History of dental education in Bulgaria and in the world

Dentistry was practised for centuries by healers, barbers and surgeons before it had schools of its own. The first dental school opened in Baltimore in 1839. In Europe two models of training then developed: stomatological training, which is tied to medicine, and dental training, which is independent. Only one of the 130 dental schools in the European Union is stomatological. In Bulgaria the first dental training was set up in 1942, as a department of the Medical Faculty in Sofia, after more than 30 years of argument. Bulgaria now has three dental faculties, in Sofia, Plovdiv and Varna.

Early healers and written records

Dental care is as old as mankind. The Ebers Papyrus from ancient Egypt describes toothache, dental caries and ulcerative inflammation of the gums, and gives remedies for them. The Canon of Medicine from ancient China has two chapters on dental care: one on oral diseases and one on disorders of the teeth and gums.

Findings dated to the 5th and 6th centuries BC show that the Phoenicians and the Etruscans knew how to restore missing teeth. Gold dentures and animal teeth were fixed to natural teeth with gold wire, and such pieces have been found in Etruscan tombs.

Greece, Rome and the Islamic world

Hippocrates is the author of the Hippocratic Oath, which describes the moral values of medicine. Every graduating physician and dentist still swears to respect them. Aristotle wrote about teeth and tooth diseases, but he had some wrong ideas. For example, he supposed that men had more teeth than women, and his followers accepted this for many years.

In ancient Rome the Twelve Tables law was in force. A person who caused the loss of another person's tooth paid 300 Roman coins if the injured person was a free citizen, and 150 coins if the injured person was a slave. The law shows how much value society placed on teeth.

Cornelius Celsus wrote De Medicina, which describes the earliest orthodontic treatment, carried out by pressure from the fingers. Claudius Galen described teeth as human bones, and he was the first to say that there were nerves in teeth.

During the Islamic Golden Age, Avicenna (Ibn Sina) became famous with his Canon of Medicine and used arsenic as a remedy in dental treatment. Serapion described the number of tooth roots. He interpreted that the upper molars had three roots to hold their hanging position, while the two roots of the lower molars were enough because of the support of the lower jawbone. Abulcasis, who lived in Spain (1050-1122), was considered the greatest Arabian surgeon of the Middle Ages. In his work De Chirurgia, in three parts, he described tartar for the first time and explained that it injured the alveolar bone. He wrote rules for tooth extraction and said it should be done only if necessary.

The Renaissance and the 18th century

Andreas Vesalius (1514-1564), the founder of modern anatomy, described the exact articulation between the teeth. Today this is called occlusion.

Ambroise Paré (1517-1590), one of the fathers of surgery, described treatments for gum disease, methods of tooth extraction and tooth replantation. He designed a prosthetic device to close a palatal perforation. He remarked that toothache was the most severe pain that can torture a person without leading to death.

Pierre Fauchard (1678-1761) is called the father of modern dentistry. The FDI (Federation Dentaire Internationale) conferred this title on him. He was the first to use the term "tooth decay", and he rejected the idea that decay was caused by "tooth worm". His book Le Chirurgien Dentiste (1728) was considered an encyclopaedia of dentistry and one of the most important books in dental literature. It describes cases from his own practice.

John Hunter (1728-1793), a Scottish physiologist and surgeon, analysed tooth disorders on a scientific basis. He introduced a classification of teeth into incisors, cuspids, premolars and molars, and he was the first to start pulp extirpation. His book Natural History of the Teeth (1771) was called the cornerstone of dentistry. It gave information about the structure, formation, growth and disorders of the teeth. In 1778 he published A Practical Treatise on the Diseases of the Teeth in London.

Dentistry becomes a science

Until the middle of the 19th century, dentists were people with some practical experience, the so-called "people pulling out teeth", and doctors who had graduated in medicine from European universities. In the 19th century dentistry turned from a craft into a science, studied at approved schools.

Green Vardiman Black (1836-1915) described the structure, characteristics and physical features of dental enamel in 1891. On the basis of his research he established methods and rules for cavity preparation and filling. He brought in the doctrine of "widening in order to protect", which means widening the cavity to healthy dentine and enamel to protect against secondary caries. He also made a significant contribution to the improvement and standardisation of dental amalgam. His book Operative Dentistry is still a major work in dental literature. His son, Doctor Arthur Black, started the Index of Dental Literature.

Tooth histology was studied scientifically in the same period. It was shown that dentine and enamel have no blood circulation, and that the dentine tubules in caries cavities are dilated and filled with granules.

