astringent and tonic liquids.

An endless number of local remedies evolved. In the second century A.D., one text recommended fumigation of the toothworms with smoke from burning henbane. This treatment was popular until modern times. There were two theories of tooth decay: toothworms and inflammation (excess hot moist humors).

Paul of Aegina (c. 625-690 A.D.) wrote a medical compendium of seven volumes in which he describes excision of oral tumors, e.g. fibroma (referred to as epulis), and incision and drainage of abscesses (referred to as parulis). When incision and drainage results in a putrid ulcer rather than a cure, the next step is cauterization of the area with an oval-shaped cautery. During this period we also see warnings such as "If an eye tooth hurts, do not have it extracted, because of the eye". Canines are difficult to extract because of their long wide roots. Certainly during an extraction without anesthesia it might feel like the root tip is next to the eye. It may also be that cases had actually been encountered where an infection subsequent to the extraction of a maxillary canine extended into the cavernous sinus causing great swelling in the region of the eye and serious consequences. In any case, it was firmly believed from ancient times until the time of a French surgeon-dentist Robert Bunon, c. 1750 A.D., that there was a direct connection between the maxillary canine and the eye and such an extraction could cause ocular diseases and perhaps blindness.

Misconception Concerning Anesthesia
A common misconception regarding dental and surgical treatment in this period is that the ancients had devised some clever method of surgical anesthesia by the use of drugs or compression of the carotid arteries or hypnosis. Such is not the case. Surgical procedures were extremely conservative and performed only in the face of absolute necessity. The writings and drawings of the period show surgery being done on wakeful patients generally being restrained by assistants or friends. This fallacy has been promulgated largely because the Greeks did write that compressing the carotid arteries caused a person to fall to the ground unconscious, but this is all they said about it and there is no evidence of any medical use of this simple procedure.

Advances in Oral Hygiene
The chewstick for cleaning teeth was apparently borrowed from the Chinese and Babylonians. It is first mentioned as a common method of cleaning the teeth by the Romans. It consists of a stick a little smaller in diameter.than a pencil and about 6 inches long. It is made from any one of a number of fibrous woods. One end is chewed to separate the fibers and then the teeth are scrubbed one at a time. This method is still used in many parts of Africa and many Islamic countries. It can be a very effective toothbrush.

Some Romans preferred a variation on this method, the chew sponge. Some present-day peoples still use the method also. Long branches and vines about a meter in length are collected, the bark removed by scorching, beaten with rocks to separate the fibers, washed, and then wound into a ball (referred to as a sponge). As a convenient bite-size of the sponge is chewed it releases a foaming substance. Much rinsing with astringents and expectoration accompanies the chewing which lasts about 20 minutes.

Paul of Aegina (Greek, 625-690 A.D.) mentioned that the incrustations (calculus) on the teeth must be removed either by means of scrapers or a small file.

Finally, one oral hygiene method can hardly be classified as an "advance", but it did persist long enough to earn a place in the history of dentistry. There is evidence that this custom also was borrowed from the Chinese. It consists of the use of urine as a mouthwash. It is first noted by Strabo who says it was customary among the inhabitants of Spain. Eighteen hundred years later we find the great surgeon-dentist Pierre Fauchard advising people to use their own urine and only when they are feeling well. He admits it is difficult to get accustomed to, but then he adds "what would one not do for the sake of one's health.

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