Moffitt Restorative Dentistry

Medieval Dentistry

Jul 10 2014

King Richard III remains provide insights on oral health, dentistry in the Middle Ages. 

Dry but historically informative dental facts.  By Kimber Solana, ADA News staff.

 The stereotype often seen in movies of peasants with blackened and gapped teeth during the Middle Ages may just be a myth.

Thanks to the remains of King Richard III of England, which were discovered in 2012, researchers continue to gain a better understanding of the oral hygiene habits of that era.

A study in the April 2013 British Dental Journal found that Richard III, the last English king to die in battle, had generally poor oral health, suffering from dental caries and tartar buildup. The study supports research that found, unlike modern day, people in higher social classes suffered a higher incidence of dental carries during the Middle Ages.

“For the lower social classes, access to limited range of dietary sugars and the consistent inability to cook carbohydrates resulted in a reduced caries experience,” wrote Dr. Amit Rai, the study’s author. “By the same reasoning, it is likely that the more affluent of individuals suffered with a greater caries experience, as was the case with the Grey Friars remains.”

The skeletal remains of Richard III, who wore the crown from 1483-85, were found in September 2012 under a parking lot—the former site of the Church of the Grey Friars where he was buried in an unmarked grave.

Historic teeth: Richard III was the last English king to die in battle and had generally poor oral health, suffering from dental caries and tartar buildup.

Researchers found that his left first molar, upper right second premolar and lower right first molar teeth were missing, most likely due to caries. Richard III also had mineralized deposits on the labial and buccal surfaces of the maxillary teeth, suggesting tartar buildup over a period of time.

However, the upper right central incisor showed less evidence of deposits than the adjacent anterior teeth, the study found, suggesting that Richard III had “some degree of insight with dental hygiene, however basic.”

Researchers also found that evidence of gap closure on two of the missing teeth point to the “early extraction of these teeth by skilled hands.”

According to the study, although mainly unregulated, barber surgeons legally practiced dentistry at the time.

It is also “not impossible” that Richard III had practiced the 10 rules outlined by Giovanni de Arcoli, professor of medicine and surgery in Italy from 1412-27, to help preserve the teeth. The list includes caution on eating sweets, breaking “hard things” with the teeth, rinsing and cleaning the teeth after every meal using “thin pieces of wood.” Giovanni de Arcoli was the first to record using gold leaf as a restorative material despite his unfamiliarity with tooth morphology, researchers say.

“The provision of dentistry in the 15th century was surprisingly sophisticated with evidence of restorative advances,” the study concluded.

Medieval Dentistry – Giovanni Of Arcoli

If there is one phase of our present-day medicine and surgery that most of us are likely to be quite sure is of very recent development it is dentistry. Probably most people would declare at once that they had every reason to think that the science and art of dentistry, as we have it now, developed for the first time in the world’s history during the last generation or two. It is extremely interesting to realize then, in the light of this almost universal persuasion, founded to a great extent on the conviction that man is in process of evolution and that as a consequence we must surely he doing things now that men never did before, to find that dentistry, both as an art and science, is old; that it has developed at a number of times in the world’s history, and that as fortunately for history its work was done mainly in indestructible materials, the teeth themselves and metal prosthetic apparatus, we have actual specimens of what was accomplished at a number of periods in the olden times. Surprising as it will seem to those who hear of it for the first time, dentistry reached high perfection even in what we know as ancient history. It is rather easy to trace scientific and craftsman like interest in it during the medieval period and in the magnificent development of surgery that came just at the end of the Middle Ages, dentistry shared to such degree that some of the text-books of the writers on surgery of this time furnish abundant evidence of anticipations of many of the supposedly most modern developments of dentistry.

