Dentistry
History of dentistry
Early dentistry
Dentistry, in some form, has been practiced since ancient times. For example, Egyptian skulls dating from 2900 to 2750 BCE contain evidence of small holes in the jaw in the vicinity of a tooth's roots. Such holes are believed to have been drilled to drain abscesses. In addition, accounts of dental treatment appear in Egyptian scrolls dating from 1500 BCE. It is believed that the Egyptians practiced oral surgery perhaps as early as 2500 BCE, although evidence for this is minimal. An early attempt at tooth replacement dates to Phoenicia (modern Lebanon) around 600 BCE, where missing teeth were replaced with animal teeth and were bound into place with cord.
True restorative dentistry began with the Etruscans, who lived in the area of what is today central and northern Italy. Numerous dental bridges and partial dentures of gold have been found in Etruscan tombs, which date to about 500 BCE. The Romans, who conquered the Etruscans, adopted Etruscan culture, and dentistry became a regular part of Roman medical practice. The Greeks also practiced some form of oral medicine, including tooth extractions, from the time of Hippocrates, around 400 BCE.
In the Eastern world, dentistry had a totally different history. There is evidence that the early Chinese practiced some restorative dentistry as early as the year 200 BCE, using silver amalgam as fillings. Oral medicine was part of the regular medical practice in other early Asian civilizations, such as those in India and Japan.
Because of the proscription in the Qurʾan, the sacred scripture of Islam, against mutilating the body, surgery was not practiced in Islamic countries. Instead, reliance was placed upon healing through the use of herbs and medicines; preventive dentistry through strict adherence to oral hygiene became paramount. The writings of early Arabic physicians, such as Avicenna and Abū al-Qāsim, show that scaling and cleaning of teeth were practiced. Extractions were rare and were performed only when a tooth had been loosened.
Development of dentistry in Europe
With the demise of the western Roman Empire about the year 475 CE, medicine in Europe declined into a torpor that would last for almost a thousand years. About the only places where medicine or surgery was practiced were monasteries, and monks were aided in their surgical ministrations by the local barbers, who went to the monasteries to cut the monks' hair and shave the monks' beards. In 1163 a church council at Tours, France, ordered that henceforth no monks or priests were to practice any surgery, since it was felt that the shedding of blood was incompatible with the holy office of the clergy. Thus, the only people who had any rudimentary knowledge of surgery were the barbers, and they stepped into the breach, calling themselves barber-surgeons. They practiced simple dentistry, including extractions and cleaning of teeth. In the 1600s a number of barber-surgeons began restricting their activity to surgery and dropped the word “barber,” simply calling themselves surgeons. In England, Henry VIII granted a charter to a combined group of barbers and surgeons, which ultimately evolved into the Royal College of Surgeons.
In 1530 the first book devoted entirely to dentistry was published in Germany and was written in German instead of Latin. It addressed barber-surgeons and surgeons, who treated the mouth, rather than university-trained physicians, who ignored all diseases of the teeth. Subsequent to this publication, other surgeons published texts incorporating aspects of dental treatment.
By the 1700s in France, a number of surgeons were restricting their practice to dentistry, and in 1728 a leading Parisian surgeon, Pierre Fauchard, gathered together all that was then known about dentistry in a monumental book, The Surgeon Dentist, or Treatise on the Teeth. In it he discussed and described all facets of diagnosis and treatment of dental diseases, including orthodontics, prosthetics, periodontal diseases, and oral surgery. Fauchard effectively separated dentistry from the larger field of surgery and thus established dentistry as its own profession. Fauchard is known today as the father of modern dentistry. Other surgeons in Germany and France, who made notable contributions to the field of dentistry, readily followed his lead.
