Stent: The Man and Word Behind the Coronary Metal Prosthesis | Circulation: Cardiovascular Interventions Stent: The Man and Word Behind the Coronary Metal Prosthesis Ariel Roguin Originally published April 19, 2011 Ariel Roguin prosthesis Introduction Interventional cardiologists implant stents every day. Stents are also used in numerous other medical disciplines such as plastic surgery, gastroenterology, urology, and oral and maxillofacial surgery. 1 – 5 Uses range from rebuilding mandibles and other oral surgical procedures, constructing new ureters, keeping skin flaps, and as biliary conduits. 6 – 11 What is the source of this word stent everyone is using in daily practice? This article describes the origin of the word, how it became so popular, its use in medicine outside the cardiovascular system, and the people who used this term first. Charles Thomas Stent: An English Dentist The current acceptable origin of the word stent is that it derives from the name of a dentist. Charles Thomas Stent (1807 to 1885) was an English dentist notable for his advances in the field of denture-making.

He was born in Brighton, England, on October 17, 1807 ( Figure 1 ), and was the 6th son of William and Hannah Stent. He was a dentist in London and is most famous for improving and modifying the denture base of the gutta-percha, creating the Stent's compounding that made it practical as a material for dental impressions. His accomplishments led to his appointment as Dentist to the Royal Household in 1855. 1 – 4 Figure 1. Charles Thomas Stent (1807 to 1885). Image courtesy of the Journal of the History of Dentistry. Gutta-percha is a natural latex produced from tropical trees native to Southeast Asia and northern Australasia. In 1847 it was introduced as a material for making dental impressions. It was used to fill the empty space inside the root of a tooth after it has undergone endodontic therapy. Interestingly, this same material was also used for furniture, and, because of its good electric insulation properties, it was used also to insulate telegraph wires.

Gutta-percha served as the insulating material for some of the earliest undersea telegraph cables, including the first transatlantic telegraph cable. However, in dentistry this material was unsatisfactory for several reasons, including its tendency to distort on removal from the patient's mouth and to shrink on cooling. In 1856, Charles Thomas Stent added several other materials to the gutta-percha, notably stearine, a glyceride of stearic, palmitic, and oleic acids, a substance derived from animal fat that markedly improved the plasticity of the material as well as its stability. He also added talc as an inert filler to give more body to the material and added red coloring. He and his wife Caroline had 2 sons and a daughter, Fanny. Both his sons, Charles R. Stent (1845 to 1901) and Arthur H. Stent (1849 to 1900), became dentists, and together they founded a firm, C. R. and A. Stent, which manufactured the increasingly popular Stent's Compound. Charles T. Stent died in 1885 and was buried in London.

The sons continued marketing the compound through the prestigious dental supply company, Claudius Ash and Sons of London. When the last of the Stent brothers died in 1901, Ash's firm purchased all rights to the compound and manufactured it, keeping the Stent name ( Figure 2 ). Claudius Ash and Sons became an international company, in 1924 merging with de Trey & Company to form the Amalgamated Dental Company; it is now a division of Plandent Limited. Download powerpoint Figure 2. Logo stamp of the Stent compound when manufactured by Claudius Ash and Sons. Image courtesy of the Journal of the History of Dentistry. Early Use of Stent's Name in Surgery The transition of the dental impression compound into a surgical tool is attributable to Johannes Fredericus Esser (1877 to 1946), a Dutch plastic surgeon who pioneered innovative methods of reconstructive surgery on soldiers with face wounds during the First World War. This war saw the introduction of trench warfare. Soldiers in the trenches were fairly well protected so long as they stayed below ground level. To fire their rifles, however, they had to raise themselves above the edge of the trench and thus were very susceptible to facial wounds.

The number of these disfiguring wounds was staggering, and surgeons had little experience in handling them. 1 – 3 , 7 Esser was designated Special Surgeon for Plastic Operations and assigned to a hospital in Vienna. He applied sterilized Stent's dental mass to stabilize the skin grafts. In 1917, he described his experience with these wounds and how he used “the mold of dentical mass (Stent's) in fixation of skin grafts in oral surgical repair of war wounds.” 12 This he accomplished by means of what he termed the “epidermic inlay technique,” which used Stent's compound to stretch and fix in place grafts to enlarge the conjunctival opening and in ear reconstruction as well as intraoral grafting. Later in the article, he simply called it “stents mold,” without a capital letter. Interestingly, his monograph also dealt with hypospadias repair. An English army surgeon, H.D.

