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HEALTH AND WELLNESS 2/2015
WELLNESS AND SOCIETY
CHAPTER II
Department of Normal Human Anatomy, Wrocław Medical University,
Wrocław, Poland
Katedra i Zakład Anatomii Prawidłowej
Uniwersytetu Medycznego we Wrocławiu
1
2
Department of Dental Anatomy, Wrocław Medical University,
Wrocław, Poland
Zakład Anatomii Stomatologicznej
Uniwersytetu Medycznego we Wrocławiu
PAWEŁ DĄBROWSKI1, ZYGMUT DOMAGAŁA1,
WIESŁAW KURLEJ2, BOŻENA KURC-DARAK2,
MICHAŁ PORWOLIK1, SŁAWOMIR WOŹNIAK1,
RYSZARD KACAŁA1, PIOTR CHMIELEWSKI1,
ALEKSANDRA KOTYLAK1, BOHDAN GWORYS1
Dental caries and calculus in an early medieval population
of Prząsław (11-12th century), Jędrzejów municipality,
Świętokrzyskie province, Poland
Próchnica zębów i kamień nazębny we wczesnośredniowiecznej
populacji z Prząsławia (XI - XII w.), gm. Jędrzejów,
woj. Świętokrzyskie, Polska
Key words: dental caries, calculus, oral hygiene, early medieval period
słowa kluczowe: próchnica zębów, kamień nazębny, higiena zębów, wczesne średniowiecze
INTRODUCTION
Odontological analysis is one of the methods for assessing health and dietary habits, and, indirectly, the living conditions characteristic for historical human populations. Macroscopic analysis is usually focused on the quantitative indicators of physiological stress detectable on the surface of tooth crowns, epidemiological indicators
of caries and its complications, as well as indices of oral hygiene recommended by
Wellness and society
WHO and adapted for the purposes of paleoanthropological studies [7,19]. The determination of the type and size of mineral deposits, and measurements of alveolar atrophy are very useful in the assessment of health-related behaviours [18,41]. The reconstruction of diet and the degree of food refinement requires a microscopic analysis
(SEM) of superficial minor injuries on the enamel of crowns [e.g. 43].
Dental caries is the most widespread disease of the masticator organ identified in
historical populations. It is defined as a pathological process involving hard dental
tissues such as enamel, dentine and cementum, characterized by demineralization of
these structures [23,27]. The main etiological factors responsible for caries are acidic
bacterial metabolites, especially those produced by Lactobacillus acidophilus and
Streptococcus mutans during the incomplete aerobic fermentation of carbohydrates
[e.g. 12]. The formation of carious cavities on the tooth surface or an exposed part of
the root is usually preceded by the deposition of calculus. Other important factors
contributing to the formation of cavities are congenital and/or acquired defects of hard
dental tissues and the associated areas of poor mineralisation [16,23]. Other causes of
tooth loss include: chronic periodontitis, often caused by the presence of mineralized
calculus, periapical inflammatory lesions, attrition of crowns and injuries [8,11,17].
Under fossilized conditions teeth, the hardest parts of the human skeleton, are preserved unchanged and do not undergo remodelling at the site of their deposition
[7,19]. Human dentition may therefore be the major source of information on the
health status, hygiene, living conditions and diet of historical human populations [e.g.
13, 23, 42, 45].
The aim of the study was to carry out a macroscopic analysis and identify the
incidence rate of carious lesions and their complications in men and women, expressed by epidemiological indicators, i.e. the frequency and intensity of caries and
the size of mineral deposits (calculus) reflecting oral hygiene in a population buried
at the cemetery in Prząsław (11-12th cent.).
MATERIAL
Bone material was excavated from 50 graves identified at the archaeological site
Prząsław 1, Central-Eastern Poland, Świętokrzyskie province, Jędrzejów municipality
(Fig. 1). The relatively well preserved skeletons inside graves were in an anatomical
arrangement of bones along the E-W axis, with a slight dislocation towards the NWSE axis. The material for analyses was provided by the archaeological company
ARKADIA, with its registered office in Leszno, Wielkopolskie province, Western
Poland, cooperating in the field of anthropological and paleoanatomical research with
the Laboratory of Paleoanatomy, Department of Normal Human Anatomy, Wrocław
Medical University. The preservation status and general biological characteristics of
the bone material were presented in an odontological report on enamel hypoplasia in
adult individuals from Prząsław [9].