Other milestones of the 19th century:

• Horace Wells (1815-1848), an American dentist, pioneered the use of anaesthesia in dentistry, specifically nitrous oxide ("laughing gas").
• Sanford Barnum (1838-1885) discovered the rubber dam. It is still the most effective device against moisture in the operating field.
• Wilhelm Conrad Roentgen discovered X-rays in 1895 while he was a professor of physics at the University of Würzburg, Germany. The X-ray apparatus soon came into dental offices.

Dentistry became a separate area of medical education, science and practice soon after the first dental schools were founded.

The first woman to graduate as a dentist was Lucy Beaman Hobbs Taylor, in 1886. The first dental school that opened its doors to women was the Ohio College of Dental Surgery.

The dental assistant

In 1885 Dr Edmund Kells was the first to hire an assistant in his dental office. At first the role of the "Lady in Attendance" was to accompany women patients, so that they did not need to come with their husbands or family. As time passed it became clear that the lady assistant could help in the treatment itself. By 1900 Dr Kells worked with two assistants, one assistant to the chair and one secretary.

Dentistry in the 20th century

In the 20th century dental research and discovery grew rapidly. Dental treatment changed from a mostly technical, skill-based craft into a continuously updated medico-biological profession, based on firm scientific grounds. New materials for prosthetic treatment were discovered and introduced, including impression materials, alloys, plastics and ceramics, as well as composites for aesthetic restorations. In 1948 the first subperiosteal implant was placed, which marked the beginning of implantology.

Until 1990, basic medical disciplines prevailed over dental disciplines in dental training. Since 1990 the balance has been the opposite. Different history, cultures, traditions, religions, foreign influence, language and other factors in the European countries have shaped the range of training in dentistry.

At one end of the spectrum there is stomatological education, which is deeply connected to medicine. At the other end there is dental training, which develops apart from medicine.

Under EU documents:

• Stomatology is a medical specialty. Students graduate in medicine and then specialise in dentistry for 2-3 years.
• Dentistry is independent training, based on Council Directive 78/687/EEC.

Stomatological training was used in Austria until 1998. It was also used in France and Italy, and one reason for the change there was the shortage of dentists caused by the long duration of education.

Changes in dental education in Central European countries were driven by democracy, the market economy, changes in the structure of the health service, and the desire for EU membership and recognised diplomas.

Whatever the type of training, the most important goal is the final result: professionals who gain the right knowledge and skills. The core knowledge and competencies of a graduating dentist are described in the document "Competencies for the European Dentist". Identifying these basic and core competencies is important, so that graduates can provide basic care to patients without endangering their safety and can move freely within the EU.

Dental education in Europe is harmonised through a network of organisations. The main ones are:

The Faculty of Dental Medicine in Sofia has been a member of ADEE since 2004.

Healers, barbers and blacksmiths

Medieval Bulgarian writings also mention dentistry. The medical collection Zeleynik describes prescriptions against toothache. Joan Exarch, a popular Bulgarian writer of the early 10th century, described the anatomy of the face, lips, tongue, jaw and teeth in his book Shestodnev, a description of the human body. Dental diseases were treated by praying to saints: St Lawrence was called on for gum inflammation, St Ignatius for wisdom tooth aches, St Cosmas and St Damian for tooth extractions, St Albert for abscesses, and St Catherine was respected as the patron of dental surgeons. At that time the first hospitals attached to monasteries were established, at the Bachkovo, Rila, Plovdiv and Bitola monasteries and at the church of Cosmas and Damian.

The Rila Lekarstvenik (17th-18th century) is the oldest manual for drug use in Bulgaria. It describes herbs used in dentistry at that time. For example, opium, incense and clove root were used for tooth disease, and decoctions of seeds, roots and cinnamon for gum disease. Linseed, roasted figs and warm bran compresses were used for abscesses, and aromatic resins such as mastic and cloves were recommended for pleasant breath. Teeth were bleached by rubbing them with a mixture of burnt bread and dust from burned wood.

Until the Liberation of Bulgaria, dental care was provided by barbers, healers and doctors. Barbers, blacksmiths and farriers, the so-called dental healers, performed the most common procedure, tooth extraction, often in unsanitary conditions and with rusty tools. Complications such as fractured teeth and jaws, infections and removal of a healthy tooth by mistake were common. Instruments were made by local blacksmiths and passed from one generation to the next. These instruments were similar to those used today, which shows that the healers knew the anatomy of the teeth. There are no data about prosthetic treatment or cavity filling in that period.