Gillies, cited Esser's work in his 1920 book, Plastic Surgery of the Face, when he wrote “The dental composition for this purpose is that put forward by Stent and a mold composed of it is known as a ‘Stent’.” This is probably the first use of Dr Stent's name as a noun. 13 The principle of the fixation of skin grafts by “stenting” was quickly adopted and persisted long after Stent's compound ceased to be the material of choice for this technique. 7 Stents in Noncardiovascular Fields The application of the word stent in the surgical literature was not immediate. Since the beginning of the 20th century, numerous inert tubes and biological tissue to bridge a gap or restore bile duct continuity were tested. Such a device was referred to in various ways: tube, catheter, internal splint, internal strut, and later, endoprosthesis. The first reference to a polyethylene tube “to act as a stent for the anastomosis” in experimental biliary reconstruction in dogs was made in 1954.

14 ReMine recalls that, “because he was using a skin graft for a conduit, he wished to prevent contraction of the skin graft, and hence the principle of Stent's dressing was extended to a tubular structure.” 2 In 1966, Menick and Kim 15 reported on a patient in whom a rubber tube had been left in situ in a repaired common bile duct for 27 years. The text described the tube as “a splint and prosthesis,” but the title of the article used the term stent. In urology, even as genitourinary reconstruction of the ureter and urethra expanded in the first half of the 20th century after World War I, the terms used were tube, catheter, and specifically, retention catheter. After World War II, the terminology remained limited to ureteral, urethral, and vassal splinting. 8 Because the spoken word generally precedes the written word, it is reasonable to suppose that some urologists must have started to use the word stent once it was established in the surgical vocabulary.

In urology, stenting first appeared in 1972, when Goodwin 16 wrote a brief commentary titled Splint, Stent, Stint, concluding: “Urologists are always talking about putting a tube in a ureter or urethra. When they do this, it is not a splint. It may be a stent. It probably is never a stint. Perhaps the process is most properly described as leaving a tube or stent in an organ.” Firlit and Brown, 17 also in 1972, made the switch from splint to stent. Montie et al 18 commented specifically on their terminology: Since there has been considerable confusion in the literature in reference to the words “splint,” “stent,” and “stint,” brief reference is made here to the reason for choosing the word “stent” in these experiments. As described succinctly by Goodwin in 1972, a splint is something that is put outside a structure to make it stable, whereas a stent is a compound, or a mold made of a compound, for holding some form of a graft in place.

When referring to an intralumenal device to maintain patency until healing has taken place, the word ‘stent’ is most appropriate. By 1980, the urinary tract stent was widely in use in adult and pediatric urologic practice and was also the word used for hypospadias repair, similar to the work described by Esser in 1916. 12 , 19 In the second half of the 20th century, stents were used in a variety of surgical terrains, including nasal surgery stents, spiral Teflon stents for gynecologic tuboplasty, T-tube tracheal stents, skin graft stents for mandibular reconstruction, and flexible stents for heart valve fabrication. 20 – 24 Today, stents and stenting became frequent in vascular surgery, gastrointestinal surgery, radiology, cardiology, neurosurgery, thoracic surgery, and other medical specialties. First Citation in Cardiology The first reference in the cardiovascular literature of the word stent was by Weldon et al 25 in 1966, when they described a prosthetic-stented aortic homograft used for mitral valve replacement.

Weldon was aware of the use of the word stent by plastic and oral surgeons and assumed that it was an all-purpose term for “any kind of nonbiological support used to give shape or form to biological tissue.” What about the coronary stent as we know today? In the original article from 1964 by Dotter and Judkins 26 on “dottering,” the authors alluded to the promise of these endovascular devices, yet they termed them “a manually guided dilator” or “a device suitable for percutaneous insertion, which is a functional equivalent of the present spring guide but capable of externally controlled concentric expansion over a suitable portion of its length.” However, Dotter and Judkins did not use the word stent in print until 1983. Dotter was the first to use the word in his article in Radiology in April 1983, which was titled “Transluminal Expandable Nitinol Stent Grafting: Preliminary Report.” 27 The first coronary stent was implanted into a patient by Jacques Puel in Toulouse, France, on March 28, 1986.

28 , 29 In their report in French, they used the term endo-prothèses coronariennes autoexpansives. Ulrich Sigwart has been credited with the concept and realization of endoluminal stenting, a procedure that has revolutionized coronary and peripheral arterial revascularization. 30 , 31 Sigwart worked at the University Hospital, Lausanne, Switzerland (1979 to 1989), and played a pivotal role in the concept and ultimate application of coronary stenting. Jacques Puel and Ulrich Sigwart were invited almost simultaneously by the company Medinvent to help with the initial animal and clinical research pertaining to their new product, the Wallstent. Ulrich Sigwart was contacted because he practiced in Lausanne, Switzerland, the headquarters of Medinvent, and the French engineer behind the product contacted his French colleague, Jacques Puel. Sigwart and Puel were the first to report on the clinical use of stents to prevent sudden occlusion and restenosis after transluminal angioplasty in their landmark work published on March 19, 1987, in the New England Journal of Medicine.

