Dental Care

A. Organization and Regulation of Dental Practice

1. France
The French Revolution had a very detrimental effect on dentistry around the turn of the 19th century. In 1792, by vote, the 18 medical faculties, 15 medical colleges, the Royal Society of Medicine, and the Academy of Surgery were all abolished. An edict was issued abolishing all restrictions on professions and trades. The practices of medicine, surgery, midwifery and dentistry were thrown open to anyone who could pay for a license. By about 1820, the French had realized what a disastrous situation had been created and began trying to reestablish restrictions. It took until 1846 to begin again regulating dental practice, and it was not really successful until 1892.

2. Germany
The first serious attempt to regulate dental practice in Germany occurred in August, 1825 when a law was passed requiring that aspirants for the title of dentist must first already be practicing physicians or surgeons and then pass the examination in dentistry. Shortly after this, the law was modified to allow candidates to take the examination if they had completed a satisfactory course in anatomy, surgery, materia medica, and therapeutics (even though they may not have received a diploma in medicine or surgery). In 1852 this was changed again to restrict the practice of dentistry to practitioners holding the M.D. degree. This kind of vacillation about who could practice dentistry has resulted in a two-level system in many countries in Europe and Russia. One type of dentist in these countries is the M.D.-Stomatologist; the other level is a more technically educated dentist without the doctor's degree. There has always been a problem in producing enough M.D.-Stomatologists to meet the demand for care, but the current trend in Russia and some European countries is to increase the number.

3. United States
In the United States there were French surgeon-dentists who had emigrated during the French Revolution; there were British dentists with and without the M.D. Degree, but before long the majority of American dentists were Americans who had served preceptorships under other established dentists. Beginning in the late 1700's they began to refer to themselves as dental surgeons.

The first regularly established course of lectures on dentistry was given at the medical school at the University of Maryland in 1821. In 1837, these lectures were being presented by a prominent American dentist named Horace Hayden. Hayden had served a preceptorship under John Greenwood, Washington's dentist. He studied medicine after he began practicing dentistry and was later awarded an honorary M.D. Degree.

Another prominent dentist in Baltimore at this time was Chapin Harris who had received his license to practice medicine first and then served a preceptorship in dentistry. Both Hayden and Harris recognized the need for some kind of organized, comprehensive instruction for dentists. They discussed the subject at length and then submitted a request to the University of Maryland for the establishment of a dental department. Had this request been approved, it is possible that dentistry may have been established as a specialty of medicine in the United States. The application was not approved. Hayden and Harris both felt there was more than one way to achieve their goal, and organizing a separate independent school seemed a very good alternative. They applied to the state legislature for a charter to establish an independent school of dentistry and to award a new degree "Chirurgiae Dentium DoctorÓ (Doctor of Dental Surgery) and to use the English initials D.D.S. The legislature at Annapolis approved the request. In 1839 the first dental school in the world was organized, the Baltimore College of Dental Surgery.

That same year the first dental periodical was published, the American Journal of Dental Science and the first national dental society was formed, the American Society of Dental Surgeons. 1839 was the year of the birth of organized dentistry in the United States, and for the next 100 years American dentists led the world both in the development of clinical procedures and in dental research.

A common misconception about this event is that dentistry was rejected by the medical profession. A few medical educators in Baltimore in 1839 were opposed to the establishment of dentistry as a new specialty, but this was not very important. Most specialties, such as obstetrics, surgery and psychiatry had to struggle for recognition.

The problem with establishing a full dental department was that internal dissensions and a lack of facilities made it impractical to "graft" another department of any kind upon the medical school at that time, but the general attitude toward dentistry was favorable. In 1839, one of the medical school faculty wrote of the new American Journal of Dental Science "the above is the title of a new periodical devoted particularly to the interest of the file and the forceps . . . We commend it to (the) favorable of the medical community. We do this most cheerfully because of the intimate connection which exists in reality between this branch of our profession and thus to the interest of which we are more immediately devoted.Ó

In 1840, the charter for Baltimore College was actually granted. The same year, the medical school awarded Horace Hayden the honorary degree Doctor of Medicine. Hayden had taken some medical courses to enhance his dental practice (medical schools were very flexible in those days) but had not completed the entire curriculum.

The dental historian, M. D. K. Bremner, refers to the three events of 1839 -- dental organization, education and journalism -- as the three essential foundation blocks of a profession. In my opinion, as the disorganization following the French Revolution illustrates, a fourth must be added -- regulation. In the history of dentistry (and medicine and surgery) whenever there has been a lack of regulation, quackery has flourished.

