Perio Millennium The journey of periodontology from then to now

Introduction

Paleostomatology is a part of anthropology which studies facial structures in archaeological forms. A part of this study has put forward evidences which predict and give us an idea about the historical existence of periodontological art and science. The ancient estimation of periodontal pathology and therapeutics were sketched based on anatomical discoveries from human skeleton, mummies, instruments, equipment collected during archaeological excavations and engravings.¹ Anthropological studies have indicated that periodontal diseases escorted human beings existing in different cultures since ages.^2,3 To understand the evolution of periodontology, it is also imperative to understand how and when periodontology came into its existence. Historians classified the evolving dentistry into three periods:⁴

1. Magico-religious medicine (5000– 400 BC)

2. Empirico-rational medicine (400 BC–1500 AD)

3. Scientific medicine (1500 AD – until today) The Magico-religious period includes excerpts from textbooks, epics and handwritten documents where periodontal disease has been referred to as ‘plague’ and periodontal treatment as ‘divine magic’.

As we cross the Before Christ period and enter the Accrodominion, the era of Emperico-Rational Medicine ventures into the timeline where significant medical scholars have given their ideas on periodontal diseases and treatment planning such as Paulus Aegineta, Abu al-Qasim, Ibn Sina, Guy de Chauliac, and Serefeddin Sabuncuoglu.⁵ Later, down the lane, the scientific medicine began with renaissance when European Scholars like Leonardo da Vinci, Girolamo Cardano, Ambroise Paré, Anton van Leeuwenhoek, Pierre Fauchard, John Hunter, Thomas Berdmore and many more turned their wheels of intellectuality and presented the world with new concepts and identity of oral hygiene and dentistry.⁶

Paracelsus, in 1500s developed an appealing theory of infection, “The Doctrine of Calculus,”⁷ where he recognized the extensive formation of tartar on the teeth and related it to toothache and compared it to the pain produced by calculus in other organs, such as the kidneys.

John M. Riggs became an important authority with respect to periodontal disease, terming periodontitis as “Riggs’ disease”. He became the first individual to limit his practice to periodontology and gave periodontology its special identity.⁸

L. Taylor, D. D. Smith, R. B. Adair and W. J. Younger, Willoughby D. Miller, Leon J. Williams, J. H. Vinsent, Moritz Karolyi further continued the legacy of evolving periodontology through their research and inventions.⁹

Both dentistry and periodontology have come a long way crossing the bridge of time and have also eventually evolved by contributions of all the above-mentioned scholars along with several unsung scholars, but this relationship was not unidirectional. In a gradual evolution where individuals have contributed to periodontology and dentistry, even periodontology has contributed to an individual`s life process and this relationship of mutual evolution continues till today.

The early civilisations and periodontal health

The earliest mention of periodontal issues have been acquired from the Egyptian civilisations which was one of the early traced civilisations in the prehistoric era. The Ebers papyrus dated back to the thirty-seven century, BC claims to have certain remedies to strengthen the gums.¹⁰ The Egyptians had also believed in herbal therapeutics which were mentioned in studies to prevent dental caries and periodontal destruction.¹¹ There is an abundance of evidence which suggests that diseases and their herbal remedies were also prevalent among other civilisations like Greeks, Phoenicians, Etruscans, Hebrews, Chinese and Romans.¹² Around 936 AD, Abulcasis wrote a medical encyclopaedia named al –Tasrif which described the etiologic roles of calculus and its removal using instruments. He also wrote about the technique of splinting loose teeth with golden wires. Evidence discovered in Egyptian pyramids also had confirmed that gold wires were used for splinting the teeth along with radiographs to prove that the pharaohs of Egypt suffered majorly from periodontal diseases.¹⁰ The Sumerians and Babylonian scripts gave an account of practicing oral hygiene through gingival massage in combination with various herbal medications using decorated gold toothpicks, which were excavated at the Nigel Temple in Mesopotamia. In a recent historical excavation, fluorescent scriptures were found in monuments which once upon a time existed near the river Nile. Historians and archaeologists discovered that these fluorescent writings were written with a chemical named ‘Lapus Lazuli’ possibly extracted from dental calculus.¹³

And hence the history has always remained a mystery!!