32 The article reported their experience from Lausanne, Switzerland, and Toulouse, France, of 10 stent implantations in 6 patients for iliac or femoral arterial disease; 24 coronary artery stents implanted in 19 patients who presented with coronary artery restenoses (n=17) or abrupt closure (n=4) after transluminal angioplasty or deterioration of coronary-bypass grafts (n=3). Sigwart also observed the shortcoming of stents when, 3 months after one had been implanted in the proximal left anterior descending artery, the patient had recurrent chest pain. Angiography revealed severe restenosis, and he wrote that a combination of mechanical and biological factors would be the sine qua non to overcome the problem of recurrence. 33 Sigwart wrote in a letter to the editor 34 of the American Journal of Cardiology that, “When submitting the first article on human stenting in 1986, the New England Journal of Medicine persuaded me to drop the verb ‘stenting’ and use instead the noun ‘stent.’” In parallel, in the United States, several groups were actively developing and testing these devices in the coronaries.

35 Julio Palmaz, an interventional vascular radiologist, is known for inventing the balloon-expandable stent, for which he received a patent filed in 1985. This patent has been included on the list of the 10 most important inventions of all times. Julio Palmaz born in La Plata, Argentina, and Richard Schatz, a cardiologist from the Brooke Army Medical Center, worked together in the University of Texas Health and Science Center at San Antonio. They miniaturized the Palmaz balloon-expandable stent for coronary use and performed extensive animal studies. In October 1987, Palmaz implanted his first peripheral stent in a patient at Freiburg University in Germany. Later that same year, the first Palmaz-Schatz coronary stent was implanted in Sao Paolo, Brazil. Both procedures were very successful. At the same time, another group in Emory University, Atlanta, Georgia, led by Gary Roubin and Spencer B. King III, used a device pioneered by Cesare Gianturco, a creative Italian radiologist who also developed tools such as occlusive coils and vascular filters. Both of their seminal reports appeared in Circulation.

36 , 37 The Gianturco-Roubin Flex-Stent and the Gianturco-Roubin (GR II) Coronary Stents (Cook Inc) were the first Food and Drug Administration–approved coronary artery stents in February 2002. The Palmaz-Schatz stent did not get approved until 1994, after the BENESTENT and STRESS randomized trials, comparing stents with balloon angioplasty. Within 4 years of Food and Drug Administration approval, the balloon-expandable stent was used in >80% of percutaneous coronary interventions, a virtually unparalleled success. Older Origins of the Word Stent According to the medical dictionaries, 38 – 40 the word stent is much older than Charles Stent and is derived from an old and long-forgotten Scottish word for extend, set, or stretch out as a sail. According to the Oxford English Dictionary Word and Language Service, the word stent has already been used in the 14th century. 38 The noun stent refers to a stake for stretching out fishing nets on a river.

Furthermore, it could also be used as a verb in the context of stretching out sails, curtains, or fishing nets. In addition, it has been used to describe the act of stiffening a garment; an assessment of property for the purposes of taxation; and tin-mining rubble. Most of these forms are Scot or obsolete and are derived from the Old French estente, meaning extent. Hedin 3 questioned whether the Stent family name might have been derived from the obsolete English and Scottish meaning; however, Sterioff 2 researched the family name Stent, and, according to The Historical Research Center, there is no connection of the surname and the ancient meaning. In summary, all the evidence has it that Charles T. Stent gave his name to our coronary endovascular prosthesis (the stent), and Charles T. Dotter was the first to use the name in a publication. Eponyms have long been commonplace in medical practice. Very rarely, however, does a name, standing alone, become part of the living language. 41 The word stent, used both as a noun and a verb, is just such a case.

The greatest tribute that can be given to any inventor is to have the initial capital letter dropped from his or her name changed to lowercase and the name itself to a verb. That is the ultimate recognition that the word is now in the general language. Disclosures Pierre Fauchard – The Story of Dr. Charles Stent References by Malvin E. Ring, DDS, MLS, FACD – Stents have been used in numerous medical disciplines, as well as in oral surgical procedures. Uses range from rebuilding mandibles and constructing new ureters, to keeping coronary arteries patent after angioplasty. The earliest use of the word listent” to describe this item was in 1916, when a Dutch plastic surgeon described how he used a dental impression compound as a matrix around which to form tissue in the process of rebuilding a shattered face. What is generally unknown is that the word “stent” derives from the name of an English dentist, who invented this impression compound in 1856… Stents have been used in numerous medical disciplines, as well as in oral surgical procedures. Uses range from rebuilding mandibles and constructing new ureters, to keeping coronary arteries patent after angioplasty.