The dentists of New York State had organized in 1934 and stated one of their main goals to be the regulation of dental practice in that state. The first state, though, to pass a law to regulate the practice of dentistry was Alabama in 1841. By 1876 a large number of states had passed similar laws.

The D.M.D. Degree
Between 1840 and 1867, nine more dental schools were organized after the pattern of Baltimore College -- completely separate autonomous schools. In 1867, the first dental school associated with a larger parent university was organized, Harvard University Dental School. The organizers were not happy with the D.D.S. Degree. If they used the Latin initials, as was the classical tradition, it came out C.D.D. In addition it was felt that dentistry was not a branch of surgery and not a separate science, but a branch of medicine. It was finally decided to prefix the Latin word "Dentariae" to the old degree "Medicinae Doctoris" thus meeting the classical requirements and making a distinctive title, D.M.D. for the profession which was actually a branch of medicine.

For many years there were only four schools in the United States that awarded the D.M.D. Degree -- Harvard, Tufts, North Pacific (University of Oregon), and Alabama. Since 1970 approximately fifteen additional U.S. schools have discontinued the D.D.S. and adopted the D.M.D. Degree. The different degrees in no way reflect any differences in curricula. Many educators simply see the D.M.D. as a more correct designation of dentistry as a branch of the large field of medicine and not limited to surgery.

4. Britain
In 1857 two dental organizations were formed in England. One was the Odontological Society of London, dedicated to establishing dentistry as a specialty of medicine or surgery. The other was the College of Dentists of England, with three times as many members, favoring the establishment of an independent profession. Neither organization included a very large percentage of the practicing dentists. Most of them remained aloof and indifferent to the battle.

The unwillingness of either group to compromise and unite prevented the early establishment of either system. Eventually they did unite and the outcome was that the original licensing was under the control of the Royal College of Surgeons, and the diploma awarded was Licentiate in Dental Surgery (L.D.S.); but the profession has evolved as an independent profession.

Early dental practice acts in England were so faulty and full of loopholes that effective regulation of the profession was not achieved until 1921. The basic science component of dental education under all three of these systems is very similar to the medical curriculum. This has been so since the inception of all three systems. In the 1930's, the dental historian Arthur Lufkin assessed them this way: the American system (in his opinion) stressed the technical aspects at the expense of medical sciences; the Stomatologic system (e.g. in Italy) stressed medical science at the expense of technical dental education, and the British system he felt represented a more healthy balance. In recent years, much activity occurred in reassessing dental curricula to find the best balance of basic science, clinical science, behavioral science, and clinical practice.

B. Giuseppangelo Fonzi and Prosthetics
At the turn of the 19th century, artificial dentures did little more than fill in the sunken appearance of the face of an edentulous patient. Carved ivory had a uniform color, tended to stain, decay, and smell bad. Human and animal teeth had similar problems. Dentures did not fit well and had to be held in by opposing action of springs. Masticatory function was virtually impossible. Duch‰teau and deChamant had worked with porcelain but had given the profession nothing of any practical value.

The first big breakthrough in solving the problems of removable dentures came in 1808 with a report on individual porcelain teeth with platinum pins to be soldered to a metal denture base. This technique was invented and reported by an Italian dentist living in Paris, Giuseppangelo Fonzi.

Fonzi was born near Terano in central Italy in 1768. From an early age he gave evidence of extraordinary intelligence. He had just turned 16 when he finished school and began studying law -- the profession of his father. Fonzi grew impatient to travel and expand his horizons; so he approached his father asking to be allowed to attend the university at Naples. The family had one other son in the university at Naples and two in seminary. Because of the added cost, his father told him he would have to wait until the oldest son had finished his studies. Fonzi couldn't wait, so he took a silver knife, fork and spoon from his home (to sell) and went to Rome. He spent some time with some poets there (Fonzi had considerable literary talent), then traveled to Naples and after a brief stay, joined the Spanish Navy.