 There are a number of historical traditions with regard to dentistry and the treatment of the teeth in Egypt that can be traced back to good authorities in Egyptology of a generation or more ago, but it is rather hard to confirm the accounts we have by actual specimens; either none were found or for some reason those actually discovered are now not readily available for study. Among the Phenicians however, though we have good reasons to think that they learned their arts and crafts from the Egyptians, there is convincing evidence of a high development of dentistry. M. Ernest Renan, during an exploring expedition in Phenicia, found in the old necropolis at Sidon a set of teeth wired together, two of which were artificial. It was a striking example of bridgework, very well done, and may now be seen in the Louvre. It would be more than a little surprising, from what we know of the lack of inventiveness on the part of the Phenicians and their tendency to acquire their arts by imitation, if they had reached such a climax of invention by themselves. Since they adapted and adopted most of their arts and crafts from Egypt, with which they were in close commercial relations, it has been argued with some plausibility- that the Egyptians may have had many modes of dental prosthesis, but removed all artificial teeth and dental appliances from the mouth of corpses before embalming them, in preparation for the next world, because there was some religious objection to such human handiwork being loft in place for the hereafter, as they Loped fur it.

There is a well-authenticated tradition of intimate intercourse in a commercial way between the old Etruscans who inhabited the Italian hill country and the Phenicians, so that it is no surprise to find that the oldest. of Etruscan tombs contain some fine examples of bridgework. An improvement has come over Phenician work however, and bands of gold instead of wire are used for holding artificial teeth in place. Guerini, whose ” History of Dentistry ” is the standard work on the subject, on a commission from the Italian government, carefully studied these specimens of Etruscan dental work in the museums of Italy, and has made some interesting observations on them. In one specimen, which is especially notable, two incisor teeth are replaced by a single tooth from a calf. This was grooved in such a way as to make it seem like two separate teeth. Guerini suggests a very interesting and quite unexpected source for this. While examining the specimen he wondered where the old Etruscan dentist had obtained a calf’s tooth without a trace of wear on it. Ile came to the conclusion that he must. have cut into the gums of a young calf before the permanent tooth was erupted in order to get this structure absolutely unworn for his purpose. A number of examples of bridgework have been found in the old Etruscan tombs. The dates of their construction are probably not later than 500 B.C., and some of them are perhaps earlier than 700 B.C.

 The Etruscans affected the old Romans in the matter of dentistry, so that it is easy to understand the passage in the ” Laws of the Twelve Tables,” issued about 450 B.C., which, while forbidding the burial of gold with corpses, made a special exception for such gold as was fastened to the teeth. Gold was rare at Rome, and care was exercised not to allow any unnecessary decrease of the visible supply almost in the same way as governments now protect their gold reserves. It may seem like comparing little things with great, but the underlying principle is the same. Hence this special law and its quite natural exception.

 In Pope Julius’ Museum in Rome there is a specimen of a gold cap made of two plates of gold riveted together and also riveted to bands of metal which were fastened around the neighboring teeth in order to hold the cap in place. This is from later Republican times at Rome. At the end of the Republic and the beginning of the Empire there appear to have been many forms of dental appliances. Martial says that the reason why one lady’s teeth whose name he does not conceal are white and another’s —name also given were dark, was that the first one bought hers and the second still had her own. In another satiric poem he describes an elderly woman as so much frightened that when she ran away her teeth fell out, while her friends lost their false hair. Fillings of many kinds were used, dentrifices of nearly every kind were invented, and dentistry evidently reached a high stage of development, though we have nowhere a special name for dentist, and the work seems to have been done by physicians, who took this as a specialty.

While in the Middle Ages there was, owing to conditions, a loss of much of this knowledge of antiquity with regard to dentistry, or an obscuration of it, it never disappeared completely, and whenever men have written seriously about medicine, above all about surgery in relation to the face and the mouth, the teeth have conic in for their share of scientific and practical consideration. Aetius, the first important Christian writer on medicine and surgery, discusses, as we have seen in the sketch of him, the nutrition of the teeth, their nerves, ” which came from the third pair and entered the teeth by a small hole existing at the end of the root,” and other interesting details of anatomy and physiology. lie knows much about the hygiene of the teeth, discusses extraction and the cure of fistula and other details. Paul of AEgina in the next century has much more, and while they both quote mainly from older authors there seems no doubt that they themselves had made not a few observations and had practical experience.

