The Birth of a Profession: Dentistry in the Nineteenth Century

Overview

The nineteenth century saw the rise of dentistry as a distinct profession, with its own practitioners, techniques, and standards. The emphasis of dental care shifted from simply removing painful teeth to trying to avoid extractions by filling cavities. By the end of the century, preventive dentistry sought ways to keep the cavities from developing in the first place. Nineteenth-century dentists were the first professionals to use anesthetic drugs, a development that made modern surgery possible.

Background

The writings of ancient Greek and medieval Moorish physicians described treatments for dental problems such as teething and diseases of the mouth. But the solution to most dental pain was to extract the offending tooth. Early physicians sometimes performed this procedure, but so did barbers and blacksmiths. False teeth were luxury items fashioned by jewelers and other skilled craftsmen. Folk healers, with their poultices and potions, were another option if care by a physician was unavailable or unaffordable. Some of their simple remedies, such as gargling with salt water, are still used today.

Like so many other fields, dentistry was put on a more scientific basis in the eighteenth century. The invention of the microscope in the 1700s had provided the means for understanding the structure of the tooth. French surgeon Pierre Fauchard developed a number of new techniques for repairing, replacing, and straightening teeth. He also coined the term "surgeondentiste," from which we get the word "dentist." Important texts on dentistry were published in both France and England.

With the new energy and optimism brought by American independence, the leadership in dentistry began passing to the New World. Many skilled European dentists crossed the Atlantic, to take advantage of increased economic opportunities or in flight from the bloody French Revolution. They trained American dentists in the most advanced techniques of the time. The famous patriot Paul Revere was a silversmith, and also made false teeth. He initiated the science of forensic dentistry by recognizing his own work and thereby identifying the skull of Dr. Joseph Warren, killed at the Battle of Bunker Hill. The first native-born American dentist, Josiah Flagg, practiced a wide variety of dental techniques including gold fillings, orthodontics, root canal, and even oral surgery to correct harelip. He also invented the first dental chair, by fitting an ordinary wooden chair with an adjustable headrest and an extended arm to hold his instruments.

Dentists were generally trained by the apprentice system, but there was nothing stopping anyone from taking out newspaper ads claiming to be an "operator on the tooth." Itinerant practitioners roamed the countryside, announced by posters and handbills and stopping a few days at a time. While many were skilled and reputable dentists dedicated to serving a far-flung population, others were quacks, glad to leave the results of their ineptitude behind as they moved to the next town.

Organized dentistry arose in the late 1830s as a movement by trained dentists to separate themselves from the charlatans. After several unsuccessful attempts, the first nationwide organization of dentists, the American Society of Dental Surgeons (ASDS), was established in 1840. It soon took over the publication of the first authoritative dental periodical, the American Journal of Dental Science, which had begun publishing in 1839. The first dental college in the world opened in Baltimore in 1840, offering the new degree of "Doctor of Dental Surgery," or D.D.S. The faculty of the Baltimore College of Dental Surgery consisted of two physicians and two dentists, and the course of study lasted two years, just as did medical training at that time.

Impact

With the organization of the dental profession came wider dissemination of new techniques. At the same time, pressure increased for standardization, as a forum now existed for debate about which techniques were the best and which should be rejected. One of the early battles concerned the best way to fill teeth.

While the emphasis in dentistry was now moving from extracting to saving decaying teeth, restorative techniques were in their infancy. Before a tooth can be filled, all the decay must be removed. Dentists of the early nineteenth century were limited to manual drills, which were twirled between the thumb and forefinger. It wasn't until 1871 that James Beall Morrison patented a much faster foot-operated treadle drill, modeled after the workings of early sewing machines. The next year, an electrical drill was patented by George F. Green. But since most dental offices were not electrified at that time, the innovation was adopted only gradually. High-speed drills, which reduced pain from heat and pressure, were not introduced until the 1950s.

Many types of materials were tried for filling teeth. In mid-century, a compound based on tree resin was marketed as "Hill's Stopping." But resin-based materials were not strong enough to provide a permanent chewing surface. Some dentists experimented with molten metal, but its heat damaged the tooth. Eventually, gold foil became the standard among reputable dentists.

In 1833 a pair of French brothers named Crawcour came to the United States touting their "Royal Mineral Succedaneum" for filling teeth. The material was an amalgam, or pasty mixture of silver and mercury. Consideration of the amalgam on its merits was confounded by the terrible reputation of the Crawcour brothers. They left decay in teeth they filled, and indulged in outrageous advertising. Finally, they were run out of the country. Some dentists wanted to experiment with amalgam, because gold foil was expensive and difficult to work with. Still, tainted by association with its promoters, amalgam was rejected by the ASDS, which for a time required its members to sign a pledge forswearing the new material. The conflict split the profession. Many dentists refused to sign the pledge, because certain difficult jobs could be done better with amalgam, and some of their patients could not afford gold.