His first commander became a personal friend and enjoyed Fonzi's company and his poetry, and Fonzi enjoyed traveling with the Navy for several years. When he was assigned a different ship, the picture changed and he found his life drudgerous; so he abandoned ship in a Spanish port and never went back. He saw a "tooth drawer" one day working in a public square. The work intrigued him and he needed to make a living, so he served a short apprenticeship as a tooth drawer. Not satisfied with this narrow scope of practice, he studied on his own to make himself a dentist. Spain at this time was very backward in dentistry and there were very few books, so he learned French and read the works of the great French dentists, Fauchard, Bunon, Bourdette and others. He built a successful practice in Spain but needed a more stimulating environment. About 1795 he went to Paris and soon had an established practice there. It is not known if he served any kind of preceptorship there since the restrictions had been abolished by the revolutionary government. In 1801, Fonzi returned to Italy and for a while was dentist to the King and Queen of Naples. He was a brilliant conversationalist with vast experience and ability in languages so the queen approached him with the proposal that, for considerable pay, he become an informant to the king and queen concerning the noble families of the kingdom of Naples. Not wanting to accept the offer, he chose to return to Paris.

Fonzi loved physics and chemistry and for the next six years he worked continuously on the idea of making individual porcelain teeth that would look natural and could be attached to the denture base. In 1808 he presented his invention which he called terro-metallic teeth to the Athenium of Arts and the Academy of Medicine of Paris (which had been reinstated after their dissolution by the revolutionary government).

What this invention meant was that dentures would require less time to make because there was no carving. Bulky denture bases would no longer be needed. A thin metal base could be swaged to a model getting closer adaptation to the mouth. Since the bases were not so bulky the entire palate could be covered obtaining some suction (a principle already discovered but little used). The teeth looked more natural than carved ivory because they were actually separate and could be made slightly different shades of color. The teeth would not stain, decay or smell bad. Dentures for the first time looked a little bit natural, didn't stink, and could actually sometimes provide a little function.

Fonzi became famous and people from all over Europe crowded his office in Paris. He traveled to Bavaria, Russia and Spain at the request of those countries to serve the dental needs of the royal families and was given a lifetime pension by the Spanish government. He also made other less spectacular inventions, wrote five plays, three epic poems and books on The Religions of India, The Origin of the Gods, and A History of Persian Customs.

At the age of 72, Fonzi wished to return to his home and family in Italy. Upon arriving in Barcelona to board a ship to Naples, he fell seriously ill and died on September 2, 1840.

C. Levi Spear Parmly and Preventive Dentistry
In 1800, the accepted theory of decay was that it was initiated by an internal inflammation caused by an excess of acrid humors. This theory had first been posited by Galen and had not changed substantially. Some people still believed in the toothworms, but most dentists from Fauchard's time on were either skeptical or flatly stated that there were no such parasites.

One American dentist published, in 1819, a book, A Practical Guide to the Management of Teeth, comprising the discovery of the origin of caries or decay of the teeth. He was far ahead of his time.

The dentist was Levi Spear Parmly (1790-1859). The following is an excerpt from his book:

D. Fusible Metal -- Silver Paste and the Amalgam War
Joseph Fox, a prominent English dentist and former student of John Hunter, invented, in 1803, a metallic filling material to be put into a cavity in liquid form which when it cooled would solidify to the exact shape of the cavity. He referred to it as "Fusible Metal". It consisted of 8 parts bismuth, 5 parts lead, and 3 parts tin. The first problem with the material was that the melting temperature was 212¡ F, the boiling temperature for water. This is a low fusing temperature for a metal but not low enough for the patient to accept cheerfully. A second problem with Fox's material was the awkwardness and danger involved in trying to fill cavities in maxillary teeth! The technique gained the attention of dentists and the public and was employed in France, England and the United States, but was not a raving success.

By adding mercury to the alloy the fusing temperature was brought down to 140¡ F. Pieces of the metal could then be put into cavities and melted with a red-hot iron -- a distinct improvement. Somewhere around 1826, August Taveau of Paris and Thomas Bell of England both conceived the idea of mixing coin silver filings with mercury to make an amalgam filling material that would be soft during insertion and harden very quickly. Taveau is best known for this and he called his material "silver paste". Coin silver at that time was 90% or more silver with the rest mainly copper. When mixed with mercury it made a good filling material except for one thing. After setting there was a considerable delayed expansion, and it was not rare for a patient to return in a few days with a fractured tooth or the filling protruding above the cavity and interfering with the bite.

In spite of this drawback many dentists used it and experimented with the material. Some tried altering the formula but without sufficient scientific control and then went the other way -- the material shrunk upon setting and began to leak or fell out of the cavity.

The material was introduced into the United States by two French dentists, the Crawcour brothers in 1833. They did so with extravagant claims for this new material which they called "Royal Mineral Succedaneum" because it was supposed to take the place of the "royal mineral", gold.

