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Dental care and dentistry practice in the Medieval Medical School of Salerno

Key Points

  • The Medieval Medical School of Salerno (9th century) is considered the first institution in the western world for the teaching of medical knowledge.

  • The Regimen Sanitatis Salerni, the School's main text, and numerous other texts written by illustrious School's physicians pay attention to dentistry and dental therapies.

  • Trotula De Ruggiero, one of the first women physicians of the history, recommended specific procedures and officinal plants for oral hygiene, still used today.

Abstract

Even though dental care is sometimes erroneously considered a modern practice, written records from major ancient civilisation all around the world date back to several millennia BC. In particular, in the Middle Ages, among the tenth and thirteenth centuries, the illustrious Medical School of Salerno in Italy, the most important institution in the Western world for the diffusion of medical knowledge, disseminated through its precepts the importance of oral hygiene and practiced specific dental therapies for tooth decay, gingivitis, paradentosis and halitosis among others. Interestingly, several of the officinal plants and natural ingredients proposed for oral care by the school's most famous physicians recipes, notably those of the legendary Trotula De Ruggiero, considered the first female physician in history, are still in vogue in the twenty-first century.

Main

The history of dental care dates back several millennia with archaeological evidence of dental decay and dental fillings dated at around 8000 BC. The first written record comes from a Sumerian text of 5000 BC, followed by ancient Egyptian, Greek, Roman, Chinese and Indian writings.1

Some of the methods and recipes used in those ancient times were still used and improved on in Europe in the Middle Ages, when the illustrious Medical School of Salerno prospered. It was considered the most ancient institution in the western world for the teaching of medical knowledge and a model for the Schools of Medicine and universities that arose in the following centuries in Europe. The Medical School of Salerno was established in the ninth century and achieved its prime during the final period of Longobard kingdom in Southern Italy, among the tenth and thirteenth centuries.2 It was located in Salerno, which took the illustrious appellation of Hippocratica civitas, a town existing to this day, in Southern Italy in the south-east of Naples, with a favourable position on the Mediterranean sea, at the crossroads of different cultures (Latin, Greek, Arab) and with an optimal climate for convalescence. The School was indeed famous for wisely combining the knowledge of different medical cultures (Greek, Latin, Arab and Jewish) in an innovative and comprehensive way, and applying this to both medical practice and to its teaching, thus attracting both students, physicians and ill people from all European territories and also from the Middle East (for example, the knights returning from the Crusades).3 According to legend the school was founded by four physicians, the Greek Pontus, the Arab Adale, the Jewish Rabbi Helinus and the Latin Salernus (native of Salerno), cited also by De Renzi in his collection of studies on the School.4 Its birth, most probably a long and gradual process, began inside the monasteries through the acquisition and translation of medical textbooks from all these cultures. The teachers and physicians of the School wrote a lot of new texts, concerning all branches of medicine. The most famous was the Regimen Sanitatis Salerni which was translated into other languages, including English by Sir John Harington in 1607. It addressed not only medical practitioners, but common people too, since it was written in a simple way so it could be remembered as a poem in Leonin verses.5

Among the different disciplines the Medieval Medical School of Salerno paid specific attention to dentistry and to domestic oral hygiene. The most respected bibliographic sources that testify to the interest of the School's physicians toward the dental therapies are represented by the Regimen Sanitatis Salerni, the main text of the School, and by the writings ascribed to Rogerio Frugardi (Rogerius Salernitanus) and Trotula De Ruggiero, both illustrious physicians belonging to the School, even if in different historic periods.5,6,7

At the time dental therapies were predominantly carried out to eliminate pain caused by tooth decay, but there were specific interventions for gingivitis and halitosis. In the opinion of the School's doctors, tooth decay was due to the presence of the so-called 'odontalgic worm', able to create cavities into the tooth, and thus causing intermittent pain due to the worm's spasmodic movements. The concept of an evil tooth-worm as the cause of caries and periodontitis arose a long time ago, appearing for the first time in the Sumerian text of 5,000 B.C. and spreading through different ancient cultures in China, Egypt, India and Rome. The legend persisted in popular belief through the centuries up to the nineteenth century, even after the birth of microbiology and the development of analytical instruments that were able to exclude its real existence.8

In particular, Rogerio Frugardi believed that tooth decay was a direct consequence of the detrimental action of the worms parasitising the tooth ('si fuerit cibi vermes'), whereas Trotula sustained that worms arose directly into the tooth's rotten cavities ('vermes in dentibus procreantur in concavitate eorum putrefactae').6,7

In popular medicine numerous therapies were adopted to eliminate the tooth-worm, ranging from fumigations to magical formulas and oaths, reported in different writings. The therapeutic strategy adopted by the School's physicians endured for a long time into the dental practice. Briefly, it consisted of relieving ache by pushing away the worms through the vapour produced burning Hyoscyamus niger and leek on a brazier. The patient bent over the brazier and the vapours exhaling from the flames were guided to the diseased teeth through a conical funnel ('Sic dente serva: porrum college grana, ne cares jure, cum giusquiamo simula pure; sicure per embotum fumum cape dente remotum'). The use in medicine of Hyoscyamus niger, commonly known as henbane, a narcotic related to the belladonna, has an ancient tradition, as its use appears in the writings of Dioscorides, Celsus and Plater.9 In many areas the henbane-seeds constituted a very popular way of fumigation having a favourable effect on the pain of hollow teeth due to hyoscyamine contained in its vapours.

In order to achieve disinfection and to destroy the rotten dental pulp, the school's physicians introduced a red-hot cautery to the deepest point of the tooth. The cavity was then plugged with wax or mastic. The improvement of aching symptomatology was due to the destruction of the pulp's innervation.

