Saint Apollonia and the Ethical Foundations of Contemporary Dental Practice

Introduction

The diamond jubilee of the International Dental Journal, which commenced in September 2025, marks 75 years of advancing evidence-based dentistry and professional standards globally.¹ This milestone provides an opportunity not only to recognise scientific progress but also to reflect on the ethical foundations that define contemporary dental practice. Dentistry derives its legitimacy from technical competence, but equally from public trust, patient-centred care, and robust professional regulation.

Saint Apollonia, traditionally associated with dental suffering, occupies a distinctive place in this reflection (Figure 1).² Her third-century martyrdom narrative centres on the deliberate destruction of her teeth. When examined critically and historically, the episode offers a striking contrast to modern dentistry’s core commitments: informed consent, pain control, nonmaleficence, and accountability.

Figure 1.

Saint Apollonia, Piero della Francesca. Tempera on panel, 1455-1460. 38.8 × 28 cm. National Gallery of Art, Washington (public domain).

This commentary does not approach Apollonia devotionally. Rather, it uses the historical record and its reception to frame a clinically oriented discussion of how dentistry has evolved into a regulated profession defined by ethical obligations and systematic pain management.

Apollonia in the historical record

The earliest surviving account of Apollonia’s death appears in Book VI of Eusebius of Caesarea’s Ecclesiastical History, which transmits part of a letter attributed to Dionysius of Alexandria describing persecution in mid-third-century CE Alexandria.³ According to this account, Apollonia was struck on the jaw, her teeth were forcibly traumatised, and she was threatened with death unless she complied with the demands of her persecutors; she ultimately died by burning.³

The documentary base is limited. The episode survives through Eusebius, whose work blends historical reporting with theological interpretation.^3,4 No independent administrative record confirms the event. Nevertheless, the narrative is unusually specific regarding dental injury. Teeth are described as the primary focus of violence rather than incidental details.

For contemporary dentistry, the significance lies less in establishing historical certainty than in recognising how dental pain is represented. The account portrays oral injury as an instrument of coercion. In contrast, modern dentistry defines itself through the prevention and relief of such suffering.

Oral care in late antiquity

Dentistry did not exist as a distinct, regulated profession in the third century. Oral maladies were treated by physicians, surgeons, and other practitioners without standardised licensure, formal ethical codes, or effective analgesia.

Documentary evidence from the Roman era in Egypt demonstrates a degree of awareness of oral pathology and attempts at treatment. P.Oxy. LXXX 5244, dated to the mid-to-late third century and written on the verso of a military document (244-249 CE), records a recipe for tooth powder intended to address gum ulceration.⁵ This papyrus confirms that written therapeutic knowledge relating to oral conditions circulated within broader medical practice.^5,6

Earlier literary sources also discuss dental intervention. In De Medicina, Aulus Cornelius Celsus describes dental pain and extraction, outlining indications and procedural considerations.⁷ Extraction was recognised as necessary in some circumstances, but it was performed without modern anaesthesia, antisepsis, or regulatory oversight.

Archaeological findings, including the instrument assemblage from the “Domus del Chirurgo” in Rimini, indicate that invasive procedures were technically feasible.⁸ While attribution of specific instruments to dental extraction requires caution, the broader context suggests that oral interventions could be undertaken, often under painful and hazardous conditions. Within this clinical environment, dental pain was common and difficult to control. Apollonia’s narrative reflects a world in which oral injury could occur outside any framework of consent, professional accountability, or enforceable ethical standards.

Ethical transformation and professionalisation

The most significant distinction between ancient oral intervention and contemporary dentistry lies not only in technological development but in ethical transformation and professional regulation.

Modern dentistry is structured around established ethical principles, including autonomy, nonmaleficence, beneficence, justice, and veracity. These principles are articulated in professional codes such as the American Dental Association’s Principles of Ethics and Code of Conduct, which recognises dentistry’s “special position of trust” within society and affirms that ethical duties may exceed legal requirements.⁹ Comparable regulatory frameworks operate internationally through licensure systems, accreditation standards, and disciplinary mechanisms.

In contrast, Apollonia’s experience reflects the absence of such protections. Her narrative illustrates:

• •Absence of consent
• •Deliberate infliction of pain
• •Lack of professional accountability
• •Vulnerability without recourse

Modern dentistry, by comparison, is defined by:

• •Informed consent and shared decision-making
• •Evidence-based pain control
• •Duty of care and nonmaleficence
• •Regulatory supervision and enforceable standards

This shift represents a fundamental redefinition of the clinician–patient relationship. Dentistry’s authority is no longer grounded merely in technical ability to extract or restore but in its commitment to safeguard patient welfare.

Pain management as a defining obligation

Pain control is central to dental practice. The oral cavity is highly innervated and functionally essential, making interventions potentially distressing. Effective analgesia and anxiety management are therefore not optional adjuncts but core professional responsibilities. Apollonia’s narrative provides a stark depiction of dental pain inflicted without consent or mitigation. Contemporary practice requires systematic pain assessment, appropriate local anaesthesia, adjunctive pharmacologic support where indicated, and clear communication regarding procedures and risks.