The most competent dentists in the country very quickly recognized the problems of this early amalgam and were violently opposed to the use of innocent paying patients for experimentation. In addition to the expansion -- contraction problems, many dentists were worried about the casual use of mercury (a concern which has been raised again recently).

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E. The Amalgam War
The American Society of Dental Surgeons was organized in 1840 and in 1843 took up the amalgam controversy. The controversy developed into what dental historians call the "Amalgam War" and is a prime example of the damage that can be done when a controversy becomes an emotional fight resolved by force rather than objective arbitration.

The first thing done was to appoint a select committee to report back on all mercury compounds used for dental fillings. Without adequate scientific proof, the committee reported "that all such articles were harmful to the teeth and every part of the patients' mouths". The Society then, on July 20, 1843, went on record declaring "the use of amalgam to be malpractice". The statement had little effect though, and those who wished to, continued to use the material -- perhaps even more so. A faction had formed in the Society, determined to push this issue to the limit, undoubtedly convinced that what they were doing was for the best good of both the profession and the public. They pushed through a resolution establishing a committee to investigate the membership "regarding their use of and attitude toward amalgam". This resulted in their designing the following pledge to be signed by every member or they would face expulsion from the organization:

"I hereby certify it to be my opinion and firm conviction that any amalgam whatever...is unfit for the plugging of teeth or fangs and I pledge myself never under any circumstances to make use of it in my practice, as a dental surgeon, and furthermore, as a member of the American Association of Dental surgeons, I do subscribe and unite with them in this protest against the use of the same. Given under my hand and seal the _________ day of ______________, 184_ .

Signed ______________________Ó

Many of those who were strongly opposed to amalgam as a filling material were even more strongly opposed to this infringement on their individual freedom to exercise their own professional judgement. This resulted in a tremendous loss of membership. A few members were expelled but many more withdrew voluntarily. By 1850 the pledge was rescinded but it was too late. At the annual meeting scheduled for August 1, 1856, the American Society of Dental Surgeons was disbanded for lack of a quorum.

In 1859, representatives of several state dental societies met in Niagara Falls, New York, and formed a new national organization, The American Dental Association.

F. The Discovery of Anesthesia
In the history of science, there has been in the past much controversy over who should be called the "discoverer" of one principle or another and who should be credited with "priority" or the first statement or use of a principle. One answer to this dilemma, and the one used by many current historians, is to designate as a discoverer, the person whose work actually altered the course of history in the area being considered. By this standard, some historians consider Horace Wells (1815-1848), a Hartford, Connecticut dentist, the discoverer of anesthesia and others consider a Boston dentist, William T.G. Morton, the discoverer. Some considered them co-discoverers.

In the 1840's ether and nitrous oxide were being sniffed by science students at parties, and their effects demonstrated publically at more respectable quasi-scientific exhibitions. One such exhibition was given in Hartford, Connecticut on December 11, 1844. In the audience was Dr. Horace Wells with his wife. One of the volunteers to experience nitrous oxide was Sam Cooley, a man with whom Horace Wells was acquainted. At one point, Cooley, under the influence of nitrous oxide, leaped from the stage to chase one of the men in the audience who had been laughing at him. The man fled and Cooley stumbled into the seats. After the exertion and rapid ventilation, Cooley sat down next to Dr. Wells. It took several minutes for Cooley to realize he had hurt himself. Finally he pulled up his trouser leg and saw a bruised and bloody leg with a deep ugly cut across the shinbone. Dr. Wells asked him if he had not experienced any pain and Sam replied that he had not. This may have been brushed aside by many people but to Wells it was most significant. He was deeply concerned about pain and wished for some means of controlling it. He remembered once doing an extraction of a multiple-rooted tooth; when the roots fractured, a two-hour ordeal left the patient, a young healthy medical student, semi-conscious and exhausted from the agony. He had several times, after very painful operations, abandoned his practice for weeks at a time and had seriously considered giving up the practice of dentistry because of the unbearable stress of having to inflict such pain.