The earliest use of the word “listent” to describe this item was in 1916, when a Dutch plastic surgeon described how he used a dental impression compound as a matrix around which to form tissue in the process of rebuilding a shattered face. What is generally unknown is that the word “stent” derives from the name of an English dentist, who invented this impression compound in 1856. Ask any informed lay-person what a “stent” is and the answer will generally be “a tube put into a heart artery during ballooning to keep the artery open.” Ask a urologist and you’ll learn that a stent is used to artificially produce a tube to replace a damaged ureter or other natural conduit. Radiologists will tell you that it is a device used by them to indicate an interventional device as part of a prosthesis.’ Other branches of medicine have their own ideas of what a stent is and what it’s used for, but most have no idea from where the name stems. However, some in the medical profession are intrigued with the origin of this word “stent,” and numerous articles have been published in medical journals speculating over its origin.

Two English surgeons wrote: “On seeing an advertisement for a conference to be held in May, 1996 in Westminster entitled ‘The Stent Summit I0 Years of Stenting’, the authors were intrigued that the word should become so commonly used in urological, cardiac and vascu-lar surgery to describe the splinting open of a hollow tube or viscus. Is there a relationship and if so, when and how did it develop?”10 The fact that it derives from the name of Charles Stent, an English dentist, would make one think that dental publications would have published some articles about its origin. (Fig. 1) But, to date, only medical journals have done so. This paper, therefore, is an attempt to inform the dental profession about its genesis. Numerous times in the English language proper nouns have become common words and the word 11 stent” seems to be one such example.

There are many others, such as guillotine (after its inventor, the French physician, Guillotin), draconian (after Draco, an Athenian statesman who drew up a severe code of laws), as well as stentorian (after the Greek messenger, Stentor, in the Trojan War, who had the “voice of 50 men”) . Stents in Surgical and Medical Practice Mosby’s medical dictionary defines a stent as “1. a compound used in making dental impressions and medical molds. 2.

a mold or device made of stent, used in anchoring skin grafts and for supporting body openings and cavities during grafting of vessels and tubes of the body during surgical anastomosis.”Il A recent history of medicine describes stents as “custom-built steel or hard plastic tubes [which] can be inserted under angioscopic or ultrasound guidance, to prevent the collapse of blood vessels and ducts.”” Dorland’s medical dictionary stresses its use as a molded appliance used to hold a graft in place or act as an obturator.’ No matter the uses, the term originated with a material devised by a dentist to enable him to more easily secure better and more accurate impressions of the mouth and oral structures.18 Surgeons trained in both England and the United States during the early years of the 20th century were aware of Stent’s material and its use in dentistry as well as in plastic surgery. “In the generalized training of surgeons, principles and applications of one specialty merged into another, an outcome that extended Stent’s concept and Stent’s dressing into other anatomic applications and hence new technologies.”16 A cardiac surgeon, T. 0.

Cheng, in commenting on the use of the name Stent as a noun says, “The greatest accolade that can be given to any inventor is to have the initial capital letter dropped from his name, for that is recognition that the word is now in the general language .3 Today stents are used everywhere, and the word stent has now become one of the most commonly used words in a number of medical disciplines. An investigation of MEDLINE searches for the year 1995 listed more than 500 instances in which the word stent appeared in the title or subject heading of a published article! Stents were apparently used in a large variety of procedures including nasal reconstruction; in gynecology, where different ducts and tubes had to be reconstructed; in surgery of the trachea; in plastic surgery, especially in rebuilding of the mandible; and most well-known, in cardiac surgery.1 Stents are now produced commercially by a number of firms and are most commonly made of inert metals. However, a major breakthrough occurred when a new bioabsorbable stent, sold under the trade name SpiroFlo, was introduced in 1992 by the Bionx Company of Blue Bell, Pennsylvania. (Fig.

2) This is especially useful where the stent would normally be removed when the desired reconstruction of the deficient part was completed. Another firm, MoBeta, of Los Altos, Califon-da, devised a method to make stents radioactive so that they could be more easily seen on a radiograph. Early use of Stent’s Name The First World War saw the introduction of trench warfare. Soldiers in the trenches were fairly well protected so long as they stayed below ground level. In order to fire their rifles, however, they had to raise themselves above the edge of the trench, and thus were very susceptible to facial wounds. The number of these disfiguring wounds was staggering, and surgeons had little experience in handling them. One Dutch physician, J. F. Esser, was designated Special Surgeon for Plastic C)operations and assigned to a hospital in Vienna.

