Oral & Maxillofacial Pathology
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The chapter titles in Bond's original book demonstrate his interest in the broad scope of oral diseases, not simply dental caries and tooth anomalies (Table 1). They also reflect his differential diagnosis approach to pathologic entities. And yet, even when discussing dental caries he demonstrates considerable original thinking and insight. During a time when many dentists considered dental caries to be an unpreventable destruction arising from within individual teeth, he was proposing that it resulted from the influence of external acids on the enamel, and he dissolved enamel in lemon juice by way of demonstrating the feasibility of his theory.
In his introductory remarks he was the first textbook author to explain that cervical lymphadenopathy and tonsillar hyperplasia were frequently the result of mucosal inflammations, and his designation of enlarged cervical lymph nodes as "inflammation of submaxillary glands" was popularity accepted and is still in common use today as "swollen glands." His proposition that carcinomas of the lip and lateral tongue were produced by constant trauma from adjacent ragged tooth structures was a logical one at the time and was accepted until the early 1960s.
He was also among the first to broadly outline the extra-dental effects of poor dentition, such as palatal and facial abscesses, traumatic ulcers, bone "caries" or osteomyelitis, hypercementosis and concrescence ("exostosis of the fangs"), neuralgic pain ("neuralgia faciei") from damaged or inflamed nerves.
His text was one of the first to emphasize the neural connection between the teeth and the central nervous system (CNS), although he was writing so soon after the discovery of the trigeminal nerve connections that he mistakenly proposed that teething causes such CNS conditions as epilepsy, somnolence, stertor, coma, palsy, hydrocephalus, insanity, and marasmus (whatever that may have been). This, because of the close temporal association between such diseases in childhood and the onset of teething difficulties. He recommended the common practice of scarification, that is, quickly incising over erupting teeth in order to release them from their "tensions" so that their neural connections to the CNS would no longer be "irritated." He also echoed the contemporary belief that primary herpes simplex and cholera often result from difficult teething. The terms "strophulus," "tooth rash" and "red gum" were used at the time to refer to inflamed gingivae secondary to tooth eruption. Impetigo was also thought to result from eruption of the primary or "milk" teeth, as exemplified by its common name "crusta lactea" or "milk crust."
Bond discussed diseases of the gingiva or "gums" also, and was among the few who considered "epulis" to be of inflammatory origin, probably related to poor oral hygiene and bacteria (remember that this was two decades before the germ theory of disease came into existence). His descriptions were complete enough to be reasonably certain that he was among the first to describe pyogenic granuloma, peripheral giant cell granuloma, peripheral ossifying fibroma, and epulis granuloma of the gingiva.
He attempted to differentiate these from gingival carcinomas ("scirrhus," "fungus"), which he knew to be rare, and was probably the first in the dental profession to recommend close follow-up of innocuous but suspicious lesions. He clearly recommended radical surgery, however, for those lesions known by their growth characteristics to be malignant (the microscope was just coming into general use at the time of his writing). He was among the few authors to differentiate between several cancer types, discussing "fungus haematodes" or "soft cancer" separately from cartilaginous or bony malignancies, although he insisted on using the term "sarcoma" for a number of benign tumors.
Bond distinguished between a wide variety of nonmalignant ulcers. Traumatic or "callous" ulcers were, in his mind, associated with simple trauma from the teeth. He described them in detail and felt that they were especially associated with "varicose veins," possibly because they were so often seen on the lateral and ventral tongue surfaces in older patients, i.e. in those patients most likely to have developed substantial tooth damage over the years. He cautioned his reader to be careful with chronic traumatic ulcers, as they may mimic or transform into "cancerous" ulcers, especially on the tongue and lip vermilion.
He also differentiated the painful ulceration of scorbutic gingivitis is differentiated from the painless "chancres" of syphilis and "tubercles" of tuberculosis, with emphasis placed on the importance of palatal perforation in the diagnosis of the latter two diseases. Bond clearly considered these ulcerations different from the soft tissue necrosis or "mortification" of "cancrum oris" and "phagedenic" (Greek for "I eat") or "devastating" ulcers (probably carcinomas). He also emphasized that the surface lesion may simply be a reflection of underlying dental or bone infections, i.e. parulis or osteomyelitis. Ironically, he reserved the term "aphthae" (Greek for "I burn") for "thrush" or candidiasis.