The first Bulgarian doctors who had graduated in Western Europe, Russia, Turkey and Romania came back and practised in their home towns. Foreign dentists also worked in some Bulgarian towns. Dr S. Landau from Vienna worked in Ruse in 1865. Later foreign dentists included Angelo Gastaldi (1873) and Dr Zh. G. Pop, a dentist of the Imperial court in Vienna (1875).

The first licensed and certified dentists

After the Liberation, the new state organised health services. In the Principality of Bulgaria and in Eastern Rumelia, two documents governed the organisation and management of health services and created the legal basis of the medical and dental profession in the two Bulgarias. They were the "Temporary rules for medical service management in Bulgaria" and the "Public administrative health rules No 30 for Eastern Rumelia". The country was divided by the Treaty of Berlin until September 1885.

• 1880the Sanitary Board of Eastern Rumelia issued licence No 1 to Vasil Argirov, a graduate of the Bucharest dental school, to practise dentistry in Eastern Rumelia. He was the first licensed dentist.
• 1890Dr Themistocle Paraskevov, who had graduated in medicine in Athens and specialised in dentistry in Paris, was the first certified Bulgarian physician-dentist.
• 1894Dr Michael Elmazov graduated in Kiev. He was the first certified Bulgarian dentist.

The first Bulgarian dentists had mainly graduated in Russia. Both doctors and dentists worked in public service establishments.

In 1893 there were 14 foreign dentists practising in the Principality of Bulgaria: 2 in Vidin, 3 in Plovdiv, 1 in Pleven, 2 in Ruse, 4 in Sofia, 1 in Tarnovo and 1 in Harmanli. In 1903 there were 27 practising dentists: 16 Bulgarians, 5 Greeks, 3 Armenians, 1 American, 1 Polish and 1 Czech.

The number of dentists in Bulgaria grew rapidly in the years 1905 to 1930. The statistical table gives the numbers of dentists, physicians, pharmacists, paramedics, midwives and nurses for 1893, 1910 and 1930.

In 1893 there were 14 dentists and 500 physicians. In 1910 there were 121 dentists and 657 physicians.

Early dental organisations

In 1905 the first congress of the Bulgarian odontology association was held in a small hall of the Cultural Centre "Slavjanska beseda" in Sofia. Dr Michael Elmazov was elected president, and Dr D. Toshkov was secretary. The association had 9 dentist members. Fr. Flamich chaired the constituent assembly of the first Bulgarian Odontology Society in 1905. The increase in the number of dentists, and the need to protect their professional interests, required an organisation that united dentists and helped decision making on urgent matters of the dental society.

At the 4th congress (1910) the association was renamed the Bulgarian Dental Association. After the 5th congress (1911) it started publishing the journal Dental Review. The journal was published under this name until 1950, then as Stomatolog until 2001, and in 2001 it was again renamed Dental Review. Since 2007 it has been published as Dental Medicine.

The Bulgarian Dental Association contributed to four things:

1. the creation of the school of dentistry in Bulgaria;
2. the establishment of a public dental service, with the first dental office opened in the Sofia School for Boys;
3. the financial support of dentists through the Dental Cooperative, established in 1919 to help them acquire office equipment and materials;
4. the regulation of the profession, by defining the relationships with physicians, dental technicians, barbers and others.

Early dentists and dental healers performed paid tooth extractions and prosthetic services. Many of them later fixed hours or days in their schedule for free services for poor patients. Later the idea of public dental offices was discussed as a central issue. In 1907, 1911 and 1912 the first dental offices were set up in public schools, factories and the army.

Regulation of the profession in the 1920s and 1930s

The Public Health Act of 1929 reduced the many titles of dentist, tooth doctor, doctor and surgeon to two: dentist and dental doctor. Only those who had a university degree were called doctors. By a ministerial decree of 1932, physicians who wanted to practise dentistry had to pass a two-year training course. Technicians were qualified as craftsmen, without the right to work directly with patients, and barbers were definitely prohibited from any medical practice.

After the Balkan Wars and the First World War, several acts in the field of health were adopted. They included the Act to insure employees for accident or illness, the Public Insurance Act, the Act of insurance for unemployment, and the Act of Social Insurance (1924), which allowed all insured persons to receive partly free dental care.