English dentistry did not advance as far as French dentistry in the 18th century. The guild that had united the barbers and surgeons was dissolved in 1745, with the surgeons going their own way. Some barbers continued their dental ministrations and were designated “tooth drawers.” A second group, as a result of the French influence, referred to themselves as “dentists,” while those who did all manner of dentistry were called “operators for the teeth.” The first English book on dentistry, The Operator for the Teeth, by Englishman Charles Allen, was published in 1685; however, no other works on English dentistry were published until Thomas Berdmore, dentist to King George III, published his treatise on dental disorders and deformities, in 1768. In 1771 English surgeon John Hunter, famed as the father of modern surgery, published The Natural History of the Human Teeth, an outstanding text on dental anatomy. Hunter also pioneered the transplantation of teeth from one individual to another, and, because of his tremendous reputation, this practice was widely adopted. Although tooth transplantation between individuals did not prove successful, it was nevertheless the first attempt to transplant human tissue from one person to another. In 1806 English dentist Joseph Fox, who served on the staff of Guy's Hospital in London, offered the first observations on what is today recognized as the “rejection phenomenon” of transplants.
Dentistry in 18th- and 19th-century America
The beginnings of dentistry in the United States came in the 1630s with the settlers of the Massachusetts Bay Colony, who were accompanied by barber-surgeons. One of the first dentists in America was English surgeon and dentist John Baker, who settled in Boston in 1763. Other immigrants to follow included Robert Wooffendale, who emigrated from England in 1766 and practiced in New York City, and Jacques Gardette, who moved from France in 1778, eventually settling in Philadelphia. In early colonial America, dental care was also rendered by artisans such as ivory turners. One such artisan was Isaac Greenwood, who began practicing dentistry in 1779 and is considered to be the first American-born dentist. Four of his six sons became dentists. The most prominent, John Greenwood, served as George Washington's dentist. Other craftsmen performed a variety of dental services, the most well known being Paul Revere, who practiced dentistry for seven years in Boston. The first book on dentistry to be published in the United States appeared in 1801 and was written by Richard Cortland Skinner, a young immigrant from England.
By the first quarter of the 19th century, the United States had become the leading centre in the world for dental developments. From 1839 to 1840 three major events in dental practice facilitated the establishment of dentistry as a true profession. In 1839 the first dental journal, the American Journal of Dental Science, was launched; in 1840 the first dental school, the Baltimore College of Dental Surgery, was established; and in 1840 the first national society of dentists, the American Society of Dental Surgeons, was founded in New York City.
Numerous advances in equipment, materials, and techniques followed one upon the other. In 1864 vulcanized rubber was introduced as a substitute for difficult and costly gold dentures, allowing dentists to supply dentures at a lower cost. The introduction of a foot-treadle drill in 1871 by American dentist James Beall Morrison of Missouri supplanted awkward handheld drills and gave dentists the ability to create intricate and aesthetic restorations.
New dental schools were being established in many parts of the nation. The first dental school to be affiliated with a university was that at Harvard University in 1867. Nevertheless, most dentists were still being trained by a system of preceptorship with an established dentist. The beginning of licensure in the United States came about in 1868, with the states of New York, Ohio, and Kentucky leading the way.
In 1890 American dentist Willoughby Dayton Miller published The Micro-organisms of the Human Mouth, in which he proposed the theory that dental caries were the result of bacterial activity. Miller's publication led to a tremendous wave of interest in oral hygiene. In 1913 American dentist Alfred C. Fones opened the Fones Clinic for Dental Hygienists in Bridgeport, Conn., the first establishment for formal training, at the college level, of dental hygienists.
Dentistry in 19th-century Europe
In Britain, dentistry was also coming of age. In 1856 English dentist Sir John Tomes led the formation of the first dental organization in England, the Odontological Society. It was through the activity of this group that the Royal Dental Hospital of London was established in 1858. In opposition to the Odontological Society, a group of dental professionals formed the College of Dentists of England in 1857, seeking independence from the Royal College of Surgeons, which influenced the proceedings of the Odontological Society. The College of Dentists of England established the Metropolitan School of Dental Science, the forerunner of the University College Hospital Dental School. In 1878 the passage of the Dentists Act, which put dentistry under the General Medical Council, led to the authorization and formation of the Dental Register, a precursor to ultimate licensure that prescribed a curriculum for the training of dentists. This system remained in effect until 1921, when new laws provided for stricter requirements for examination and licensure. In 1880 the British Dental Association was established; it remains the most important dental organization in the United Kingdom.