He seized on the possibility of finding an answer to the problem of surgical pain and approached the demonstrator, a self-proclaimed professor of science, Gardner Q. Colton, with a suggestion to try nitrous oxide for an extraction the next day. Colton was afraid to administer as much of the gas as he thought would be necessary to achieve the result but Wells was insistent, agreeing to have one of his own teeth extracted by a colleague. Colton agreed. Then Wells spent half the night persuading his associate, Dr. John Riggs, to perform the operation. Riggs also felt they were taking too great a risk to push the effect of nitrous oxide to such a degree, but he finally agreed to do the extraction. The next day they carried out their plan. Af ter the procedure was done and the nitrous oxide wore off, Wells exclaimed "I didn't feel so much as the prick of a pin". Riggs went on in 1881 to introduce techniques for treatment of periodontal disease known as Riggs' disease.

Over the next few weeks Wells administered nitrous oxide to 15 patients. He obtained complete pain control on about half of them and only partial pain control on the rest. He was in a hurry to give his discovery to the world, so he went to Boston to ask his former partner Dr. William T. G. Morton (1819-1868) to arrange a demonstration at Massachusetts General Hospital. Morton, who was a former student of Wells, was well known in Boston and acquainted with the medical officials at the hospital. The story is quite well known that when Wells gave his demonstration, the patient screamed and the audience booed and walked out.

Wells was devastated by this experience. He returned to Hartford and continued to use nitrous oxide and later to experiment with other agents, but apparently never quite recovered from the humiliation. Perhaps that same sensitivity that caused him to have the insight and perseverance to discover the anesthetic effects of nitrous oxide also contributed to his downfall.

During the next year and a half Morton may have heard that Wells was still using nitrous oxide. In any case, on September 30, 1846, he visited a physician/chemist Charles T. Jackson to find out how to get some nitrous oxide. Jackson was not impressed with the idea of anesthesia, but suggested that ether would be easier to obtain than nitrous oxide and would produce essentially the same effect.

That same evening, a man came to Dr. Morton's office suffering great pain from a toothache. He wanted the tooth extracted but was terrified of the operation. He had been reading about mesmerism. Apparently he thought Morton might be familiar with the technique because he asked him if he could mesmerize him before the extraction. Morton told him he had something better; he saturated his handkerchief with ether and gave it to the man to breathe through. The patient became unconscious and the tooth was extracted painlessly.

About two weeks later, Morton contacted the same man who had previously arranged Well's unsuccessful demonstration, the Chief Surgeon, Dr. John Collins Warren. One has to admire Dr. Morton's perseverance. Warren, surprisingly, agreed to another demonstration. For the demonstration, Morton had a glass bulb made with an opening for the patient to breathe through. A sponge was placed inside the bulb and saturated with ether.

The demonstration occurred on October 16, 1846, in what is now called the Ether Dome of Massachusetts General Hospital. It is considered by historians to be one of the most significant events in the history of mankind. Dr. Morton administered the anesthetic. Dr. Warren removed a tumor from the patient's lower jaw -- with no pain.

A short time after this, a report came out of India of successful operations using hypnosis, but was completely overshadowed by the magnitude of the news about ether.

The following year, chloroform anesthesia was discovered in Scotland. Horace Wells began to experiment with it and became addicted. He had moved to New York and opened an office. One day as he was just recovering from the effects of some self-administered chloroform, he saw two prostitutes on the street, grabbed a vial of acid and ran out and threw it on them. He was arrested and put in Tombs Prison. This was on a Friday. He was to be released the following Monday. After attending church services in the prison, he spent the rest of the day composing a letter to his family and praying. That night, he apparently administered himself a vial of chloroform and then slashed his left femoral artery.

His letter read in part: "... May God forgive me! Oh! my dear wife and child, whom I leave destitute of the means of support -- I would still live and work for you, but I cannot -- for were I to live on, I should become a maniac. I feel that I am but little better than one already ..."

Had he lived just a week or two longer, Horace Wells would have received a letter which had already been mailed from Paris informing him that the French Academy of Medicine had, after considerable investigation and debate, decided to recognize Horace Wells of Hartford, Connecticut as the Discoverer of Anesthesia.

Today many historians argue that since Morton used a more effective agent, and conducted the first successful demonstration of anesthesia, his work changed the course of history and should be designated the discoverer. I believe they should be considered codiscoverers since it was really the work of both men that produced the result.

Perhaps more important than the question of who did the most is a consideration of the personality traits in these two men that caused them to achieve what they did.

Horace Wells had the original insight because he was a warm empathetic man with an overriding dedication to finding a way to control pain. William T. G. Morton was also committed to finding a way to control pain. He may not have been as sensitive as Wells but displayed an admirable degree of courage and perseverance necessary to achieve the breakthrough of surgical anesthesia.

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