24
Paweł Dąbrowski, Zygmut Domagała, Wiesław Kurlej, Bożena Kurc-Darak,
Michał Porwolik, Sławomir Woźniak, Ryszard Kacała, Piotr Chmielewski,
Aleksandra Kotylak, Bohdan Gworys
of Prząsław (11-12th century), Jędrzejów municipality, Świętokrzyskie province,
Poland
Figure 1. Location of the archaeological site Prząsław 1, Jędrzejów municipality,
Świętokrzyskie province
The cemetery in Prząsław was used in the 11th and 12th centuries, as indicated by
items found in graves: iron knives, glass beads, temple rings and pendants, typical for
early-Christian burial practices and identified in many other archaeological sites in
Poland (Fig. 2) [e.g. 3, 29, 36, 46].
25
Figure 2. Grave no. 24, fragments of the skeleton in the anatomical arrangement
of bones and grave goods – iron knife, Prząsław 1 site. (phot. by K. Nowaczyk)
Information on sex and age structure was derived from a previously published paper by Dąbrowski et al [9]. The analysis included teeth from 41 excavated adult skeletons (22 male and 19 female). Initial analysis was also carried out for teeth from 9
individuals classified as subadultus (Tab. 1).
Table I. Sex and age structure of skeletal material found at the cemetery in
Prząsław (11-12th cent.) (after Dąbrowski et al. 2014)
Male
Sex
Female
Unidentified
Infans I
-
-
5
5
Infans II
-
-
2
2
Juvenis
1
1
-
2
Adultus
17
13
-
30
Maturus
5
6
-
11
Total
23
20
7
50
Total
Dental analysis included 784 permanent teeth (38 from juvenis, 577 from adultus,
and 169 from maturus). The preservation of teeth in terms of mechanical injuries of
crown surface allowed for the assessment of carious lesions involving enamel and
roots. The degree of functional tooth wear, determining the suitability of material for
26
Poland
further analysis, was established for all teeth on their examination in alveoli (727).
Further analysis, focused on the incidence of carious lesions, was carried out only on
the dental material from male and female skeletons classified as adultus and maturus.
METHODS
The sex and age-at-death of adult individuals were estimated based on the popular
skeletal and dental sets of diagnostic features [1, 7, 19, 25, 31, 33, 37]. Paleodontological analysis was carried out on teeth with the preserved crown and root, characterised by mild functional wear (Fig. 3). The degree of tooth wear was estimated according to a classification by Smith [after 19] using a simplified 3-degree scoring
variant. All teeth in alveoli and separated from dental arches (loose) were examined
using a mouth mirror and a dental probe (WHO). The examination of carious lesions
in the material from the population of Prząsław included the location, type and advancement of cavities in hard dental tissues, followed by the calculation of indices of
caries frequency [19, 20] and intensity - Stloukal index [after 6].
Grave no. 20
Figure 3. Grave no. 20. Preserved occlusal surface and deep caries on the occlusal
surface of M3, the right side of the mandible (phot. by P. Dąbrowski)
27
The Stloukal index considers the observed state of normal crowns and those affected by caries, as well as the state of alveoli after antemortem and postmortem tooth
loss. The components of the Stloukal index include (capital letters): A – dental alveoli
with teeth remaining and dental alveoli of teeth lost antemortem and postmortem, as
well as unerupted teeth available for examination, E – teeth lost antemortem, %E –
percentage of teeth lost antemortem in comparison to all examined teeth, Z – number
of teeth available for examination, C – number of teeth affected by caries, %C – percentage of teeth with caries in comparison to the total number of examined teeth, %E
+ %C – caries intensity index. The stage of caries was assessed using generally accepted clinical criteria [12, 34] (Fig. 4):
P1 – incipient caries – limited discolouration of enamel without enamel loss and
superficial caries – enamel lesion; P2 – moderate caries – cavity in enamel and superficial part of dentine; P3 – deep caries – cavity in enamel and dentine reaching the
pulp chamber.
Grave no. 32
Figure 4. Grave no. 32. Wear of crowns and deep carious cavity in M2, right side
of the maxillary arch (phot. by P. Dąbrowski)
The level of oral hygiene was assessed based on calculus deposition according to
a 4-degree scoring system by Brothwell [after 19]: 0 – no calculus, 1 – mild calculus,
up to 1 mm, 2 – moderate calculus, up to 1/2 of the crown height, 3 – abundant calculus, over 1/2 of the crown height. Statistical analysis was carried out using a STATISTICA 10.0. PL package (Statsoft, Inc. Tulsa, USA). Qualitative features were analysed using a test for two structural parameters (proportion) and the chi 2 test. The
statistical significance was adopted at p<0.05 [39].
