History in the Making
Exploring dentistry’s roots can help us shape the profession’s future.
By Nicholas Manos, MS, CDT; and Renata Budny, MBA, MDT, CDT
The roots of dentistry run deeper than perhaps even some of us in the profession realize. Consider, for example, that researchers discovered a skull in Pakistan with perfectly drilled holes in the teeth and supporting bone structure, carbon dated between 7000 BC and 5500 BC. This discovery proved that dentistry has been practiced in some form for at least 4,000 years longer than was previously thought.
From the simple fabrication of retention appliances in the Bronze Age to 21st century advances in design, fabrication, and materials, the technologies being developed today are products of the trial, error, and experimentation of the past 9,000-plus years.
This article will attempt to trace the roots of dentistry and provide a frame of reference as we search for new ways to push dental technology forward. Knowing where we came from can help us to build on the knowledge we already possess, continue to advance the profession, and create our own place in the history of dentistry.
In ancient times, the average person could not read or write, lived half as long as we do today, and traveled no more than 50 miles from home between birth and death. Written records were kept primarily by royalty, clergy, and the wealthy. Not surprisingly, very few individuals received dental care.
Of course, dental care was delivered much differently back then, and the understanding of what caused tooth decay and pain was limited. For instance, many cultures believed in the “legend of the worm,” a theory first noted in approximately 1000 BC, which held that tooth decay, pain, and gum disease were caused by a worm sent by demons to drink the blood from human teeth.That idea progressed for nearly 2,000 years—into the Middle Ages—until Arabic cultures correctly identified tooth pain and decay as being caused by unknown substances in the oral cavity. Unfortunately, significant breakthroughs in the field were hampered by mankind’s limited ability to communicate new discoveries between Europe, Asia, the Middle East, and North America. However, many cultures were making progress, albeit independently. A skull unearthed from the Phoenician city of Sidon that dates to approximately 400 BC was fitted with a rudimentary bridge with four natural teeth and two carved ivory incisors, held in place by thin gold wire.
The Egyptians also practiced medicine with significant success as far back as 4,500 years ago, with specialists who restricted their practice to teeth, eyes, the stomach, and the treatment of various diseases. A skull dating from 1500 BC, found in the ancient Egyptian city of Saqqara, exhibits perfectly drilled holes of equal size and depth below the molars; most likely done to relieve pain caused by dental-related diseases due to diet and sand particles in the food that wore down occlusal and incisal surfaces.
Rome and Greece
The Greek civilization flourished throughout the Mediterranean and Near East during this period as well, with medical and dental centers being established in Athens and the Greek Islands. Of course, Greece is also the birthplace of Hippocrates, born in 460 BC and generally considered the father of Western medicine. During his life, he studied and wrote extensively about medicine and dentistry, as did Aristotle. Still, medical and dental treatment in Greece at that time were primitive at best, and were administered in conjunction with prayers and offerings to the gods.
As the ancient Greek civilization began its long decline, Rome was on the rise, borrowing philosophical, architectural, medical, and military knowledge from the Greeks. Many of Rome’s original scientists, philosophers, and educators were actually Greeks who migrated to Rome. In fact, it was Asia Minor’s Asclepiades who founded the first Roman medical school in 14 AD.
Medical doctors in Rome performed all dental work, and Roman visionaries such as the medical historian Aulus Cornelius Celsus (25 AD–50 AD) wrote extensively about dental care and treatments. Extractions were frowned upon but necessary in some cases; to keep the tooth intact, the decayed area was filled with linen and lead prior to extraction. Additionally, crowns were filed smooth if fractured, and repositioning malposed teeth was a common practice.
Gold restorations, fashioned by goldsmiths and inserted by trained physicians, were customary at the height of the Roman Empire and improved dental hygiene was becoming relatively commonplace. Numerous writings have been found that refer to teeth being cleaned with various abrasive materials as well as gold toothpicks. Potassium carbonate and sodium carbonate mixed with burnt ground oyster shells were also used to clean teeth. By the time the Roman Empire fell, much had been written on patient care, disease, treatment, observation, and analysis. As Rome began its decline, knowledge was transferred east to Constantinople, which became the capital of the Eastern Roman Empire in 330 AD.
India, China, and the Far East
By the 6th century AD, a professional class of physicians emerged in India. Medical schools were established, and true empirical systems developed on observation rather than traditional magic became the norm. Preventive dentistry continued to advance for the next several hundred years. There is no data available to show that Indian cultures were concerned with restoring missing or damaged teeth, but that does not mean that craftsmen were not skilled in this area.