In a seminal paper he wrote: In this war I went to Austria to help repair and undo a little part of the cruel mangling that millions of men have produced all over Europe… As I made in Austria over 700 plastic operations on war cripples, I enlarged my practical experience, especially in repairing defects of the face in an important manner .6 He then went on to describe on page 309 how he used “the mould of dentical mass (Stent’s) in fixation of skin grafts in oral surgical repair of war wounds.” This he accomplished by means of what he termed the “epidermic inlay technique” which used Stent’s compound to stretch and fix in place grafts to enlarge the conjunctival fomices, and in ear reconstruction as well as intraoral grafting. Later, on page 311 of the same article he referred to the material he used as “stents mould.” A former English army surgeon, H.D.

Gillies, cited Esser’s work in his 1920 book, Plastic Surgery of the Face, when he wrote “The dental composition for this purpose is that put forward by Stent and a mould composed of it is known as a ‘Stent.”” This is probably the first use of Dr. Stent’s name as a noun. Notwithstanding this very obvious reference to Dr. Stent by one of the first physicians to use a “stent” and to publish a paper regarding how he came to call it that, several medical researchers still are trying to seek a more ancient source for the name. One English physician prefers the Oxford English Dictionary’s definition of a stent as “a stake for stretching out fishing nets upon a river.” To compare this to the use of Stent’s compound as a form around which to build a tube, is stretching things indeed!

15 Another medical researcher tackling this problem of the etymology of the word seems to clinch the case when he wrote “We have been unable to find the word used in medical literature with a lower case “s” before the publication by Esser in 1917, in which the word changes from a capitalized surname to an adjective, to a common noun.”13 The Contribution of Charles Stent In the nineteenth century the principal dental impression materials were bees wax and plaster of Paris. Both had inherent weaknesses; wax distorted upon removal from the mouth, and plaster was very difficult to use. In 1847 the English dentist, Edwin Truman (1819-1905) introduced gutta percha as a denture base. 12 He patented a method of refining this crude form of rubber, and won renown when he suggested using this material as a coating for the undersea Atlantic Cable which had broken several times as a result of corrosion by sea water. His accomplishments led to his appointment as “Dentist to the Royal Household” in 1855.14 Dr.

Truman tried using this gutta-percha material for impression taking, but it was unsatisfactory since it distorted during removal from the mouth and shrank upon cooling. The breakthrough came when the London dentist, Charles Stent (1807-1885) added several other materials to the gutta-percha, notably stearine a substance derived from animal fat which markedly improved the plasticity of the material as well as its stability. He also added talc as an inert filler to give more body to the material, and red coloring. This new material, introduced in 1856, proved so successful that Dr. Stent was hailed by the dental profession. Sir John Tomes, England’s great dental surgeon, lauded him for his contribution at the meeting of the Odontological Society of Great Britain in 1857.2 Dr. Stent had two sons, Charles Robert Stent and Arthur Howard Osborne Stent, who were also practicing dentists. The senior Dr. Stent’s home and dental office was at 21A Coventry Street in the heart of downtown London. Here, assisted by his sons, he began producing his impression compound and marketed it under the firm name C. R.

and A. Stent. In 1885 Dr. Stent, senior, died at the age of 78 and his son Arthur moved back into the family home on Coventry Street. He and his brother, Charles Robert, continued running the business, marketing the compound through the prestigious dental supply company, Claudius Ash and Sons. When these two sons died, around 1900, Ash’s firm purchased all rights to the compound and manufactured it, keeping the Stent name. (Fig. 3) Ash’s catalogue of 1871 listed “Stent’s Impression Compound” at 6 shillings a pound. The 1875 catalogue, however, listed two products, “Stent’s Composition,” which sold in packages of six pounds, at five shillings a pound, and also “Stent’s Improved Composition” which was available in pink, yellow or white, packaged in half pound boxes, and which sold for six shillings a pound.4 Dr. Stent’s invention is but one in a long line of contributions made by dentists, which have benefited patents everywhere, and have advanced not only dentistry, but all of the healing arts. The author wishes to thank Ms.