The emerging concepts of periodontology

The period of Renaissance started from the fourteenth century in Italy and continued up to seventeenth century, emerging as a period for new concepts and ideas. This was the period when Andreas Vesalius, who is considered as the father of modern anatomy wrote a magnificent book on anatomy including gross anatomy of teeth.¹⁰

After the decline of the Roman empire, the Islamic dynasties emerged as pioneers of early research. Researchers like Abu-al Qasim described the dental instruments and Ibn Sinha was one of the first authors to write about periodontal diseases. Serefeddin Sabuncuoglu in early 15^th century wrote a book illustrating the surgical removal of hypertrophic and swollen gingiva and lingual frenum.¹⁴ This work was further elaborated in 16^th century of Rome by Bartholomeus Eustachius who wrote Libellus de Dentibus, the first original book which described the periodontal pathologies and its treatment.¹⁵ The seventeenth century introduced microscopy to the world and laid foundations to modern day microbiology. Anton van Leeuwenhoek, who is considered as the father of microscope detected oral spirochetes and bacilli. He also became the first person to conduct antiplaque experiments in his own mouth.¹⁶

The post renaissance period and beginning of modern dentistry

The eighteenth century embraced and laid foundations to modern day dentistry. The rise of Pierre Fauchard with his book, Le Chirurgien Dentiste¹⁷ in 1728 covered all the aspects of dental practice. He specially emphasised on periodontal health and also described in detail about the periodontal instruments which he had invented, along with their applications in scaling. He also suggested immobilization of the loose teeth with golden wire. In 1796, John Hunter proposed the famous landmark theory- “The theory of focal infection”,¹⁸ a historical concept which was based on the assumption that some infections may lay a foundation to many diseases in different regions of the body. This theory pavemented a way for many researchers to refine their hypothesis and channelise their ideas in the development of periodontology. Contributing to this, the middle of the 19th century saw an upsurge in the number of practising dentists, malpractices and incompetence. The reforms of the profession was brought by researchers like Leonard Koecker. He presented himself as an advocate of the “Odontogenic focal infection” theory, and he recommended the extraction of all severely involved teeth and roots, including all unopposed molars to prevent systemic infections.

The twentieth century saw the rise of Vienna school which developed the basic histopathologic concepts on which modern periodontology stands today. It also saw a rise in two groups which were termed as localists and generalists.¹⁹ The Localists considered the primary cause of periodontal disease to be of intraoral origin, whereas the generalists considered the primary cause of periodontal disease to be of extraoral origin. Both these groups emphasized upon the fact that removal of the etiological causes is the only way to re-establish the lost oral health.

This period of renaissance also became a foundation for many theories like the Discovery of DNA, Focal sepsis theory, Specific plaque hypothesis, Booster mechanisms etc. The nineteenth and twentieth century have witnessed the maturation of periodontology and its branches, growing towards a demand to be claimed as a super speciality in dentistry.

A glimpse into the indian periodontology

India has always been a country of varied culture and diversity and has presented the world with some unique qualities. The medicinal wealth of India traces its evidence to the epics of Ramayan with a mention of ‘sanjeevani aushadhi’. Periodontal disease has also been discussed in the ancient Indian literature by Sushruta in his book titled ‘Sushruta Sanhita’, where he describes periodontal disease in a statement, “the gums of the teeth suddenly bleed and become putrefied, black and slimy and emit fetid smell”. Few scholars believe this as one of the first description of periodontal disease. Around the same period, another scholar of India, Charakha gave an idea about the importance of tooth brushing. Hence, for the sake of easy conceptualisation, historians and researchers divided the Indian health care history into two parts -

a. Vedic period

b. Bramhan period

The Vedic period of India includes the excerpts mentioned in the Vedas. The Rig Vedas had suggested remedies for various tooth and gum problems via use of herbal medicine. India has been a land of eminent, pioneer periodontists like Dr. Tehmi M.S. Ginwalla, Dr. Govind B Shankwalkar, Dr. Lalit M Guglani, right from the period when Rafiuddin Ahmed became the Founding pioneer of dentistry on Indian soil and Dr. Shankwalkar became the first teacher, while Dr. Ginwalla became the first president of Indian Society of Periodontology.²⁰

As per August 2013, Indian Periodontists had published around 750 most cited articles in 107 journals starting from 1960, with original research being almost 500 in International forums. The interdisciplinary approach of Ayurveda and Periodontology has laid foundations in the discovery of many natural products which not only help in the cure of periodontal diseases but also have an added advantage to act as an immunity boosters. The use of products like neem, turmeric, garlic etc have gained international attention in recent times.²¹