India was also a frequent trading partner with Europe and Asia, which resulted in the sharing of information between the cultures. The Indian culture practiced good overall hygiene, which included brushing teeth daily with toothbrushes made of twigs and toothpaste that was formulated with honey, oil, pepper, cinnamon, ginger, and salt.
By 221 BC, China, which had been unified as one country , was split apart again by numerous invasions and power struggles. However, during this period, the Chinese made remarkable contributions to dentistry. By 659 AD, the Chinese were using toothbrushes and amalgam fillings composed of 100 parts mercury, 45 parts silver, and 900 parts tin. Those metals were combined in a pot and added to the carious tooth. Such developments eventually spread to Korea and Japan, where practitioners combined these practices with mystical and natural remedies to relieve pain and decay. The Japanese also fabricated intricate dentures carved from wood with nail heads as occlusal surfaces, and mother of pearl for reconstruction of anterior teeth.
In 1368, China entered a dark period when the Ming Dynasty once again reunified the country and began construction of the Great Wall of China, cutting China off from the rest of the known world. Chinese medicine evolved in virtual isolation. As in Europe, early medicine was practiced in combination with magical concepts and superstitions. As late as the 18th century, tooth decay was still attributed to worms that traveled from tooth to tooth. Warm drinks, ground rhino horns, peony fruit, and human urine were used for the treatment of tooth decay.
Some of the first people to arrive in the New World crossed the Bering Strait from Asia between 30,000 and 40,000 years ago. Their descendants migrated south as hunters and gatherers, settling in Central and South America. The three main cultures established there were the Mayans of the Yucatan, the Aztecs of Mexico’s inland, and the Incas in the Andes Mountains. Although the Spanish Invasion of the 1500s effectively erased many records of the accomplishments of these cultures, some artifacts have since been found, and writings from Spanish priests document the vast knowledge of medicine and dentistry these cultures possessed.
The Aztecs regularly dyed their teeth and filed incisal edges into points. They chewed hot chili peppers to prevent cavities, filled decayed teeth with powdered snail shells, and used chewing tobacco combined with lime to relieve tooth pain. Relatively speaking, the Aztecs generally maintained high levels of oral hygiene. Aware that small pieces of food stuck between teeth resulted in tooth decay, many Aztecs brushed daily. The Aztecs drilled small holes into the labial surfaces of the anterior teeth, into which emeralds were inserted and held in place with cement composed of resin. When skulls were discovered hundreds of years later, the cement was still intact. Equipped with extensive knowledge of anatomy, the Aztecs took great care to not disturb the pulp.
The Mayans of Mexico also filed their incisors and adorned their teeth with jewels for esthetic purposes. The dental cements used to fix the stones were composed of iron ore and natural tree sap. The Mayan culture placed great value on healthy dentition, and believed that significant loss of teeth would ultimately result in death. Skulls have been unearthed that demonstrate how seashells were carved into the shape of incisors and then hammered into the tooth socket.
The Inca Kingdom, which existed predominantly in the Peruvian highlands, was an advanced civilization that interacted and traded with the Mayans and Aztecs. Treating oral diseases with a mixture of natural herbs, rituals, and magic, the Incas believed that rainbows were responsible for tooth loss and pain. As such, one should immediately close and cover his or her mouth upon seeing a rainbow in the sky. Tooth decay was treated with the pulverized bark of the guinea tree. Young Incas chewed leaves to prevent dental caries. Repeated twice a year, the process led to blackened teeth, but ultimately prevented tooth decay. To reduce pain, the fruit of the mulberry tree was chewed prior to tooth extraction, a process that began with placing a wooden instrument against the tooth and hitting it until it loosened. For adornment, the Incas fastened rectangular gold inlays to anterior teeth.
As early as 1000 AD, these Native Americans were familiar with oral hygiene, the construction and insertion of gold inlays, and the use of cements and filling materials. Additionally, numerous herbs harvested from the tropical forests contributed to an overall quality of care that was far superior to European conquerors of the same period.
The Middle East
At its height, the Islamic world extended from Spain all the way east to India, with many educational institutions springing up in Damascus, Cairo, and Samarkand. Writings from that period—many of which were derived from Greek medicine—emphasized oral hygiene, and warned against chewing sweet or sour foods, hard nuts, perishable foods, milk products, and salts. It was recommended to clean teeth after every meal.
