dentist - editted - 4-92e-2-fainal
Journal of Medical Ethics and History of Medicine
Dental and oral diseases in Medieval Persia, lessons from Hedayat Akhawayni
Kazem Khodadoust1, Mohammadreza Ardalan2*, Reza Pourabbas3, Majid Abdolrahimi4
1PhD, Philosophy and History of Medicine Research Center and Faculty of Dentistry, Tabriz University of Medical
Sciences, Tabriz, Iran;
2Professor, Chronic Kidney Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran;
3Professor, Dental and Periodontal Research Center, Tabriz University of Medical Sciences, Tabriz, Iran;
4Researcher, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran
Corresponding Author:
Mohammadreza Ardalan
Address: Chronic Kidney Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
Email: Ardalan34@yahoo.com
Tel: 98 9141168518
Fax: 0411 3366579
Received: 03/28/2013
Accepted: 10/26/2013
Published: 11/2/2013
J Med Ethics Hist Med, 2013, 6:9
© 2013 Kazem Khodadoust et al.; license Tehran Univ. Med. Sci.
Abstract
Persian physicians had a great role in assimilation and expansion of medical sciences during the medieval period
and Islamic golden age. In fact the dominant medical figures of that period were of Persian origin such as Avicenna
and Razes, but their works have been written in Arabic that was the lingua franca of the period. Undoubtedly the
most substantial medical book of that period that has been written in Persian belongs to Abubakr Rabi ibn Ahmad
al-Akhawayni al-Bokhari and his book, Hidayat al-Mutallimin fi-al-Tibb (Learner’s Guide to Medicine).There are two
chapters related to oral and dental diseases in the Hidayat, a chapter on dental pain and a chapter on bouccal pain.
Akhawayni's views on dental diseases and treatments are mainly based on anatomical principles and less influ-
enced by humeral theory and no mention about the charms, magic and amulets. False idea of dental worm cannot
be seen among his writings. Cutting of the dental nerve for relieving the pain, using the anesthetizing fume, using
the natural antiseptic and keeping the tooth extraction as the last recourse deserves high praise.
Keywords: dental diseases, Akhawayni, history of medicine, medieval period, Persian
mailto:Ardalan34@yahoo.com
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Introduction
During the Islamic scientific Golden Age that
started in the 9th century, Islamic medicine greatly
influenced European science, an effect that
continued until the Renaissance. Islamic scientists
not only accumulated the existing information, but
added to this knowledge through their own
observations, trials and skills (1-3). Persian
physicians had a great role in this period of
innovation, commentary and systematization, and
the dominant medical figures of that period were of
Persian origin: Ali ibn Sahl Rabban al-Tabari (807
- 870 AD, 194 - 257 Hijra), Muhammad ibn
Zakariya al-Razi (865 - 925 AD, 252 - 312 Hijra),
Ali ibn al-Abas al-Majusi (930 - 994 AD, 317 - 381
Hijra) and Abu-Ali al-Husayn ibn Abdallah ibn
Sina (981- 1037 AD, 368 - 424 Hijra). All their
great works, however, have been written in Arabic,
as it was the lingua franca of the period (1, 2). The
Samanid dynasty (875 - 999 AD, 262 - 386 Hijra)
established an autonomic state and nurtured the
revival of Persian literature and traditions. Persian
language that had lost its official status after the
Arab conquest once again started to be used in the
arts and sciences with increasing nationalistic vigor
(1, 2). Undoubtedly the most substantial medical
book of this period belongs to Abubakr Rabi ibn
Ahmad al-Akhawayni al-Bokhari (died 983 AD,
circa 370 Hijra), and his book, Hidayat al-
Mutallimin fi-al-Tibb (Learner’s Guide to Medi-
cine). The Hidayat consists of 185 chapters (Bab),
the first six chapters are on the humors (akhlat) and
faculties (quwa), followed by 28 chapters on
anatomy, 21 on physiology, symptoms and
comments on diet and hygiene, and 130 chapters on
the diseases of various organs. Hidayat al-
Mutaallemin fi-al-Tibb (Learner's Guide to
Medicine) is the oldest treatise on medicine written
in Persian. Some years after the death of Akhaway-
ni, three known manuscripts of the Hidayat were
copied. The oldest one, copied in 1058, is the
manuscript in the Bodleian Library, University of
Oxford. Dr. Jalal Matini, a contemporary Persian
writer, compared the three existing manuscripts and
published a literary edition of the Hidayat in 1965
that has been published by Mashhad University
Press (4). It is an attempt to increase our under-
standing of the dental problems and their manage-
ment in medieval Persia. We intend to introduce
specific chapters of this book to dentists and other
specialists who are interested in the subject. This
would increase our historical understanding of the
dental problems that existed more than one
thousand years ago, and some of those old reme-
dies and herbal products may have certain clinical
benefits and could reenter modern medicine.