RESULTS
Among the teeth remaining in dental alveoli on examination, the test for two structural parameters demonstrated a significantly greater number of teeth with mild wear
28
Poland
of crown (ca. 70%), which in further analysis allowed for the identification of carious
lesions located on the occlusal surface. The analysis also demonstrated a significantly
lower percentage of teeth with severe wear (ca. 19%) (Tab. 2). No tooth wear was
mainly identified in teeth from younger age categories and in recently erupted teeth,
particularly third molars.
Table II. Degree of tooth wear in permanent dentition from male and female
individuals from Prząsław (11-12th cent.)
Sex
Total
Male
Female
54 13.43%
P*
28 8.62%
82 11.28%
1***,3***,
2 - mild 262 65.17%
246 75.69% 1***,3*** 508 69.88% 1***,3***
P**
1**,2***,
3 - severe 86 21.39%
51 15.69% 1**,2*** 137 18.84% 1***,2***
P*
Total
402
325
727
1 – difference vs degree 1; 2 – difference vs degree 2; 3 – difference vs degree 3; P – difference
between sexes; * - p<0.05; ** - p<0.01;*** - p<0.001
Degree
of wear
1 no wear
In both sexes the same trend was observed, although no wear or severe tooth wear
was identified more frequently in male individuals than in females. The differences
were statistically significant (22% vs ca. 16%; p<0.05 for severe wear and 13% vs 9%
for no wear).The incidence rate of caries in the analysed population of Prząsław was
similar in both sexes (Tab. 3).
Table III. Incidence of caries in the population of Prząsław (11-12th cent.)
Sex
Total
Male
Female
Incidence %
15/22
13/19
28/41
(68.18%) (68.42%) (68.29%)
NS – difference not statistically significant
Male vs
Female
NS
Data analysis using the test for two structural parameters did not demonstrate any
statistically significant differences between sexes in the incidence of caries, similar to
the distribution of values for the Stloukal index reflecting the intensity of caries. Analysis of caries incidence expressed by the components of the Stloukal index showed
no statistically significant differences between sexes for values %E and %C, although
the intensity of caries in dental material from male individuals was slightly greater
(ca. 14%) than in females (ca. 13%). Differences in the values of %E + %C between
sexes were at the limit of statistical significance, which may indicate a trend towards
more advanced caries in males when compared to females from medieval Prząsław
(Tab. 4).
29
Table IV. Intensity of caries in adult individuals from medieval Prząsław (11-12th
cent.) vs other urban populations
Component of the
index of
caries
intensity
Prząsław (11- 12 cent)
Sex
Sypniewo (11-12 cent.)
Wrocław – St. Elizabeth’s
Church (13-14 cent.)
and Wrocław – Ołbin
(12-13 cent.)
Sex
Sex
Male
vs FeTotal
Male Female Total male Male Female
Male Female Total
A
644
518 1162
542
320
862
657
460
1117
E
41
23
64
79
32
111
56
53
109
6.37 4.44 5.51
14.58 10.00
8.52
11.52
9.76
%E
NS
12.88%
%
%
%
%
%
%
%
%
Z
396
350
746
158
101
259
322
150
472
C
57
45
102
35
31
66
47
32
79
14.39 12.86
22.15 30.69
14.60
21.33
%C
13.67% NS
25.48%
16.74%
%
%
%
%
%
%
20.76 17.30
36.73 40.69
23.12
32.85
%E + %C
19.18% p=0.06
38.36%
26.50%
%
%
%
%
%
%
A – dental alveoli with teeth remaining and dental alveoli of teeth lost antemortem and postmortem plus unerupted teeth; E – teeth lost antemortem, Z – number of teeth available for
examination; C – number of teeth affected by caries; %E – percentage of teeth lost antemortem
in comparison to all examined alveoli, %C – percentage of teeth with caries in comparison to
the total number of examined teeth; p - level of statistical significance; NS – difference not
statistically significant
The opposite trend was found in medieval skeletal series from Poland: Sypniewo
(11-12th cent.) and cemeteries in Wrocław: St. Elizabeth’s Church (13-14th cent.), and
Ołbin (12-13th cent.) (Tab. 4). The postmortem assessment of the size of mineral deposits on tooth crowns is an indicator of oral hygiene, type of diet and health-related
behaviours in male and female representatives of the analysed population.
Table V. Presence of calculus in the population of Prząsław (11-12th cent.)