In the Medical School of Salerno the mechanic removal of the rotten dental tissue was not practiced. Only Avicenna, a Persian physician contemporary to the School, described in his writings the procedure of dental trepanation to allow the discharge of the bad humours caused by the inflammation and how to eliminate the dental rotten tissue induced by the detrimental action of the worms.10 It is important to note that at those times, in accordance with the Hippocratic theory, a good state of health was considered dependent on the balance of the four humours, which were black bile, yellow bile, phlegm and blood. Their alterations were associated, as Pazzini remembers in his fundamental Treaty,11 to tooth decay and, as a consequence, the therapeutic interventions or remedies were aimed to restore their equilibrium. In particular, in the chapter 'De dolore dentium' of the Practica brevis ascribed, also by De Renzi, to Johannes Platearius junior, one of the most celebrated doctors in the Salernitan School, teeth pain was described as caused by warm and cold humours from the brain or stomach.12 For each of them, the author identified a different cure: if warm humours descended from brain, he recommended the opening of the vena cephalica or, alternatively, a scarification on the throat, and a decoction of violets and plums, Cassia fistula and manna; if humours from the brain were cold, blanca or gold-pills were used. In the case of hot humours in the stomach, the administration of oxiinelle (a mixture of vinegar and honey) was the most efficacious therapy; for cold ones, a purification with benedicta (Geum urbanum) or other similar medicines. Moreover, wine was considered as a remedy, together with a powder of mastics, olibanus, drakeblood and the white of eggs, for the post-purging application on the forehead and on the temples.11 A remedy for gingivitis from lipsticks containing lead, derived from Cofone il Giovane who proposed, in his work De virtutibus medicine- De modo medendi, the treatment of inflamed dental pulp with acid burn.13 Moreover, paradentosis, the teeth loss disease, was also treated in the Medical School of Salerno: Platearius advised the application of a plaster on the lips containing the same plant-medicines used for caries.11,12 Dental extractions are scarcely cited in the treatises of the school since the practice of exodontia was not a specific task of physicians, being usually carried out by tooth drawers, frequently only charlatans who practiced their profession in the streets and in open-air markets, and replacing the tooth with a tiny piece of wood or an iron bolt. This practice was chosen only after the final attempt of dental care by the cutting of a blood vessel in the ear, followed by burning with a tiny hot iron.

The issue of oral hygiene was instead treated by Trotula De Ruggiero, considered the first women physician in history and surely the most famous among the so called 'mulierae salernitanae', female medical practitioners of the Salerno's School. Trotula wrote several treatises that were translated in Spanish, French, English and German and were used as medical textbooks for centuries throughout Europe. Due to the paucity of information about her life she is considered a legendary character and several historians still debate her real existence, her gender and the authorship of her treatises.14 Beyond this debate, an analysis of the writings originally ascribed to Trotula by De Renzi,4 reveals that she applied innovative hygiene precepts in gynecology and obstetrics practice, and also commenting on the importance of personal hygiene associated to a correct diet and physical activity to maintain good health and prevent diseases.2,15,16 In the De Ornatu mulierum, the first known cosmetic treatise of history, she instructed her coevals to preserve and improve their beauty through useful advice and natural remedies.17 With regard to oral hygiene, Trotula reported widely on dental care. She suggested to carry out a home-made deep mechanical cleaning and whitening, brushing the teeth with the powder of white marble and date's burn pits, wrapped in wet wool inside a linen rag; an ancestor of the modern toothbrush. As a daily adjuvant of oral hygiene she recommended to rinse with an alcoholic mouthwash represented by 'good wine', every eveing, followed by brushing with a clean white rag. Throughout the day, she suggested chewing aromatic herbs such as mint, eucalyptus, fennel and parsley, as a sort of chewing gums, with the aim of keeping teeth and ginigivae clean and yielding a pleasant smell. She also provided a remedy for gingivitis and halitosis based on the manufacturing of quicklime, natural sulphur, orpiment (an arsenic sulphide mineral), and incinerated pumpkin and pepper. Such dust was distributed on ill gingivae, previously washed with a solution made from great mullein (Verbascum Thapsus) roots, a plant with well-established emollient, refreshing and decongestant properties, boiled into vinegar.

Analysing from a scientific point of view the therapeutic effectiveness of the remedies for oral care proposed by Trotula in her treatise, we find that most of the officinal plants used in her recipes are still used in the twenty-first century. For example, date (Phoenix dactylifera), fennel (Foeniculum), marrow (Cucurbita), pepper (Piper nigrum L.) and parsley (Petroselinum) as well as mineral derivatives such as Armenian bole (Bolus armenus), calcium carbonate and sodium carbonate, used in Trotula's recipes for bad breath, teeth whitening and oral hygiene, are still now commonly used as toothpaste or mouthwash ingredients. Other ingredients, such as pumice and sulphur, proposed by Trotula, for teeth whitening and bad breath respectively, are not used nowadays in oral care, but are still used in cosmetics, as skin exfoliator and for the treatment of oily skin. Other plants, such as absinthe (Artemisia absinthium), used by Trotula as a remedy for bad breath and cheilitis is now a well-known ingredient for natural insect repellents.17

In conclusion, from a historical point of view, the Medical School of Salerno, through its writings, provides useful information about the practice of dentistry in the medieval age. It also highlights the limitations of dental knowledge and hence the therapeutic interventions (eg the tooth worm). On the other hand, innovations such as attention to oral hygiene and dental cosmetics, and the use of natural ingredients, are still in vogue today.

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Correspondence to M. Bifulco or S. Pisanti.

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Bifulco, M., Amato, M., Gangemi, G. et al. Dental care and dentistry practice in the Medieval Medical School of Salerno. Br Dent J 221, 87–89 (2016). https://doi.org/10.1038/sj.bdj.2016.528

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