Method
What we did in this research at first was to find
chapters that are related to dental and oral medi-
cine. Our criteria were to select those chapters that
contained more clear descriptions of diseases and
related therapies. We tried to understand the basic
concepts and meanings of those chapters, and in
order to preserve the genuine form of those
passages, we tried to translate some segments word
for word. In the discussion part we have tried to
clarify the concepts and to compare them with
those of Akhawayni’s predecessors and successors,
and modern medicine ideas.
There are two chapters related to oral and dental
diseases in Akhawayni’s book: a chapter on dental
pain and one on buccal pain. What follows is a
translation of some parts of these two chapters (4).
At first we will present the original text and then
try to explain them with a modern outlook. We
have tried to translate the original passages word
for word, and in those instances where it was
difficult to convey the concept through existing
words, we added some words or sentences in
brackets.
Passages and Descriptions
In the following passage there is an interesting
elaboration of the role of the dental nerve in
generation of pain, and also considerations on the
periodontal soft tissue inflammation, and infections
that could mimic dental pain. The implementation
of natural antiseptics such as vinegar and some
other probable antiseptic and anti-inflammatory
herbal and nonorganic remedies are also interest-
ing. Nerve cautery has also been discussed and
dental extraction has been mentioned as the last
therapeutic option. There are also interesting
prescriptions of some natural breath fresheners and
the need for differentiation between different
causes of this symptom including dental or
gastrointestinal origins. [pages 298, 299, 302, 303] .
Passage 1
If the tooth is painful, it means that the nerve
that is under the tooth and around it [is painful] ; if
the pain is accompanied by inflamed gum that is
red and burning, it could be alleviated with cold
objects… and gurgling with Oxime, and chewing
Plantago psyllium soaked in vinegar… and the
tooth is not painful unless [because of] a faulty
meal … and if those incompatible matters remain
there, they create inflammation and if they remain
within the dental body, they decay the tooth and
blacken the tooth… and if the pain does not
improve with oil of flower (Salix babilonia) and
Pistacia lentiscus, [in the second stage] you should
use the vinegar and salt frequently until those
faulty materials dry out…. [page 298] .
Passage 2
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And if the pain is without inflammation, it is
phlegmatic … and the patient should gargle [a
mixture of] Muscari comosum mill and tar, and if
the pain does not improve [then] boil the Citrullus
colocynthis Schrad with vinegar and gargle until
the phlegm is removed … or boil dried leaves of
Ruscus aculeatus and dried pine tree wood and two
cloves of garlic with vinegar and gargle this
mixture when it is still warm … or grind and mix
the Anthemis pyrethrum with the skin of the root of
Capparis spinosa and then boil with vinegar and
gargle the mixture. If the pain does not subside
then incise the periphery of the tooth with a lancet
to separate the nerve from the tooth, and if [this
method] is ineffective then one deramsang (4.6
grams) of the seed of black Hyoscyamus niger and
two deramsangs of wet Styrax officinale should be
ground, mixed, burned and the fume [of the burned
mixture] should be conducted by a tube to the
painful tooth to anesthetize it…. [page 298] . And if
you did all and none was effective and the pain
does not improve, then the tooth should be ex-
tracted or cauterized, and if it is hollow, extraction
is inevitable.... [Page 299] (Look at Figures 1 and
2).
Figure 1 : Albucassis Dental Cautery and the tube through which it was applied. Albucassis (Abu'l Qasim
Khalaf ibn Abbas, 1050-1122 AD) Genius of Arabian surgery. Born in alzahra and died in Cordova in Spain . he
is the greatest medieval surgeon in regard to dental art. Among his book is the treaties de Chirurgia (the
picture copied from Guerini V. A History of Dentistry. Chapter 8. Philadelphia: Lea & Febiger, 1909
with permission)
Figure 2; Albucassis (Abu'l Qasim Khalaf ibn Abbas, 1050-1122 AD) dental scrapers. (the picture copied
from Guerini V. A History of Dentistry. Chapter 8 .Philadelphia: Lea & Febiger, 1909 with permission)
Passage 3
Under each tooth there is a nerve … a tooth that
does not have the nerve (sense) does not feel the
pain … the nerve that is under the tooth feels the
pain (is painful).... When the tooth is painful, the
nerve that is under the tooth or within the tooth is
painful [page 298] ... and if the teeth are yellow,
they should be whitened with sea-salt and sea-foam
(meerschaum) and Ghozareh Chini (we were
unable to find the exact meaning of this substance)
and Khashar (cuminum Cyminum?) all ground
together, and you should brush the teeth with this
mixture and you should be careful not to damage
the gum ... [page 299] .