Advances in dentistry in the 20th century
In 20th-century America, advances occurred in all aspects of dentistry. Frederick McKay, a young American dentist practicing in Colorado, observed a condition of mottling of his patients' teeth, in which there was an almost total absence of decay. Following years of research, McKay and others were able to show that this was due to the presence in the drinking water of high amounts of naturally occurring fluoride, which protects teeth against decay. As a result, public health officials established measures to add fluoride to public water supplies in communities around the United States. Since fluoridation was initiated in 1945, dental caries in children have decreased by more than 50 percent.
In 1896 American dentist Charles Edmund Kells introduced X-ray technology in dentistry and thereby ushered in an era of accurate diagnosis of dental ailments. In addition, in the late 19th and early 20th centuries, American dental pathologist Greene Vardiman Black (sometimes called the father of modern dentistry, although this title is shared with Fauchard) standardized the instruments and restorative materials used by dentists. In 1903 American dentist Charles Land introduced the use of porcelain in crowns, which led to a new era of aesthetic dentistry. In 1907 American dentist William Taggart introduced a precision casting machine that allowed dentists to create gold restorations of great accuracy with a minimum of tooth removal. In 1913 American dentist Edwin J. Greenfield demonstrated the first modern and truly functional dental implant, paving the way for today's highly successful implant dentistry. The introduction in 1953 of the first commercially successful water-driven turbine drill, developed by American dentist Robert Nelson, led the way to the high-speed dental drill. The Borden air-turbine drill, introduced in 1957 and today used universally, reaches speeds of up to 400,000 revolutions per minute and allows for greater accuracy and control by the dentist and greater comfort of the patient.
Numerous research projects into dental diseases and their treatment are carried out at the U.S. National Institute of Dental and Craniofacial Research in Bethesda, Md., a component of the National Institutes of Health. The work done at such institutes promises a future in which new materials and new methods of treatment greatly diminish oral and dental disease.
The practice of dentistry
Licensure requirements
The practice of dentistry is well controlled, and, in all countries of the world in which dentistry is practiced, there is a licensing requirement. The licensing authority may be the government or national dental organizations.
Canada
In Canada each province has its own licensing authority. This can be a college, such as the Royal College of Dental Surgeons of Ontario, or an association, such as the Manitoba Dental Association. There is also a national authority, the Dental Examining Board.
The university degree (Doctor of Dental Surgery or Doctor of Dental Medicine) does not in itself entitle the holder to practice but is an academic qualification for presentation to the licensing board under whose jurisdiction the holder wants to obtain a license to practice. The regulations of the provincial licensing boards vary but usually require an examination for licensing.
United States
Licensing authority in the United States is vested in state boards of dental examiners, most of which require an examination. Most states require U.S. citizenship as a prerequisite. Some states require noncitizens to submit the declaration of intent to become a citizen or the first papers as a requirement for admission to the dental licensure examination; a few do not require citizenship for such admission.
Nationals with foreign diplomas may be admitted to practice if their diplomas were issued by a school approved by the American Dental Association and if they pass the state licensure examination. Most states, however, require that dentists from foreign countries (generally with the exception of Canada) attend an accredited dental school in the United States for at least two years.
Europe
The European Union (EU) has established policies that allow physicians and dentists to move freely and practice within any of the member countries. For this to be acceptable there has had to be mutual recognition of dental degrees and comparable forms of qualification. The EU has directives that set out the training requirements for dental education in the member states. This has created no difficulties for most European countries, where dentistry has long been recognized as a specialty in its own right. The Council of European Dentists oversees the development and execution of policies and initiatives that influence dental practice in Europe.