 It was from these men that the Arabian physicians and surgeons obtained their traditions of medicine, and so it is not surprising to find that they discuss dental diseases and their treatment rationally and in considerable detail. Abulcasis particularly has much that is of significance and interest. We have pictures of two score of dental instruments that were used by them. The Arabs not only treated and filled carious teeth and even replaced those that were lost, but they also corrected deformities of the mouth and of the dental arches. Orthodontia is sometimes said to be of much later origin and to begin many centuries after Abulcasis’ time, yet no one who knows of work can speak of Orthodontia as an invention after him. In this, however, as in most of the departments of medicine and surgery, the Arabs were merely imitators, though probably they expanded somewhat the practical knowledge that bad come to them.

 When the great revival in surgery came in the twelfth and thirteenth centuries it is not surprising that there should also have been an important renewal of interest in dentistry. A detailed review of this would take us too far afield, but at least something may be said of two or three of the great representative surgical writers who touched on this specialty.

 About the middle of the fourteenth century that prince of surgeons, and model of surgical writers, Guy de Chauliac, wrote his great text-book of surgery,¬ ” Le Grande Chirurgie.” An extremely interesting feature of this work is to be found in the chapters that treat of diseases of the teeth. These are not very comprehensive, and are evidently not so much the result of his experience, as the fruit of his reading, yet they contain many practical valuable ideas that are supposed to be ever so much later than the middle of the fourteenth century. His anatomy and physiology at least are not without many errors. His rules for the preservation of the teeth show that the ordinary causes of dental decay were well recognized even as early as this. Emphasis was laid on not taking foods too hot or too cold, and above all not to follow either hot or cold food by something very different from it in temperature. The breaking of hard things with the teeth was recognized as one of the most frequent causes of such deterioration of the enamel as gives opportunity for the development of decay. The eating of sweets, and especially the sticky sweets preserves and the like was recognized as an important source of caries. The teeth were supposed to be cleaned frequently, and not to be cleaned too roughly, for this would do more harm than good. We find these rules repeated by succeeding writers on general surgery, who touch upon dentistry, or at least the care of the teeth, and they were not original with Guy de Chauiiac, but part of the tradition of surgery.

 As noted by Guerini in his ” History of Dentistry,” the translation of which was published under the auspices of the National Dental Association of the United States of America,’ Chauliac recognized the dentists as specialists. Besides, it should be added, as is evident from his enumeration of the surgical instruments which he declares necessary for them, they were not as we might easily think in the modern time mere tooth pullers, but at least the best among them treated teeth as far as their limited knowledge and means at command enabled them to do so, and these means were much more elaborate than we have been led to think, and much more detailed than we have reason to know that they were at certain subsequent periods.

In fact, though Guy de Chauliac frankly confesses that he touches on the subject of dentistry only in order to complete his presentation of the subject of surgery and not because he has anything of his own to say with regard to the subject., there is much that is of present-day interest in his brief paragraphs. He observes that operations on the teeth are special and belong to the dentatores, or dentists, to whom doctors had given them over. He considers, however, that the operations in the mouth should be performed under the direction of a physician. It is in order to give physicians the general principles with which they may be able to judge of the advisability or necessity for dental operations that his short chapters are written. If their advice is to be of value, physicians should know the various methods of treatment suitable for dental diseases, including mouth washes, gargles, masticatories, anointments, rubbings, fumigations, cauterizations, fillings, filings, and the various manual operations. He says that the dentator must be provided with the appropriate instruments, among which he names scrapers, rasps, straight and curved spatumina, elevators, simple and with two branches, toothed tenacula, and many different forms of probes and canulas. He should also have small scalpels, tooth trephines, and files.