Ethically, the principle of nonmaleficence obliges clinicians to minimise avoidable discomfort. Beneficence requires proactive relief of suffering. These principles extend beyond pharmacology to include behavioural management and trauma-informed care. Dental anxiety remains prevalent, affecting access to treatment and oral health outcomes. Recognising and addressing psychological vulnerability is part of ethical clinical practice.

Professional identity formation literature underscores that ethical competence is inseparable from clinical proficiency.^10,11 Technical skill without attention to patient comfort and dignity does not meet contemporary professional standards. Pain management, therefore, is both a clinical requirement and a moral commitment.

Regulation, accountability, and public trust

Modern dentistry operates within comprehensive regulatory systems. Licensure requirements, continuing professional development, infection control standards, and peer-review processes create enforceable frameworks for safe practice. The ADA Code emphasises that society grants privileges to the profession in exchange for adherence to high ethical standards.⁹ Violations may result in disciplinary action, reinforcing that professional obligations are institutionalised rather than aspirational.

Apollonia’s historical context lacked such structures. Oral injury could occur without oversight or redress. The contrast underscores the importance of maintaining rigorous regulatory standards today. Public trust depends on the assurance that practitioners are accountable to recognised professional bodies and subject to consistent ethical expectations. Regulatory vigilance is particularly relevant in areas such as sedation, pain management, antimicrobial stewardship, and digital technologies. Ethical dentistry requires continual adaptation to emerging risks while maintaining patient-centred principles.

Symbolism and contemporary relevance

Over time, Apollonia became symbolically associated with dentistry and is frequently depicted holding a tooth and an extraction instrument, as seen in works by Piero della Francesca and Francisco de Zurbarán (Figure 1, Figure 2).^2,12 These images consolidate the link between her narrative and dental suffering.

Figure 2.

Francisco de Zurbarán. Sainte Apolline. Oil on canvas, c. 1636-1640. Musée du Louvre, Paris. (public domain).

In contemporary pluralistic societies, professional identity must remain inclusive and grounded in universal ethical commitments. When interpreted historically rather than devotionally, Apollonia’s narrative serves as a reflective contrast rather than a sectarian emblem. It highlights the asymmetry inherent in dental care: the practitioner possesses instruments capable of causing discomfort; the patient consents on the basis of trust. Ethical practice requires that this asymmetry be governed by competence, transparency, and compassion. In this sense, Apollonia’s story functions as a reminder of what dentistry has evolved beyond: unregulated, uncontrolled infliction of oral pain.

Implications for clinical practice

Several practical implications flow from the above for contemporary dentistry. First, ongoing education in pain control and sedation remains essential. Advances in local anaesthesia, minimally invasive techniques, and digital planning should be understood not only as technological progress but as ethical improvements that enhance patient comfort and safety.

Second, trauma-informed and patient-centred communication should be integrated into routine care. Clear explanations, respect for autonomy, and responsiveness to anxiety strengthen therapeutic alliances and support ethical standards. Third, adherence to regulatory frameworks must remain rigorous. Ethical codes and clinical guidelines require active implementation. Professional self-regulation depends on collective commitment to maintaining standards that protect patients and preserve public confidence.

Jubilee reflection

The 75-year history of the International Dental Journal reflects the scientific maturation of dentistry as a global discipline. Innovations in preventive care, restorative materials, implantology, and digital technologies have improved outcomes and expanded access to treatment. Equally significant, however, is the consolidation of ethical and regulatory frameworks that define contemporary practice. Dentistry’s legitimacy derives from the integration of scientific excellence with principled conduct.

Apollonia’s narrative endures because it encapsulates a fundamental contrast. It depicts deliberate dental pain inflicted without protection. Modern dentistry is defined by a diametrically opposite commitment: to relieve pain, respect autonomy, and operate within accountable professional systems. In this jubilee year of the International Dental Journal, reflection on this ethical transformation affirms that the profession’s progress has been both scientific and moral. The development of effective analgesia, structured education, and enforceable codes of conduct represents a central achievement of modern dentistry.

Conclusion

Saint Apollonia was not a dental practitioner, nor does her story document organised dentistry. Her relevance for contemporary clinicians lies in the ethical contrast her narrative provides. In the absence of regulation, analgesia, or enforceable standards, oral injury could occur without protection for the vulnerable. Modern dentistry is defined by informed consent, systematic pain management, patient welfare, and professional accountability. These commitments are codified in ethical frameworks and sustained through regulatory systems.

As the International Dental Journal celebrates its diamond jubilee,¹ the profession may appropriately recognise not only its technological achievements but also its ethical evolution. Dentistry’s transformation into a regulated, patient-centred discipline committed to minimising harm represents one of its most enduring accomplishments.

The historical memory of dental pain reinforces a central professional obligation: the clinician’s instruments must always serve care rather than coercion.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions

L.F.: Conceptualization; Writing – original draft; Writing – review & editing; Supervision. L.P.S. Writing – review & editing, approval of the final version.

Conflict of interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.