Permission to practice in the United Kingdom is granted by the General Dental Council (GDC) to those holding (1) a degree or diploma in dentistry or dental surgery conferred in Great Britain or Northern Ireland, (2) a degree or diploma in dentistry or dental surgery granted elsewhere that has been recognized by the GDC, or (3) a degree or diploma approved by the GDC, provided that these graduates have passed the statutory examination written under arrangements made by the GDC.
Dentists in Germany must hold a dental surgeon's diploma, which authorizes private practice without further examination. They must be registered by local dental boards and by health authorities.
In Italy a diploma in dentistry, which allows the use of the title of specialist in diseases of the mouth, teeth, and jaws, constitutes a license to practice. Holders of the diploma of Doctor of Medicine have passed examinations in dentistry and for this reason may also practice dentistry but do not have the specialist title.
Japan
Since about 1903 Japanese dentistry has been mainly patterned after that practiced throughout the United States. Those wanting to practice dentistry or dental surgery must be recognized by the national government. Applicants for registration must pass the national examination for dentists and obtain a license to practice. These requirements must also be fulfilled by registered medical practitioners wanting to practice dentistry, by Japanese citizens, and by foreigners who have qualified in Japan.
Types of practice
Private practice
In Canada, the United States, the United Kingdom, and Australia, dentists in private practice constitute the vast majority of all licensed dentists. The situation is much the same in France and various other countries.
Dental practice has changed significantly since the 1920s, without a concurrent change in the basic dental curriculum. Dental procedures have shifted from the repair and extraction of teeth for the relief of pain to the prevention of disease. Dental practice has also changed in larger urban centres from the isolated private practice common in the early decades of the 20th century to a complex system of groups of professionals in a central location. Extensive use is made of dental hygienists, who often receive the patient from the examining dentist. Dental hygienists provide services such as performing preventive procedures, scaling, taking X-rays, and teaching dental health strategies. Most practices also use dental assistants.
Another development that has occurred in dental health care services is the extension of the duties currently carried out by dental auxiliaries. New Zealand has pioneered in the field with the creation of the dental nurse, an auxiliary who is trained to provide dental care for children without the supervision of a dentist. The United Kingdom has also developed the dental auxiliary, who performs somewhat similar duties but under closer supervision. In Canada and the United States, pilot projects have been conducted to test the feasibility of using dental auxiliaries for certain operative procedures in order to increase productivity, quality, and general service to the public.
France may be taken as an example of the development of the practice of dentistry in continental Europe. There are two types of dentists practicing in France, the chirurgien dentiste (“dental surgeon”) and the stomatologist. The practice of dentistry in France by a chirurgien dentiste has since 1892 been restricted to persons of French nationality who hold a state diploma and who are registered with the Order of Dentists. The Order of Dentists is responsible for registration and discipline but is not concerned with dental education, which is controlled by the state through the common state diploma.
Stomatologists are practitioners who have a diploma in medicine and either a diploma in dental surgery or a certificate of special studies (two years) in stomatology (see below Other disciplines). Specialization within the field of dentistry is not encouraged. There are no rules laid down for it, nor are there any special courses or diplomas or titles.
Hospital dental practice
Three types of dental care are normally carried out in the hospital environment: (1) clinical procedures normally provided in a dental office, for ambulatory inpatients and outpatients, (2) bedside care for persons admitted for other medical reasons, and (3) inpatient care for patients admitted to a hospital for purely dental conditions.
Dentists may treat patients in hospitals either privately, on a fee-for-service basis, or under some form of government program, such as the National Health Service in the United Kingdom or the Provincial Medicare Plan (surgery only) in Canada. Hospital dental services have for years been an integral part of dental health care and dental education in the United Kingdom, and such services by hospital dental departments have expanded steadily in the United States and Canada.