By 1850 the pledge was rescinded, but the damage was done, and the ASDS disbanded in 1856. The American Dental Association (ADA) was formed in 1859 by a merger of several smaller groups. As a national organization, its growth was interrupted by the Civil War, but after several reorganizations and a few name changes, it became today's ADA in 1922.

In the 1870s the dental community finally came to the conclusion that different filling materials could be preferred for different situations. Gold foil was used for some restorative procedures, and amalgam for others. The amalgam formula devised in 1895 by G. V. Black to provide the best combination of hardness, molding ability, and thermal properties is very similar to that used today.

In addition to electricity, plumbing was another important innovation in nineteenth-century dental offices. Without plumbing, patients used brass spittoons that had to be cleaned by hand. With running water came the Whitcomb Fountain Spittoon in 1867. Water flowed continuously into the spittoon bowl to keep it clean, and drinking water was supplied from a pipe. In keeping with the Victorian fashion of dressing up utilitarian objects, the pipe was shaped like a swan. Similarly, dental chairs of the day were often made of carved mahogany with plush upholstery.

Even today, some patients' teeth are beyond repair, and of course this was true in the nineteenth century as well. Early dentures were made from ivory or animal bone, which tended to discolor and absorb odors. Another alternative was to use teeth from animals or from human cadavers, but many people found this option unappealing. In the eighteenth century, French porcelain became the material of choice, but the dentures were molded as one piece, and tended to distort in the firing process.

In 1808 Giuseppangelo Fonzi invented "terro-metallic incorruptibles," the forerunners of modern dentures. Fonzi molded individual porcelain teeth, each with an embedded platinum pin for soldering into a gold or silver denture base. In 1851 John Allen of Cincinnati patented more natural-looking "continuousgum" dentures, with pink porcelain gums into which were fastened a few teeth in a row; these gum sections were then attached to the denture base. Around the same time, rubber products began to be used to produce a denture base that was much more comfortable and about one third the price of those made from precious metals.

Dentists pioneered one development with such extraordinary impact that it became known as "dentistry's gift to medicine." That innovation was anesthesia, without which modern surgery would never have developed. Before anesthesia, surgeons performed operations such as amputation of limbs as quickly as they could, while the patient experienced indescribable pain. Some chose death by gangrene rather than endure it. Others died of the shock. Abdominal surgery was almost unheard of.

In the early nineteenth century, the euphoria-inducing properties of substances such asnitrous oxide, or "laughing gas" and ether, were known, but used only for entertainment at "ether frolics" and sideshows. During an exhibition at a fair in 1844, dentist Horace Wells (1815-1848) saw an acquaintance under the influence of laughing gas. Stumbling across the stage, the man injured his shin without appearing to notice it. Wells subsequently tried using laughing gas while having a tooth extracted, and felt no pain. Two years later, another dentist, William Morton (1819-1868), gave a public demonstration of the use of ether during a surgical operation performed by a colleague. Ether, being a more powerful agent with which deep unconsciousness could be induced, became the surgical anesthetic of choice for many years, while nitrous oxide became standard in dentistry.

At the very end of the century, the invention of radiography allowed dentists to see inside patients' teeth and diagnose cavities before they caused major damage. New knowledge in microbiology also provided understanding of the bacteria that cause tooth decay. These bacteria digest the sugars and starches on the teeth, producing acids and causing the enamel to deteriorate. Once this happens, other bacteria can penetrate deeper into the tooth. Armed with this information, dentists began seeking to prevent the decay process by encouraging better dental hygiene practices and developing new tooth powders and pastes.

Women and African-Americans were practicing dentistry in the nineteenth century, although the organized profession was slow to recognize this. While neither group had adequate access to formal education, a few women and hundreds of blacks were trained under the apprentice system. One such woman, Emeline Roberts, was trained by her husband and continued their practice when he died in 1864, running it on her own for 60 years. She was not admitted to the Connecticut State Dental Society until 1893. The first woman in the world to receive a degree in dentistry was Lucy Beaman Hobbs. She graduated from the Ohio College of Dental Surgery in 1866.

The first black man to receive a D.D.S. degree was Robert Tanner Freeman, who graduated from Harvard University's School of Dental Medicine in 1869 with its first class of six students. But until 1954, when the United States Supreme Court ruled educational segregation unconstitutional, almost all African-American dentists were trained at two all-black schools, at Howard University in Washington, D.C., and Meharry Medical College in Nashville, Tennessee.

SHERRI CHASIN CALVO