In 1944 there were 824 dentists in Bulgaria, 74 of them in public dental services. By 1950 a public dental system had been set up, and a third of the population had free access to dental services. By Decree No 131 of 17 March 1951 of the Presidium of the National Assembly, free medical services for the whole population were introduced. They included diagnosis, prevention and treatment of diseases of the teeth and oral cavity, except prosthetic services, which were paid according to a price list approved by the Minister of Health. Private practice was prohibited by a decree of 1 December 1972 and restored in 1991.

The Bulgarian Dental Association existed until 1949. That year the professional associations of doctors, dentists and pharmacists were integrated into the Trade Union of Health Workers. In 1991 the Bulgarian Stomatological Association was established.

More than 30 years of argument

The discussion "for" and "against" opening a higher dental school in Bulgaria took more than 30 years. The idea was promoted by members of the Bulgarian Dental Association. Opponents said that a university would be costly for the state, that it would create an excess of dental professionals, and that there would not be well-trained teachers. The First World War and the economic and political crises that followed delayed the decision. The unsuccessful wars that Bulgaria fought in 1913 and 1919 also delayed it.

The decision

On 24 June 1942, at the 4th session of the Ordinary National Assembly, Decree No 32 was adopted for the creation of two departments at the Medical Faculty of Sofia, one in medicine and one in dentistry. The Bulgarian National Assembly agreed to the creation of a medical and dental faculty at the Medical University of Sofia.

The first years

In the early years the university faced a struggle with shortages of staff and resources. This was made worse by the war evacuation of 1943-1944. The newly created school needed trained teachers, premises, equipment, materials and instruments. Heads of the sections recruited assistant professors who had graduated abroad, and they developed their careers as lecturers and academic teachers. Three of them, who had trained in Germany, were elected heads of the sections: Associate Professor Slavcho Davidov (graduated in Leipzig), George Stiliyanov (Halle) and Dimitar Svrakov (Freiburg).

Other teachers became professors and heads of departments. These were Prof. Boyan Boyanov, Prof. Zhecho Koev, Prof. Michail Balabanov, Prof. Dinko Stranski, Prof. Todor Burkov and others. The first academic course had 79 students.

At that time the government decided that young people who had taken part in the Second World War could study without entrance examinations. This led to unexpected results: 941 first-year students enrolled in 1944 and 1139 in 1945, in the group known as the "cursus magnum". The high interest in studying dentistry was a sign of the high social prestige of the profession.

Renaming and reorganisation

In 1950 the Dental Department was renamed the Stomatological Department, to emphasise the improved medical training of students. In 1951 it was reorganised as a separate Faculty of Stomatology at the Medical Academy.

In 1950 the Institute for Specialisation and Training of Physicians (ISUL) was founded. In 1952 the Department for Specialisation and Improvement of Dentists was opened. This was the beginning of organised postgraduate education for dentists.

The faculties

The Faculty of Dental Medicine in Sofia has been housed in a 14-floor building since 1975. It has eight departments:

1. Conservative Dentistry
2. Prosthetic Dentistry
3. Periodontology
4. Orthodontics
5. Oral and Maxillo-Facial Surgery
6. Paediatric Dentistry
7. Dental Public Health
8. Radiology and Oral Diagnosis

The structure of the departments corresponds to contemporary trends in dental science and practice.

In 2005 the third Faculty of Dental Medicine in Bulgaria was opened at the Medical University of Varna. Today Bulgaria has three dental faculties, in Sofia, Plovdiv and Varna.

Students and graduates

Until 2006, 14 170 students had enrolled at the Dental Faculty in Sofia, and nearly 10 000 of them had graduated. The Faculty in Plovdiv had trained 2 508 Bulgarian and foreign dentists. Students from over 51 countries in Europe, Asia, Africa and America have studied in Bulgarian dental faculties, which shows the international prestige of the schools.

Under the Higher Education Act of 1995, graduates of the dental schools are awarded the degree of Master of Dental Medicine. Academic education lasts for 6 academic years, including one year of pre-graduation training and state examinations.

Dentists today

In Bulgaria there are about 8 000 dentists, organised in individual and group practices and dental centres, which provide primary and specialised dental care. More than two thirds of the dentists have one or more specialties. The ratio of one dentist per 1 000 people is more than ideal, but the dentists are unevenly distributed: there are more in the cities and not enough in poor regions.

Links with European dental education

The Faculty of Dental Medicine in Sofia has been a member of ADEE since 2004. The organisations that harmonise dental education in Europe are described in section 4.