Table 1: Chapter titles in the classic Bond text, A Practical Treatise on Dental Medicine, taken from the second edition, published in 1850. These titles demonstrate Bond's emphasis on non-tooth-related topics and the close association of the mouth with the rest of the body.
| Ulcers Tumours Inflammation of the several parts composing the mouth Diseases of the lips Diseases of the gums Diseases of salivary glands Diseases of the maxillary sinus Diseases of the palate Neuralgia Morbid secretions of the mouth Morbid effects of first dentition Effects of diseased teeth |
Thomas Emerson Bond, Jr., A.M., M.D.
The person who appears to be the true "Father of Oral and Maxillofacial Pathology" is Thomas Emerson Bond Jr., A.M., M.D., of Maryland. In 1840 Bond became the first Professor and Chairman of Special Pathology and Therapeutics, with the opening of the first dental school in the world, the Baltimore College of Dental Surgery. He held that position for at least 30 years. He appears to be one of the dozen most influential and recognized men of the nineteenth century dental profession, and has been listed as one of the four Americans responsible for the "birth" of the dental profession. Even though others were writing on topics of oral pathology and oral medicine, and even though others had already specialized in "oral surgery" (Hullihen, for example), "the writing of Dr. Bond was the first indication of an extended sphere for general dentistry." His work was as well recognized in Europe as in the U.S., and in 1859 he was invited to become the first Corresponding Member of the Odontologic Society of London, the first national dental society organized outside of the United States. Thomas Bell was elected to membership in the same organization a year later.
Bond's work was widely quoted by others and his 1848 textbook, A Practical Treatise on Dental Medicine, was the first English-language text devoted almost exclusively to oral and maxillofacial pathology as we know it today. At the time, his book was said to have "treated this subject [oral pathology] more fully than any previous American dental writer," and he was "the first American writer of note who incorporated, together with strictly dental lesions, a consideration of cases...which had before been considered to belong to general surgery." This text was, moreover, the first book to be described as a review of "oral medicine" in the dental literature. The term was not again used in print until 1868, when an editor used it as a section title for papers relating to the treatment of oral soft tissue diseases.
Bond was the first to report on several oral disease entities and he demonstrated insights into the etiology and pathophysiology of oral diseases which are still valid today. Altogether, his achievement was remarkable, and his writing makes it abundantly clear that he thought of himself first and foremost as a Doctor of Dental Surgery. He was, in fact, a physician with special training in dental surgery. He knew Simon Hullihen well and referred to him as "this ingenious surgeon," but he can equally be referred to as "this ingenious pathologist."
Bond's life as a physician was almost completely dedicated to the fledgling profession of dentistry. Born in 1813 in Baltimore, Maryland, as the son of Thomas E. Bond Sr., physician and first President of the Board of Visitors of the Baltimore College of Dental Surgery, Bond Jr. received an A.M. degree from the Baltimore City College in 1830 and an M.D. degree from the University of Maryland Medical School (founded by his father, among others) in 1834. In 1838 he married Anne Morris of Baltimore and settled down in his father's practice but became immediately embroiled, with Horace Hayden, Chapin Harris and H. Willis Baxley, in the founding of the Baltimore College of Dentistry.
His influence on the dental school venture cannot be underestimated. In fact, three-quarters of a century later, Thorpe considered that "his influence as a medical practitioner of standing in the establishment of the school, in the face of so much antagonism and opposition [from local physicians] was as great or greater than any other man connected with the institution." Bond continued to work throughout his life for the acceptance of trained dental surgeons as respected health professionals. As a delegate to the American Medical Association he contended unsuccessfully for the admission of dental delegates on equal terms with medical delegates. He published extensively in both medical and dental journals, and for many years held a joint appointment in the Washington Medical University of Baltimore.
Although Bond served as Dean of the Baltimore College of Dental Surgery for most of its first decade of existence (1842-1849), his real love was oral pathology. He was the first Chairman of an oral pathology department, the school's Department of Special Pathology and Therapeutics, and he remained in that position until his death in 1872. His was a hands-on, practical and clinical approach to oral pathology, and he was there to assist Chapin Harris when chloroform was first used in the school to extract a tooth.