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Description 1
It is obvious in the above passages that Akha-
wayni had an anatomical insight into the diseases
of the teeth and treated them based on a somehow
logical framework. His methods of treatment
included herbal gargles, pastilles, fumigations and
purges as well as cautery and surgery. Akhawayni
has mentioned that if application of herbal reme-
dies with different methods fails then the physician
should consider the cauterization of the area with
hot iron, and if this step also fails, tooth extraction
should be considered. Akhawayni and medieval
Persian physicians were also aware that dental pain
is directly related to the nerve and if we separate
the nerve from the painful tooth it wouldn’t be
painful anymore. Anesthetizing the tooth by
conducting a fume directly to the painful point is a
very interesting method that has been discussed by
Akhawayni. He prescribed sea-foam (magnesium
silicate, Mg4Si6O15 (OH)2·6H2O) for discolored
teeth (5, 6).
Passage 4
… and the cause that is named malus spiritus
(bad breath) could be from three sources.: from
stomach and [it is] accompanied by a high fever …
from the teeth that should be extracted, and it is
possible that it originates from the lung… (Page
300) and its treatment is
the tablet of Mask, [that includes] skin of dried
bergamot, Caryophyllus aromaticus, Valeriana
celtic,vinegar and Aquilaria malaccensis Lamk,
one deramsang (4.6 grams) from each should be
mixed and ground with a half dangsang (2.3
grams) of Moschus moschiferus. The tablet should
be taken in mouth every morning…
… and painful oral cavity or cavitatis oris has
three causes; one is because of bilious blood and
[the oral cavity] is erythematous and burning…;
and it is possible that painful oral cavity is accom-
panied by [mucosal] whiteness that is worse than
the previous case …; and it is also possible that
painful oral cavity is because of corrosive ulcer,
and the mouth and teeth are blackened and
putrefied and the tooth may be destroyed and
lost.… [page 302] and this [situation] needs
Foldfiun tablet, [which is made by] grinding and
mixing yellow Auripigmentum lime, oak apple and
aluminum sulphate together and then drenching
[the mixture] in old vinegar for one week and then
[Foldfiun] tablets are made [from this mixture] ….
… if it is necessary, brush the mouth [gum] with
a rough cloth (sackcloth) and vinegar until it
bleeds, and [as a second stage] wash the mouth
with vinegar and apply this medicine [powdered
Foldfiun tablet] morning and evening until the
condition improves…. I have treated many of these
patients and what I have mentioned here are
methods that I have experienced myself and I did
not mention those that I have not examined…
[pages 302 – 303] .
Description 2
In the above passages Akhawayni discusses the
diseases of the mouth. He maintains that bad breath
could be due to an infected tooth that should be
extracted. Stomach and lung problems are two
other reasons for bad breath. He also describes
conditions that create a painful oral cavity. He
categorizes them into conditions that are accompa-
nied with erythema, conditions that are accompa-
nied with malakoplakia, and a corrosive and
gangrenous ulcer of buccal mucosa. For treatment
of gingivitis gums should be rubbed with a strong
linen cloth until they bleed in order to remove the
rotten flesh, and then the mouth should be rinsed
with vinegar and specific remedies may be applied
(5, 6).
Discussion
Man has suffered from oral and dental diseases
since prehistoric era. In Egyptian hieroglyphs there
are remedies for relieving the throbbing pain of a
dental blister. Dental diseases have been mentioned
in Sumerian records quite vividly. During late
antiquity, dental care and even prosthetic dentistry
reached a high degree of development in the
Roman period, but fell into decadence when
Western Roman Empire began to decline and
Christianity rose (7).