Hospital dental departments are normally established in the same manner as any other hospital department and are headed by a chief of service, who has the same status as other chiefs of service within the hospital. In some instances the chief of the dental department may be responsible to the chief of surgery. There are two types of hospital dental departments—one that is established in a teaching hospital and the other that is in a general hospital with no teaching component. In the teaching hospital the dental department is associated with a faculty of dentistry and forms an integral part of the undergraduate curriculum and, if they exist, of the graduate and postgraduate programs. One of the chief purposes of hospital dental departments is to make available the service of consultants to other hospital departments and general practitioners. This service is most highly developed in teaching hospitals. Usually, certain general dental treatment is provided for inpatients and outpatients. Hospital dental services or departments are prevalent in western Europe.
Public health practice
Generally typical of dental public health practice in Canada and in many areas of the United States is the program in Ontario. There, dentists trained in public health, hygienists, and dental assistants carry out a preventive and educational program basically concerned with the examination of children, the recording of basic dental conditions, and the provision of dental health education.
Military practice
Most countries of the world provide dental care for their armed services. In Canada the Canadian Forces Dental Service, with a brigadier general as director, has the same status as the Canadian Forces Health Service. In the United States, each branch of the military has its own dental corps, each on a par with the various medical corps. There are an Army Dental Corps, a Navy Dental Corps (which serves personnel of the Marine Corps as well as the Navy), an Air Force Dental Corps, and a Coast Guard Dental Corps. Each of these corps is headed by an officer of the rank of brigadier general or rear admiral. In wartime the Public Health Service provides dental service to personnel of the merchant marine.
Governmental practice
In many countries dentists are required to work a number of years for the government before they may be considered private practitioners of the type known in Canada and the United States. This service requirement may be based on the fulfillment of an obligation for government financial support during undergraduate training, or there may be a government regulation that all dental graduates must work for the state for a prescribed number of years. Another example of government practice is in the United Kingdom, where dentists are employed by local authorities to provide dental care under the Maternal and Child Welfare Services and the School Dental Service.
The employment of dentists on a salary basis for the general practice of dentistry is not extensive in the United States or Canada. At the national level it may be the provision of dental care for eligible Native Americans and Eskimos, war veterans, or inmates of penitentiaries. At a municipal level dentists may be employed in a school dental service. Dentists in both Canada and the United States commonly agree to provide service for families who qualify for social assistance. They are paid on a fee-for-service basis; the fee schedule is usually set, normally after consultation with the dentist, by the agency responsible for the social service plan.
Government medical care was introduced in Japan in the late 1930s. This system was expanded until by 1962 almost the entire population was covered. There are limitations to the services offered by government medical care, as in orthodontics or in preventive dentistry.
Dental specialties and subspecialties
In most countries that recognize specialties in dentistry, the specialist is limited to practice in the specialty and cannot carry out the practice of general dentistry. Where the specialty is thus limited, the general dentist may refer patients, and a specialist's practice is mainly on a referral basis. In Britain and in certain provinces in Canada, specialists may conduct a general practice. In the United States nine specialties are recognized by the American Dental Association: orthodontics and dentofacial orthopedics; pediatric dentistry; periodontics; prosthodontics; oral and maxillofacial surgery; oral and maxillofacial pathology; endodontics; public health dentistry; and oral and maxillofacial radiology.
Orthodontics and dentofacial orthopedics
Orthodontics takes as its aims the prevention and correction of malocclusion of the teeth and associated dentofacial incongruities. Orthodontics has been practiced since ancient times, but methods of treatment involving the use of bands and removable appliances have been prominent only since the beginning of the 20th century. The United States gave impetus to the development of orthodontics, which was recognized as a specialty with the formation of the American Society of Orthodontists in 1900.
The demand for this service extends from the child to the mature adult, although human bone responds to tooth movement best in a person under 18, and it is generally agreed that children benefit more from treatment than do adults. In general, oral health and physical appearance are the two most important reasons for undertaking a course of orthodontic care.
Pediatric dentistry
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