Linda Lohr, Librarian, History of Medicine, Health Sciences Library, State University of New York at Buffalo, for her assistance in supplying material for this paper. References Bloom, D. A., Clayman, R. V. and McDougal, E. “Stents and Related Terms: A brief History.” Urology, 1991, 54:767-771. A Century of Dental Art: A Centenary Memoir. London, C. Ash and Sons, 1921. Cheng, T. 0. “When a proper noun becomes a common noun.” Amer I Cardiol. 1997, 80: 976. Cohen, R. A., Leamington Spa, England, personal communication, August 14,2000. Dorland’s Illustrated Medical Dictionary. 27th Edition. Philadelphia, Saunders, 1988, p. 1580. Esser, J. F. “Studies in plastic surgery of the face.” Ann Surg 1917, 65: 297-315. Gillies, H. D.

Plastic Surgery of the Face. London, Oxford Univ. Pr, 1920, p. 10. Hedin, M. “The origin of the word stent.” Acta Radiologica, 1997, 38: 937-39. Hogan, J., Bionx Company, personal communication, October 19, 2000. Morgan, B. D. G. and Osborn, R. M. “What’s in a word: The origin of the word ‘stent’.” Ann Royal Coll Surg Eng (Suppl), 1996, 78 :128. 79 Mosby’s Medical, Nursing, and Allied Health Dictionary. Anderson, K. N., Editor. St. Louis, Mosby, 1994. Mulliken, J. B. and Goldwyn, R. M. “Impressions of Charles Stent.” Plast & Reconstr Surg 1978, 62 (2): 173. O’Brien, J. C. jr.

“More on the word “Stent.” Amer I Cardiol 2000,85:919. Ring, M. E. “From the fertile minds of dentist-,.. ” Calif Dent Assn J, 1995, 23(l): 23-28. Sigwart, U. “What is a Stent and where can you get one?” Amer j Cardio, 1997, 80: 1122. Sterioff, S. “Etymology of the word “stent.” Mayo Clin Proc 1997, 72: 377-79. Publications | Pierre Fauchard Academy References by Malvin E. Ring, DDS, MLS, FACD - Stents have been used in numerous medical disciplines, as well as in oral surgical procedures. Uses range from rebuilding mandibles and constructing new ureters, to keeping coronary arteries patent after angioplasty. The earliest use of the word listent" to describe this item was in 1916, when a Dutch plastic surgeon described how he used a dental impression compound as a matrix around which to form tissue in the process of rebuilding a shattered face.

What is generally unknown is that the word "stent" derives from the name of an English dentist, who invented this impression compound in 1856... Stents have been used in numerous medical disciplines, as well as in oral surgical procedures. Uses range from rebuilding mandibles and constructing new ureters, to keeping coronary arteries patent after angioplasty. The earliest use of the word "listent" to describe this item was in 1916, when a Dutch plastic surgeon described how he used a dental impression compound as a matrix around which to form tissue in the process of rebuilding a shattered face. What is generally unknown is that the word "stent" derives from the name of an English dentist, who invented this impression compound in 1856. Ask any informed lay-person what a "stent" is and the answer will generally be "a tube put into a heart artery during ballooning to keep the artery open." Ask a urologist and you'll learn that a stent is used to artificially produce a tube to replace a damaged ureter or other natural conduit.

Radiologists will tell you that it is a device used by them to indicate an interventional device as part of a prosthesis.' Other branches of medicine have their own ideas of what a stent is and what it's used for, but most have no idea from where the name stems. However, some in the medical profession are intrigued with the origin of this word "stent," and numerous articles have been published in medical journals speculating over its origin. Two English surgeons wrote: "On seeing an advertisement for a conference to be held in May, 1996 in Westminster entitled 'The Stent Summit I0 Years of Stenting', the authors were intrigued that the word should become so commonly used in urological, cardiac and vascu-lar surgery to describe the splinting open of a hollow tube or viscus. Is there a relationship and if so, when and how did it develop?"10 The fact that it derives from the name of Charles Stent, an English dentist, would make one think that dental publications would have published some articles about its origin. (Fig. 1) But, to date, only medical journals have done so. This paper, therefore, is an attempt to inform the dental profession about its genesis.

