GENERAL

Dental care and dentistry practice in the

Medieval Medical School of Salerno
M. Bifulco,*1 M. Amato,2 G. Gangemi,1 M. Marasco,1 M. Caggiano,2 A. Amato2 and S. Pisanti*1

InInbrief
brief
The Medieval Medical School of Salerno (9th The Regimen Sanitatis Salerni, the School’s main Trotula De Ruggiero, one of the first women physicians
century) is considered the first institution in text, and numerous other texts written by illustrious of the history, recommended specific procedures and
the western world for the teaching of medical School’s physicians pay attention to dentistry and officinal plants for oral hygiene, still used today.
knowledge. dental therapies.

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.

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 illus-
trious 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 illustri-
ous appellation of Hippocratica civitas, a town
existing to this day, in Southern Italy in the
south-east of Naples, with a favourable position
1
History of Medicine Unit; 2Dentistry Unit, Department of
Medicine, Surgery and Dentistry, University of Salerno, Via S
Allende, 84081, Baronissi, Italy
*Correspondence to: Maurizio Bifulco or Simona Pisanti
Email: mbifulco@unisa.it, spisanti@unisa.it
Refereed Paper. Accepted 8 June 2016
DOI: 10.1038/sj.bdj.2016.528
©
British Dental Journal 2016; 221: 87-89
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 innova-
tive 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 physi-
cians, 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 trans-
lated 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 rep-
resented 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.5–7
At the time dental therapies were predomi-
nantly carried out to eliminate pain caused by
tooth decay, but there were specific interven-
tions 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

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 GENERAL

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 fumiga-
tion 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 improve-
ment 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 particu-
lar, in the chapter ‘De dolore dentium’ of the
Practica brevis ascribed, also by De Renzi, to
Johannes Platearius junior, one of the most cel-
ebrated 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 through-
out 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 obstet-
rics 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 gingi-
vitis and halitosis based on the manufacturing
of quicklime, natural sulphur, orpiment (an
arsenic sulphide mineral), and incinerated
pumpkin and pepper. Such dust was distrib-
uted on ill gingivae, previously washed with a
solution made from great mullein (Verbascum
Thapsus) roots, a plant with well-established
emollient, refreshing and decongestant proper-
ties, 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

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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 interven-
tions (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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12. Platearius J. Practica brevis (12th century). Biblioteque
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13. Cofone. De virtutibus medicine‑De modo medendi (12th
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14. Green MH. The Trotula. A medieval compendium of
Women’s medicine. University of Pennsylvania, Philadel-
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15. Bifulco M, Ciaglia E, Marasco M, Gangemi G. A focus on
Trotula dé Ruggiero: a pioneer in women’s and children’s
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The first cosmetic treatise of history. A female point of
view. Int J Cosmet Sci. 2008; 30: 79–86.

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