Chauliac is particularly emphatic in his insistence on not permitting alimentary materials to remain in cavities, and suggests that if cavities between the teeth tend to retain food material they should even be filed in such a way as to prevent these accumulations. His directions for cleansing the teeth were rather detailed. His favorite treatment for wounds was wine, and he knew that he succeeded by means of it in securing union by first intention. It is not surprising, then, to find that he recommends rinsing of the mouth with wine as a precaution against dental decay. A vinous decoction of wild mint and of pepper he considered particularly beneficial, though he thought that dentifrices, either powder or liquid, should also be used. He seems to recommend the powder dentifrices as more efficacious. His favorite prescription for a tooth powder, while more elaborate, resembles to such an extent, at least some, if not indeed most of those, that are used at the present time, that it seems worth while giving his directions for it. He took equal parts of cuttle bone, small white sea-shells, pumice stone, burnt stag’s horn, nitre, alum, rock salt, burnt roots of iris, aristolochia, and reeds. All of these substances should be carefully reduced to powder and then mixed. His favorite liquid dentifrice contained the following ingredients,—half a pound each of sal ammoniac and rock salt, and a quarter of a pound of sacharin alum. All these were to be reduced to powder and placed in a glass alembic and dissolved. The teeth should be rubbed with it, using a little scarlet cloth for the purpose. Just why this particular color of cleansing cloth was recommended is not quite clear.

 He recognized, however, that cleansing of the teeth properly often became impossible by any scrubbing method, no matter what the dentifrice used, because of the presence of what we call tartar and what he called hardened limosity or limyness (limosite endurcie). When that condition is present he suggests the use of rasps and spatumina and other instrumental means of removing the tartar.

 Evidently lie did not believe in the removal of the teeth unless this was absolutely necessary and no other method of treatment would avail to save the patient from continuous distress. He summarizes the authorities with regard to the extraction of teeth and the removal of dental fragments anti roots. lie evidently knew of the many methods suggested before his time of removing teeth without recourse to instrumental extraction. There were a number of applications to the gums that were claimed by older authors to remove the teeth without the need of metal instruments. We might expect that Chauliac would detect the fallacy with regard to these and expose it. He says that while much is claimed for these methods he has never seen them work in practice and he distrusts them entirely.

 The most interesting phase of what Guy de Chauliac has to say with regard to dentistry is of course to be found in his paragraphs on the artificial replacement of lost teeth and the subject of dental prosthesis generally. When teeth become loose he advises that they be fastened to the healthy ones with a gold chain. Guerini suggests that he evidently means a gold wire. If the teeth fall out they may be replaced by the teeth of another person or with artificial teeth made from oxbone, which may be fixed in place by a fine metal ligature. He says that such teeth may be serviceable for a long while. This is a rather curt way of treating so large a subject as dental prosthesis, but it contains a lot of suggestive material. He was quoting mainly the Arabian authors, and especially Abuleasis and Ali Abbas and Blazes, and these of course, as we have said, mentioned many methods of artificially replacing teeth as also of transplantation and of treatment of the deformities of the dental arches.

 On the whole, however, it must be confessed that we have here in the middle of the fourteenth century a rather surprising anticipation of the knowledge of a special department of medicine which is usually considered to be distinctly modern, and indeed as having only attracted attention seriously in comparatively recent times.

After Guy de Chauliac the next important contributor to dentistry is Giovanni of Arcoli, often better known by his Latin name, Johanues Arculanus, who was a professor of medicine and surgery at Bologna and afterwards at Padua, just before and after the middle of the fifteenth century, and who died in 1484. He is famous principally for being the first we know who mentions the filling of teeth with gold.