The evolution of periodontal disease classification

The evolution of Periodontology is not limited to treatment modalities, but is evident in studying disease pathogenesis and its classifications. The initial workers of periodontology did not specify any terminologies for the existing conditions until Fauchard in 1723 came up with the first condition ‘scurvy of gums’, instigating other researchers to classify and name the various existing conditions. The dominant paradigms in the historical development of the nomenclature system were classified into three significant periods

1) The paradigm of clinical features of disease – (1870-1920)

2) The concept of clinical pathology – (1920-1970)

3) Infection and host response paradigm – (1970-present) Few of the concepts which held a significant position in this time line were:

• Classification of periodontal diseases based on clinical features paradigm (1870)²² This classification was proposed solely on the clinical features of the disease as very little research existed on the etiopathogenesis of the diseases.

• G.V classification of Periodontal diseases (1886)²³ The period of 1870-1920 saw many researchers classify based on their understanding of diseases. G.V Black classified the disease as constitutional gingivitis, painful gingivitis, simple gingivitis, calcic inflammation of peridental membrane and phagedenic pericementitis.

• Orban`s classification of Periodontal diseases (1942)²⁴ In this classification, he divided the diseases into two categories- inflammatory diseases and degenerative diseases and further classified periodontitis as simplex and complex. This classification was accepted by American Academy of Periodontology and it gained wide acceptance.

• Page and Schroeder (1982)²⁵ This classification was based on infection and host response paradigm, which started with a published data by Harald Loe in a series of papers titled as ‘Experimental gingivitis’ in the year 1965 to 1968. Later it was modified and accepted by American Academy of Periodontology in the year 1986.

• AAP classification (1986)²⁶ This classification was based on the earlier classification given by Page and Schroeder, with an addition of refractory periodontitis in the classification.

• AAP classification (1989)²⁷ American Academy of Periodontology modified its 1986 classification system, where Ranney proposed that refractory periodontitis should be eliminated.

• AAP classification (1999)²⁸ This was a detailed classification which was widely accepted and scientifically designed including a wide variety of periodontal diseases.

• AAP classification (2017)²⁹ The year 2017 again saw a new classification which was even more comprehensive when compared to 1999. In this classification, the concept of aggressive periodontitis was challenged and diseases were better classified based on the severity and complexity of their progression.

Perio-technology: the recent advancements in perio-tools

The past twenty years have seen many innovations, inventions and advancements in tools and armamentarium which facilitated efficient diagnosis and accurate treatment planning. From using a standard conventional probe, to the use of three-dimensional computerised probes, periodontology has witnessed many such advancements and innovations.³⁰ Algorithms have played a major connecting link in pacing periodontology into a digital era. Software programs like Algorithm Neural network and Fuzzy logic³¹ have played a major role in determining a more accurate diagnosis and treatment plan. The year 2019 has seen a major invention of CARS: Catalytic Automatic Robotic System,³² which was introduced as a magnetic tool aiding in a more effective, non-invasive treatment modality. Equipment like LASERS, Non-Invasive Anesthesia, Haptics etc have made periodontology painless, less invasive and a pleasant treatment option for both the clinicians and patients. Newer techniques like Chao Pinhole Gum rejuvenation technique³³ have been much discussed and explored in 2019, initiating more and more research at the same. As we explore the year 2020, the sudden rise of a pandemic has again initiated a demand for advancements and modifications in the field of periodontology, initiating a widespread and intense research towards the same. Clinically, Perioesthetics and rehabilitation procedures like implants have given periodontology a new identity, establishing themselves as the cornerstone of the subject. Research on stem cells have also contributed to this by enhancing the importance of regeneration in the existing tooth structure.

Conclusion

As we trace back and reconnoitre the journey of periodontology, the earliest traces began with the rise of the civilisations and matured itself with the rise and fall of the empires. The history of periodontology is an interesting exploration to understand the walk of periodontology from a non-evidence based practice to an evidence-based practice, highlighting the contributions of all pioneer researchers and periodontists included in the hall of fame. This timeline gives us an idea about the way periodontology has made its way into various disciplines and still has an endless scope of growing. Despite evolution through ages, some lacunae still exists in periodontology. We are faced with few controversies due to difference of opinions amongst researchers. Even so, this discrepancy in the knowledge may pave the way to many more evolutionary discoveries and brilliant inventions.

To conclude, a quote from Sir Alferd Tennyson`s poem is best suited to explain the existence of periodontology from then to now.

“FOR MEN MAY COME AND MEN MAY GO, BUT I GO ON FOREVER”

Conflict of Interest

None.