Many dental procedures that are common today were described in great detail more than 1,000 years ago. Methods for drilling and filling decayed dentition were covered extensively, as were methods to relieve pain during the procedure. Cauterizing gums to reduce bleeding, and securing loose teeth to healthy teeth with thin gold wires was not uncommon. For the first time, the nerve of the tooth was correctly identified as a transmitter of pain. Remarkably, mandibular movements were identified as a forward shift in a biting mode. In the 9th century, the scientist Quarna stated that the cause of dental decay was an unknown acid that traveled from tooth to tooth. By the 15th century, researchers linked the articulation of the teeth to speech and other functions.
In the Islamic medical world, it was common knowledge that calculus led to tooth discoloration, pus on the gingiva, and, ultimately, tooth loss. Detailed writings surfaced on the use of specific tools to scrape anterior and posterior teeth, as well as step-by-step methods to accurately remove calculus.
Missing teeth were replaced with ox bone and held in place with tightly woven gold wire, placed between each tooth in the cervical area. Detailed surgical procedures were also developed. Methods to reset and secure a fractured jaw and reposition the mandible using interdigitation of the dentition were developed. Once set, the mandible was tightly secured with a wire until the bone set and healed.
As a whole, Persian–Arabic advancements were indeed the pinnacle of medical knowledge in the Middle Ages. During Europe’s Dark Ages, it was the Arabic cultures that protected and advanced knowledge. The fundamentals of Western medicine may not have progressed in the Middle Ages if not for the healing arts of Islamic medicine.
1000 AD – 1600 AD
During the Middle Ages, monks were the repository of knowledge, and generally practiced medicine and performed surgeries throughout that period. In the early 1100s, however, a Papal edict forbade monks from performing surgeries, so the profession of dentistry was turned over to the barbers who assisted monks on numerous tasks.
In 1210, the Guild of Barbers was established in France. This divided the profession between surgeons, who performed complex medical procedures, and barber/surgeons, who offered routine services such as bleeding, shaving, and tooth extractions. By the 1400s, barbers were prohibited from performing any surgical procedure other than bleeding, leeching, and extractions.
There are also accounts of replacement teeth being constructed out of ivory. These teeth yellowed quickly, which led to the use of various other materials for replacing lost dentition in an effort to reduce discoloration and staining. From this era came the first record of mineral mixtures being used for tooth fabrication.
1600 AD – 1900 AD
As the Renaissance drew to a close, Europe, Asia, and the Middle East had made medical progress not seen since the Roman Empire. Although medical care was still limited to a privileged few, dentistry had begun to shift from mystical remedies to true science, and universities sprung up around the world.
By 1733, the French goldsmith Pezé Pilleau was making gold teeth for patients without meeting them. The patients took wax impressions themselves and sent them to Pilleau for fabrication. In France, Claude Mouton published a text in which he explained his discovery of gold spring clasps that held partial dentures in place.
In 1728, Gamaliel Voice began a business in England, selling dentures by mail order. Patients could see Voice in person or receive an impression of sorts by mail, for which there was an extra delivery fee.
In the American colonies, Paul Revere placed an advertisement in a Boston paper, claiming he fixed artificial teeth as effectively as any surgeon in England. Records exist that verify he also fabricated gold restorations for dentists in the 1770s. It is generally accepted that Paul Revere was the first American dental technician.
Most 18th-century dentures were constructed of elephant ivory and carved in a single block. Porcelain teeth were first fabricated in 1774 by Alexis Duchateau, a pharmacist in Saint-Germain, France. In Paris, Giuseppangelo Fonzi used pins to attach metallic oxides to dentures in 1806. The teeth came in 26 shades. By this time, some dentists limited their practices to dental restoration fabrication and sold their products to fellow dentists. By the 1850s, advertisements scouting for potential customers had begun to appear in various publications.
In 1844, Charles Goodyear received a patent for the process of vulcanizing rubber. Eleven years later, he was granted a patent for using Vulcanite, which became the standard for denture fabrication for more than 80 years, until methyl methacrylate materials were introduced in the 1940s.
Numerous dental laboratories were in operation in the mid- to late-1800s. Sutton & Raynor, the earliest known dental laboratory, opened in New York City in 1854. Many of these laboratories did not survive long, however. Dentistry in the late 1880s was more mechanical than operative in nature and required special training and tools. And, unlike today, dentists closely guarded their secrets for fabricating restorations.
The first successful commercial dental laboratory was opened in Boston by Dr. W.H. Stowe in 1887. Dr. Stowe, a Boston-area dentist, eventually formed a partnership with Frank Eddy, and the laboratory came to be known as Stowe & Eddy Dental Laboratory. The pair was so successful that Dr. Stowe ultimately gave up his dental practice to focus on practicing dental technology and training apprentices, some of whom went on to open their own laboratory businesses. Stowe & Eddy grew to a staff of 30 employees and opened a second New York City location in 1900.