It appears that the major dental problems men-
tioned by Akhawayni are toothaches related to
dental caries, oral ulcer and gingival disease. He
starts with noninvasive methods mostly using
herbal remedies, and if those are ineffective, then
surgical interventions are applied. He reiterates that
he has examined his methods of treatments many
times and believes in their effectiveness. Akha-
wayni’s treatments are mainly based on anatomical
principles and less influenced by humoral theory,
and there is no mention of charms, magic and
amulets. False ideas of dental worms cannot be
seen in his chapter on dental disease (4).
The idea of ‘tooth worm’ that was first men-
tioned in Sumerian scripts continued to be dis-
cussed by Romans and Arabs, as well as in
medieval Europe and even late Anglo-Saxon
documents (7, 8). Akhawayni describes the dental
anatomy very minutely, and interestingly there is
no mention of tooth worm gnawing away the dental
substance. He believes in an incompatible material
that remains within the dental body and decays the
tooth (4). The medieval cure for tooth worm was,
inhaling the smoke of burned Hyoscyamus niger as
mentioned by Roman doctors (7, 8). Akhawayni
prescribes the smoke of Hyoscyamus niger and
Styrax officinale for toothaches but there is no
mention of tooth worm.
Interestingly we can see this false idea entering
Persian medical texts showing the weakness of
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scientific thinking and lack of innovation until the
world stepped toward the modern period.
Akhawayni subdivides toothaches into those
that are associated with inflammation, redness and
burning, and those that are not associated with
severe inflammation. He prescribes gurgling with
Oxime and chewing Plantago psyllium soaked in
vinegar for the first group. Those without severe
inflammation are due to a retained phlegm that
should be removed through gargling Muscari
comosum mill and a mixture of Citrullus colocyn-
this Schrad and vinegar and gargling until the
phlegm is removed (4).
Medieval European manuscripts of Gilbert An-
glicus and Guy de Chauliac (13th century AD) have
mentioned effective pain relief using Papaver
somniferum and oil of Caryophyllus aromaticus.
Alum and Punica granata have been mentioned by
Roger of Frugard as ingredients in a lotion to
overcome suppuration (8).
Akhawayni’s recommendations for periodontal
disease and gingivitis include scarification of the
gum to bleed and then application of vinegar and
other solutions with probable antiseptic characteris-
tics. The same prescription has been recommended
by Razes (7, 8). He believes that tooth extraction is
the last recourse when every other attempt has
proven useless, a method that no doubt deserves
high praise. In Akhawayni’s writings we cannot
find any direct description of drilling and emptying
the painful teeth as described by Avicenna and late
Byzantine-Roman physician Archigenes (7).
Akhawayni is one of the few authors who have
mentioned the cutting of the dental nerve for
relieving the pain. He describes a method of gently
pricking a lancet around the tooth and cutting the
nerve (4). However, because Akhawayni wrote his
book in Persian, which was not the lingua franca of
the Islamic world in that period, it did not receive
the credit that it deserved.
We should consider that Akhawayni was indi-
rectly a student of Razes who created the great
medical encyclopedia of “Alhavi”, which covers
most subjects and principles of medical science.
One of those subjects is dentistry, which contains
definitions, diagnosis, treatment and prognosis of
dental and oral cavity diseases and associated
medical care leading to oral health and manage-
ment (9-11).
Alli ibn al-Abbas al-Ahvazi, the great pillar of
the third century, also was a great pillar of medi-
cine with very interesting ideas on dental and oral
medicine, as he believed bad breath could originate
from the stomach. Differentiation between gingiv-
al- and dental-originated pain is paramount because
in the first case there is no need for the tooth to be
extracted. Avicenna (370 - 428) also gathered the
ideas of his great predecessors such as Razes al
Ahvazi and Akhawayni and with his novel outlooks
became one of the remaining figures of science
worldwide (9-11).
It is interesting that in the more recent medical
books we can see the entrance of false ideas such
as the tooth worm, as well as some novel ideas
such as using Anthemis pyrethrum (Anacyclus
prethrun) in vinegar for loosening the painful tooth
for its easier extraction (12).
Conclusion
Our article was an attempt to introduce Hidayat
al-Mutallimin fi-al-Tibb (Learner’s Guide to
Medicine) as an important and forgotten 10th
century Persian medical treasure. The passage on
dental and oral disease shows the importance of
oral and dental care in medieval Persia. It was very
interesting that we found great considerations of
anatomical based diagnosis and therapeutic
considerations. It shows that medieval Islamic-
Iranian physicians were aware of the importance of
the dental nerve as a root of sensation, and the oral
soft tissue and periodontal inflammation that can
very easily be confused with dental originated pain.
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