Numerous times in the English language proper nouns have become common words and the word 11 stent" seems to be one such example. There are many others, such as guillotine (after its inventor, the French physician, Guillotin), draconian (after Draco, an Athenian statesman who drew up a severe code of laws), as well as stentorian (after the Greek messenger, Stentor, in the Trojan War, who had the "voice of 50 men") . Stents in Surgical and Medical Practice Mosby's medical dictionary defines a stent as "1. a compound used in making dental impressions and medical molds. 2.

a mold or device made of stent, used in anchoring skin grafts and for supporting body openings and cavities during grafting of vessels and tubes of the body during surgical anastomosis."Il A recent history of medicine describes stents as "custom-built steel or hard plastic tubes [which] can be inserted under angioscopic or ultrasound guidance, to prevent the collapse of blood vessels and ducts."" Dorland's medical dictionary stresses its use as a molded appliance used to hold a graft in place or act as an obturator.' No matter the uses, the term originated with a material devised by a dentist to enable him to more easily secure better and more accurate impressions of the mouth and oral structures.18 Surgeons trained in both England and the United States during the early years of the 20th century were aware of Stent's material and its use in dentistry as well as in plastic surgery. "In the generalized training of surgeons, principles and applications of one specialty merged into another, an outcome that extended Stent's concept and Stent's dressing into other anatomic applications and hence new technologies."16 A cardiac surgeon, T. 0.

Cheng, in commenting on the use of the name Stent as a noun says, "The greatest accolade that can be given to any inventor is to have the initial capital letter dropped from his name, for that is recognition that the word is now in the general language .3 Today stents are used everywhere, and the word stent has now become one of the most commonly used words in a number of medical disciplines. An investigation of MEDLINE searches for the year 1995 listed more than 500 instances in which the word stent appeared in the title or subject heading of a published article! Stents were apparently used in a large variety of procedures including nasal reconstruction; in gynecology, where different ducts and tubes had to be reconstructed; in surgery of the trachea; in plastic surgery, especially in rebuilding of the mandible; and most well-known, in cardiac surgery.1 Stents are now produced commercially by a number of firms and are most commonly made of inert metals. However, a major breakthrough occurred when a new bioabsorbable stent, sold under the trade name SpiroFlo, was introduced in 1992 by the Bionx Company of Blue Bell, Pennsylvania. (Fig.

2) This is especially useful where the stent would normally be removed when the desired reconstruction of the deficient part was completed. Another firm, MoBeta, of Los Altos, Califon-da, devised a method to make stents radioactive so that they could be more easily seen on a radiograph. Early use of Stent's Name The First World War saw the introduction of trench warfare. Soldiers in the trenches were fairly well protected so long as they stayed below ground level. In order to fire their rifles, however, they had to raise themselves above the edge of the trench, and thus were very susceptible to facial wounds. The number of these disfiguring wounds was staggering, and surgeons had little experience in handling them. One Dutch physician, J. F. Esser, was designated Special Surgeon for Plastic C)operations and assigned to a hospital in Vienna. In a seminal paper he wrote: In this war I went to Austria to help repair and undo a little part of the cruel mangling that millions of men have produced all over Europe...

As I made in Austria over 700 plastic operations on war cripples, I enlarged my practical experience, especially in repairing defects of the face in an important manner .6 He then went on to describe on page 309 how he used "the mould of dentical mass (Stent's) in fixation of skin grafts in oral surgical repair of war wounds." This he accomplished by means of what he termed the "epidermic inlay technique" which used Stent's compound to stretch and fix in place grafts to enlarge the conjunctival fomices, and in ear reconstruction as well as intraoral grafting. Later, on page 311 of the same article he referred to the material he used as "stents mould." A former English army surgeon, H.D. Gillies, cited Esser's work in his 1920 book, Plastic Surgery of the Face, when he wrote "The dental composition for this purpose is that put forward by Stent and a mould composed of it is known as a 'Stent."" This is probably the first use of Dr. Stent's name as a noun. Notwithstanding this very obvious reference to Dr.

Stent by one of the first physicians to use a "stent" and to publish a paper regarding how he came to call it that, several medical researchers still are trying to seek a more ancient source for the name. One English physician prefers the Oxford English Dictionary's definition of a stent as "a stake for stretching out fishing nets upon a river." To compare this to the use of Stent's compound as a form around which to build a tube, is stretching things indeed! 15 Another medical researcher tackling this problem of the etymology of the word seems to clinch the case when he wrote "We have been unable to find the word used in medical literature with a lower case "s" before the publication by Esser in 1917, in which the word changes from a capitalized surname to an adjective, to a common noun."13 The Contribution of Charles Stent In the nineteenth century the principal dental impression materials were bees wax and plaster of Paris. Both had inherent weaknesses; wax distorted upon removal from the mouth, and plaster was very difficult to use. In 1847 the English dentist, Edwin Truman (1819-1905) introduced gutta percha as a denture base.