Other notable dental technicians from this era included Samuel G. Supplee and George A. Wiechert. Supplee opened a laboratory in New York City in 1898 and developed a technique for constructing seamless gold crowns and bridgework. Supplee’s laboratory eventually grew to 50 technicians, and he spoke regularly to dentists about the advantages of working with these new “dental lab technician specialists.” Supplee is best known for developing the lingual gold bar, for which he held the patent that he donated to the industry.
Wiechert was in charge of swedging metal dentures in Stowe & Eddy’s New York laboratory. In 1904, Wiechert and Charles Brophy opened their own laboratory in New York. They would take the castings home, where they would perform a “secret process” to cast the partials. By 1900, numerous labs had opened, and the dental laboratory technology profession had been officially established.
1900 AD – Present
The dawn of the 20th century marked many milestones: the Wright brothers’ first flight, Henry Ford’s Model T auto-mobile, and numerous advances in dental care, instruments, equipment, and restorative dentistry.
Technical progress at the beginning of the 20th century, however, was not always smooth. Some laboratories demonstrated higher standards than others. Dentists, meanwhile, had begun to demand higher-quality services. Laboratories that developed and adhered to these higher standards of restorative care established solid reputations and, in turn, became very profitable. The same business principles we espouse today have long been part of the dental laboratory industry.
Of course, there have also been obstacles to overcome throughout the profession’s long history. Much like today, remakes were a source of constant frustration for dental laboratories of the early 1900s. Poor impressions, a lack of skilled technicians, and inadequate equipment were the likely causes. Apprentices were trained “in-house.” It was not until 1947 that the first college-based program in dental laboratory technology was opened in Brooklyn, New York. Dentists still performed most of their own indirect restorative procedures, or employed technicians who worked under their supervision. As the number of laboratories increased, so did the overall quality of care, and a slow shift began from direct dentist restoration fabrication to skilled dental technician workmanship.
Many of dental technology’s pioneers deserve recognition for their roles in facilitating that shift, and for their monumental contributions to dentistry. Supplee, for example, developed the concept of closed-mouth impression-taking to increase accuracy. At this time it was not yet illegal for a technician to take impressions, and Supplee routinely administered impression-taking for many dentists. In addition to holding the patent for the lingual bar, Supplee is also credited with inventions such as a heater for modeling compound, thin impression trays, flexible trays, and artificial limbs. Supplee also lectured extensively on doctor-laboratory relationships. By the time of his death in 1956, he held 22 patents.
The individuals who advanced the science of gnathology were also instrumental in dentistry’s development. Dentists such as Everett Payne, Harry Lundeen, and Peter K. Thomas were pioneers in the study of occlusion. Much of what we have been taught in dental school or have learned on the job can be directly attributed to these individuals. Cusp-to-fossa and cusp-to-marginal ridge occlusion concepts were promoted, argued, and even disputed, but in the end resulted in superior functioning restorations.
Over the last 5,000 years, dentistry has made great strides and also experienced a few setbacks. However, the ultimate goal of the profession has always remained the same—to meet the needs of the patient. Dental technology remains a significant and valuable key to providing excellence in patient care. The role of today’s dental technician has expanded and evolved to gatekeeper of new product information, advisor on new restorative materials and techniques, advocate of new technologies to improve restorative consistency and accuracy, and educator for improved chairside techniques.
At the same time, the industry continues to wrestle with new challenges reshaping the profession. In a dental market where fewer educated and experienced technicians must meet the needs of an ever-growing population, new technologies emerged to increase production levels and awakened a global dental technology workforce. Laboratories face many challenges today—productivity, profitability, staying competitive, new technologies, global and emerging markets, and offshore competition. However, history suggests that the profession has contended with and conquered many of these same issues over hundreds, perhaps thousands, of years. No one has the key to what the future holds for our profession, but as educators and lifelong students, our future success is forever rooted in education and the continuing advancement of dental technology.
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About the Authors
Nicholas Manos, MS, CDT, is a full-time professor in the Department of Restorative Dentistry at New York City College of Technology. He was chairperson of the department for 17 years and teaches in the areas of morphology, gnathology, ceramics, dental materials, laboratory management, ethics, and jurisprudence.
Renata Budny, MBA, MDT, CDT, is a full-time assistant professor in the Department of Restorative Dentistry at New York City College of Technology. She teaches in crown and bridge, ceramics, and occlusion. She is the president and clinical director of the Greater New York CDT Study Group.