Bond's text became "a standard text book for dental students for many years and opened a new era in the history of dental surgery." The book was written especially for the American Journal of Dental Science, the first dental journal ever published, in its Library of Dental Science series of reprints of classic and standard works on dental theory and practice. His was one of only two books written, on request, for the series, all others were reprints of past publications. As late as 1940, Robinson included his text among the books "that assisted materially in establishing dentistry permanently and acceptably as a scientific profession." The third edition in 1863 remained the only text of its kind until the 1898 book, Oral pathology and practice, by W. C. Barrett, another physician-dentist who was Professor of Oral Pathology and Dean of the University of Buffalo Medical Department (dental school).
Bond's book and journal articles repeatedly emphasized the pathologic relationship between diseased teeth and other parts of the body, and it was this, more than anything else, that led Thorpe to refer to him as "a far seeing scientific man who was in advance of the medical concepts of his time, in recognizing the unity and interdependence of the whole human organism." The focus which he instilled into the "twelve apostles," his term for the students of the first graduating class of the Baltimore College of Dental Surgery, and later dental surgeons has today gained widespread acceptance in the dental profession and oral pathology is now a part of every dental school curriculum. Moreover, despite the very dour countenance displayed by his portraits, he was a very popular teacher and had a well developed sense of humor.
Bond worked closely with Chapin Harris, H. H. Hayden, and Simon Hullihen, three of the men most responsible for establishing a "scientific" foundation for the emerging dental profession. These men, along with four or five others, profoundly influenced the entire first generation of trained American dentists. This influence can best be appreciated when we remember that of the 5,000 or so dentists then practicing in the U.S., only a few hundred were formally trained in dental schools. These few hundred, however, became the foundation of organized or modern dentistry; the other thousands of itinerant "dentists" or "barber-surgeons" eventually faded out of existence in industrialized societies.
Not only was Bond an incredibly active medical/dental professional, including such esoteric activities as the translation of French texts on dentistry and the composition of the first dental college diploma, but he was a profoundly religious man. Known in the Methodist Church as "Reverend Bond," he edited both The Episcopal Methodist national magazine and The Baltimore Christian Advocate, founded by him in 1870. He repeatedly declined the degree of Doctor of Divinity conferred on him by colleagues. Religion was, literally, a second profession for Bond. Between his two or three professions, he somehow also found time to maintain a large farm, called "Kalmia," outside Baltimore until the end of his life.
Prior to a discussion of Bond's works, the present authors wish to emphasize that he was not alone in his thinking, but rather, he reflected the Golden Age of Science then underway in America and Western Europe. He was, in this regard, more fortunate than his earlier counterparts, Gariot and Bell, who, nevertheless, paved the way for his own great influence. Bond specifically emphasized that pathology was the "science of diseased conditions" and wrote his textbook in order that the dental profession could use it "to examine the etiology, pathology, and treatment of morbid conditions," with a special reference to practical dentistry.
That there was a special need for his particular skills is reflected in the 1846 prospectus for the newly published New York Dental Recorder, wherein the influential J.S. Ware emphasized that "the failure of many dental operations which have been mechanically well performed, is undoubtedly owing to a want of pathologic knowledge." The Dental Recorder was the precursor to Dental Cosmos, which in turn became incorporated into the Journal of the American Dental Association in 1936.
As Dean of the first dental school, Bond published numerous pathology reports, the most important of which was his 1843 treatise on the "morbid sympathies" between the mouth and the rest of the body. This extraordinary paper was read at the fourth annual meeting of the American Society of Dental Surgeons, the first national dental organization in the world. He spoke of 'a beautiful unity of purpose and dependence of parts," and emphasized the fact that it was absolutely necessary that "a certain organic understanding (so to speak) shall exist between the several parts, in order to enable them to act in concert, in carrying on the business of life." He discussed, especially, those things which today we call oral manifestations of systemic disease. He reviewed the detrimental effects of scrofula and rickets on developing teeth (well before Hutchinson's seminal work), the particularly severe damage wrought on gingival tissues by scurvy, and the alveolar alterations resulting from malignancy of the maxillary sinus. He also discussed the negative consequences which dental abscesses may have on the antrum and on more distant sites, especially the "painful affections of the nerves of the face" and "symptomatic fevers."