 It might possibly be suggested that coming at this time Arculanus should rather be reckoned as a Maker of Medicine in the Renaissance than as belonging to the Middle Ages and its influences. His education, however, was entirely completed before the earliest date at which the Renaissance movement is usually-said to begin, that is with the fall of Constantinople in 1452, and he was dead before the other date, that of the discovery of America in 1492, which the Germans have in recent years come to set down as the end of the Middle Ages. Besides, what he has to say about dentistry occurs in typical medieval form. It is found in a commentary on Rhazes, written just about the middle of the fifteenth century. In the later true Renaissance such a commentary would have been on a Greek author. In his commentary Arculanus touches on most of the features of medicine and surgery from the standpoint of his own experience as well as from what he knows of the writings of his predecessors and contemporaries. With the rest he has a series of chapters on diseases of the teeth. Guerini in his ” History of Dentistry ” says that ” this subject [dentistry] is treated rather fully, and with great accuracy.” Even some short, references to it will, I think, demonstrate this rather readily.’

 Arculanus is particularly full in his directions for the preservation of the teeth. We are rather prone to think that prophylaxis is comparatively a modern idea, and that most of the principles of conservation of human tissues and the prevention of deterioration and disease are distinctly modern. It needs only a little consideration of Arculanus’ instruction in the matter of the teeth, however, to undo any such false impression. For obvious reasons I prefer to quote Guerini’s summation of this medieval student of dentistry’s rules for dental hygiene :

 ” For the preservation of teeth considered by him, quite rightly, a matter of great importance Giovanni of Arcoli repeats the various counsels given on the subject by preceding writers, but he gives them as ten distinct canons or rules, creating in this way a kind of decalogue of dental hygiene. These rules are : (1) It is necessary to guard against the corruption of food and drink within the stomach; therefore, easily corruptible food– milk, salt fish, etc. must not be partaken of, and after meals all excessive movement, running exercises, bathing, coitus, and other causes that impair the digestion, must also be avoided. (2) Everything must be avoided that may provoke vomiting. (3) Sweet and viscous food such as dried figs, preserves made with honey, etc. must not be partaken of. (4) Hard things must not be broken with the teeth. (5) All food, drink, and other substances that set the teeth on edge must be avoided. (6) Food that is too hot or too cold must be avoided, and especially the rapid succession of hot and cold, and vice versa. (7) Leeks must not be eaten, as such a food, by its own nature, is injurious to the teeth. (S) The teeth must be cleaned at once, after every meal, from the particles of food left in them; and for this purpose thin pieces of wood should be used, somewhat broad at the ends, but not sharp-pointed or edged ; and preference should be given to small cypress twigs, to the wood of aloes, or pine, rosemary, or juniper and similar sorts of wood which are rather bitter and styptic; care must, however, be taken not to search too long in the dental interstices and not to injure the gums or shake the teeth. (9) After this it is necessary to rinse the mouth by using by preference a vinous decoctryon of sage, or one of cinnamon, mastich, gallia, moschata, cubeb, juniper seeds, root of cyperus, and rosemary leaves. (10) The teeth must he rubbed with suitable dentrifices before going to bed, or else in the morning before breakfast. Although Avicenna recommended various oils for this purpose, Giovanni of Arcoli appears very hostile to oleaginous frictions, because he considers them very injurious to the stomach. Ile observes, besides, that whilst moderate frictions of brief duration are helpful to the teeth, strengthen the gums, prevent the formation of tartar, and sweeten the breath, too rough or too prolonged rubbing is, on the contrary, harmful to the teeth, and makes them liable to many diseases.”

 All this is so modern in many ways that we might expect a detailed exact knowledge of the anatomy of the teeth and even something of their embryology from Arculanus. It must not be forgotten, however, that coming as he does before the Renaissance, the medical sciences in the true sense of the word are as vet unborn. Men are accumulating information for practical purposes but not for the classification and co-ordination that was to make possible the scientific development of their knowledge.