12 He patented a method of refining this crude form of rubber, and won renown when he suggested using this material as a coating for the undersea Atlantic Cable which had broken several times as a result of corrosion by sea water. His accomplishments led to his appointment as "Dentist to the Royal Household" in 1855.14 Dr. Truman tried using this gutta-percha material for impression taking, but it was unsatisfactory since it distorted during removal from the mouth and shrank upon cooling. The breakthrough came when the London dentist, Charles Stent (1807-1885) added several other materials to the gutta-percha, notably stearine a substance derived from animal fat which markedly improved the plasticity of the material as well as its stability. He also added talc as an inert filler to give more body to the material, and red coloring. This new material, introduced in 1856, proved so successful that Dr. Stent was hailed by the dental profession. Sir John Tomes, England's great dental surgeon, lauded him for his contribution at the meeting of the Odontological Society of Great Britain in 1857.2 Dr.

Stent had two sons, Charles Robert Stent and Arthur Howard Osborne Stent, who were also practicing dentists. The senior Dr. Stent's home and dental office was at 21A Coventry Street in the heart of downtown London. Here, assisted by his sons, he began producing his impression compound and marketed it under the firm name C. R. and A. Stent. In 1885 Dr. Stent, senior, died at the age of 78 and his son Arthur moved back into the family home on Coventry Street. He and his brother, Charles Robert, continued running the business, marketing the compound through the prestigious dental supply company, Claudius Ash and Sons. When these two sons died, around 1900, Ash's firm purchased all rights to the compound and manufactured it, keeping the Stent name. (Fig. 3) Ash's catalogue of 1871 listed "Stent's Impression Compound" at 6 shillings a pound.

The 1875 catalogue, however, listed two products, "Stent's Composition," which sold in packages of six pounds, at five shillings a pound, and also "Stent's Improved Composition" which was available in pink, yellow or white, packaged in half pound boxes, and which sold for six shillings a pound.4 Dr. Stent's invention is but one in a long line of contributions made by dentists, which have benefited patents everywhere, and have advanced not only dentistry, but all of the healing arts. The author wishes to thank Ms. Linda Lohr, Librarian, History of Medicine, Health Sciences Library, State University of New York at Buffalo, for her assistance in supplying material for this paper. References Bloom, D. A., Clayman, R. V. and McDougal, E. "Stents and Related Terms: A brief History." Urology, 1991, 54:767-771. A Century of Dental Art: A Centenary Memoir. London, C. Ash and Sons, 1921. Cheng, T. 0.

"When a proper noun becomes a common noun." Amer I Cardiol. 1997, 80: 976. Cohen, R. A., Leamington Spa, England, personal communication, August 14,2000. Dorland's Illustrated Medical Dictionary. 27th Edition. Philadelphia, Saunders, 1988, p. 1580. Esser, J. F. "Studies in plastic surgery of the face." Ann Surg 1917, 65: 297-315. Gillies, H. D. Plastic Surgery of the Face. London, Oxford Univ. Pr, 1920, p. 10. Hedin, M. "The origin of the word stent." Acta Radiologica, 1997, 38: 937-39. Hogan, J., Bionx Company, personal communication, October 19, 2000. Morgan, B. D. G. and Osborn, R. M.

"What's in a word: The origin of the word 'stent'." Ann Royal Coll Surg Eng (Suppl), 1996, 78 :128. 79 Mosby's Medical, Nursing, and Allied Health Dictionary. Anderson, K. N., Editor. St. Louis, Mosby, 1994. Mulliken, J. B. and Goldwyn, R. M. "Impressions of Charles Stent." Plast & Reconstr Surg 1978, 62 (2): 173. O'Brien, J. C. jr. "More on the word "Stent." Amer I Cardiol 2000,85:919. Ring, M. E. "From the fertile minds of dentist-,.. " Calif Dent Assn J, 1995, 23(l): 23-28. Sigwart, U. "What is a Stent and where can you get one?" Amer j Cardio, 1997, 80: 1122. Sterioff, S.

"Etymology of the word "stent." Mayo Clin Proc 1997, 72: 377-79. Van Urk, H. "Repairing the body" in Duin, N. and Sutcliffe J. A History of Medicine from Prehistory to the Year 2020. London, Morgan Samuel, 1992, p. 235. Ward, G. "Impression materials and impression taking." Brit Dent j 1961,110: 118-119. DR. RING is author of Dentistry An illustrated History. Requests for reprints should be directed to the author at 2 Roby Drive, Rochester, NY 14618. Article orginally published in the Journal of the History of Dentistry Vol. 49, No. 2/July 2001 copyright ©2001, all rights reserved SUBMISSION GUIDELINES Submission of photos and articles about Section activities are accepted for possible publication in the Dental World. Please contact the Editor for more information.

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Question: Charles Stent practised what surgery, for which he invented his eponymous technique?
Answer: Dental