 Giovanni of Arcoli’s acquaintance with the anatomy of the teeth was rather sadly lacking. He does not know even with certainty the number of roots that the teeth have. This has been attributed to the fact that lie obtained most of his information from books, and had not the time to verify descriptions that he had found. It has been argued from this that he was himself probably not a practical dentist, and turned to that specialty only as a portion of his work as a general surgeon, and that consequently he was not sufficiently interested to verify his statements. His chapters on dentistry would seem to bear out this conclusion to some extent, though the very fact that one who was himself not especially interested in dental surgery should have succeeded in gathering together so much that anticipates modern ideas in dentistry, is of itself a proof of how much knowledge of the subject there was available for a serious student of that time. The anatomy of the teeth continued to be rather vague until about the middle of the next century when Eustachius, whose investigations of the anatomy of the head have deservedly brought him fame and the attachment of his name to the Eustachian canal, wrote his ” Libellus de Dentibus Manual of the Teeth,” which is quite full, accurate, and detailed. Very little has been added to the microscopic anatomy of the teeth since Eustachius time. fie had the advantage, of course, of being intimately in contact with the great group of Renaissance anatomists, Vesalius, Columbus, Varolius, Fallopius, and the others, the great fathers of anatomy. Besides, his position as Papal Physician and Professor of Anatomy at the Papal Medical School at Rome gave him opportunities for original investigation, such as were not easily obtained elsewhere.

 Areulanus can scarcely be blamed, therefore, for not having anticipated the Renaissance, and we must take him as merely the culmination of medieval knowledge with regard to anatomy and surgery. Medieval medical men did not have the time nor apparently the incentive to make formal medical science, though it must. not be forgotten, as has been mid, that they did use the knowledge they obtained by their own and others’ observation to excellent advantage for the practical benefit of ailing humanity. The sciences related to medicine are conscious developments that follow the evolution of practical medicine, nor must it. be forgotten that far from always serving as an auxiliary to applied medical science, often indeed in the history of medicine scientific pursuits have led men away into side issues from which they had to be brought back by some genius medical observer. As might be expected, then, it is with regard to the practical treatment and general consideration of ailments of the teeth that Giovanni of Arcoli is most interesting. In this some of his chapters contain a marvelous series of surprises.

  While, as Gurlt remarks in his ” History of Surgery,” Arculanus’ name is one of those scarcely know lie is usually considered just one of many obscure writers of the end of the Middle Ages Lis writings deserve a better fate. They contain much that is interesting and a great deal that must have been of the highest practical value to his contemporaries. They attracted wide attention in his own and immediately succeeding generations. The proof of this is that they exist in a large number of manuscript copies. Just as soon as printing was introduced his books appeared in edition after edition. His ” Practica ” was printed in no less than seven editions in Venice. Three of them appeared before the end of the fifteenth century, which places them among the incunabula of printing.

That Arculanus’ work with regard to dentistry was no mere chance and not solely theoretic can he understood very well from his predecessors, and that it. Formed a link in a continuous, tradition which was well preserved we may judge from what. is to be found in the writings of his great successor, Giovanni or John de Vigo, who is considered one of the great surgeons of the early Renaissance., and to whom we owe what is probably the earliest treatise on ” Gunshot Wounds.” John of Vigo was a Papal physician and surgeon, generally considered one of the most distinguished members of the medical profession of his time. Two features of his writing on dental diseases deserve mention. He insists that abscesses of the gums shall be treated as other abscesses by being encouraged to come to maturity and then being opened. If they do not close promptly, an irritant Egyptian ointment containing verdigris and alum among other things should be applied to them. In the cure of old fistulous tracts near the teeth he employs not only this Egyptian ointment but also arsenic and corrosive sublimate. What he has to say with regard to the filling of the teeth is, however, most important. He says it with extreme brevity, but with the manner of a man thoroughly accustomed to doing it. ” By means of a drill or file the putrefied or corroded part of the tooth should be completely removed. The cavity left should then be filled with gold leaf.” It is evident that the members of the Papal court, the Cardinals and the Pope himself, had the advantage of rather good dentistry at John de Vigo’s hands even as early as the beginning of the sixteenth century.

John de Vigo, however, is not medieval. He lived on into the sixteenth century and was influenced deeply by the Renaissance. Tie counts among the makers of modern medicine and surgery, as his authorship of the treatise on gun-shot wounds makes clear.

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