Calculus
Degree 1 93
Sex
Total
Male
Female
2***,4***,
2**,3***,
2***,3***,
23.91%
133 33.67%
226 28.83%
P**
4***
4***
3***,4***,
50.39%
170 43.04% 3***,4*** 366 46.68% 3***,4***
P*
20.57% 4***,P*
55 13.92%
4*
135 17.22%
4***
1
96
Degree 3 80
No
20 5.14%
P*
37 9.37%
57 7.27%
calculus
Total 389
395
784
1 – difference vs degree 1; 2- difference vs degree 2; 3 – difference vs degree 3; 4 – difference
vs degree 4 (no calculus); P – difference between sexes; * - p<0.05; ** - p<0.01; *** - p<0.001
Degree 2
30
Poland
The mean incidence of calculus in the whole analysed odontological material was
close to 93% (95% for males vs 91% for females) (Tab. 5). In both sexes calculus was
usually in the form of mineralised deposits reaching up to a half of the crown height degree 2 (50% for males vs 43% for females). Differences in the frequency of this
degree of calculus were statistically significant. Mild calculus (degree 1) was more
frequent in males than in females and the difference was statistically significant.
Abundant calculus (degree 3), reaching over a half of the tooth crown height was
found with the lowest frequency in the whole material, but this type of calculus was
more frequent in males (ca. 21%) than in females (ca. 14%). Differences in the frequency of abundant calculus between the sexes were statistically significant.
DISCUSSION
Dentition is a particularly useful part of the skeleton in studies on the health and
economic status of historical human populations [e.g. 11, 19, 21]. The analysis of
fossilized bone material for the incidence and severity of dental diseases may be associated with interpretation problems resulting from either antemortem of postmortem
loss of teeth, as well as various degrees of mechanical injuries to the crowns, including
the level of functional wear of enamel. The antemortem tooth loss alone does not
indicate the cause for partial or total edentulism, although in the medieval period the
major factors responsible for this were carious lesions and periodontal diseases [e.g.
19, 26, 27]. Nevertheless, the number of teeth lost antemortem significantly influences
the final score of caries intensity.
Another important parameter in the assessment of caries intensity is the preservation status of the crowns. The severe wear of crowns may affect the assessment of
caries intensity in the analysed odontological material and result in underestimation
of the number, types and location of lesions in various age and sex groups. Paleodontological analysis of the fossilized material from Prząsław was carried out on teeth
with various stages of wear caused by attrition and the refinement and quality of food
[11, 19, 28;30]. We found a statistically significantly higher number of crowns with
mild wear (ca. 70%), which helped to validate the assessment of caries incidence in
the population from Prząsław. Due to the limited amount of dental material, further
macroscopic analysis also included teeth with greater degrees of crown wear.
The incidence of carious lesions in the population from Prząsław was assessed
using two popular paleoanthropological indices, i.e. caries frequency and intensity
according to Stloukal, in which oral health is scored based on the number of remaining
teeth and those lost antemortem [4,6]. The incidence of caries measured in the representatives of historical populations changes not only depending on historical periods,
increasing from the early Middle Ages to modern times, but also depending on the
type of urban environment [23]. In the early medieval population of Prząsław the incidence of caries was 68%, which is similar to rates identified in adults from other
rural and urban populations between the 11th and 15th centuries (Tab. 6).
31
Table VI. Incidence of caries in selected urban and rural populations between
the 11th and 14th cent. in Poland
Period
(century)
11-12*
Site
N
n
Incidence %
41
28
68.3%
64
58
91.0%
59
52
88.0%
66
47
71.0%
27
19
70.0%
269
211
78.0%
11-12*
Prząsław
Wrocław, St. Elizabeth’s
Church
Wrocław, Ołbin
Wrocław, St. Jacob’s
Church
Wrocław, St. Christopher’s
Church
Kołobrzeg, Collegiate
Church
Tomice
42
27
64.0%
15-16*
Pawłów
51
35
69.0%
11-13*
Sypniewo
112
73
65.0%
13-14**
12-13**
13-15**
15-16**
14-18***
13-15*
Gródek n. Bugiem
196
132
67.0%
* - author’s own data, ** - Kwiatkowska 2005, *** - Borysewicz, Otocki 1975
A higher incidence of caries was found for urban populations (70% to 91%). Many
researchers claimed that the effects of epidemiological factors are linked with socioeconomical factors in diversified urban populations. The compared rural and urban
populations differed in terms of economic status, living conditions and, most importantly, population rate, which is a strong modifier of the generally defined quality
of life [e.g. 13,14,24]. Urban environments are characterised by poorer hygiene and
increased incidence of diseases, but also different nutritional habits because of the
specific quality of the diet and cooking techniques [e.g. 4, 13, 22, 38]. The analysis of
caries intensity based on the Stloukal index did not demonstrate statistically significant differences between male and female individuals from the population of
Prząsław, although caries was slightly more frequent in males (Tab.4). This may be
explained by cultural, social and behavioural factors, as well as a lack of health awareness in men [22]. Novak et al. [32] suggested that the higher frequency of caries in
men was caused by their greater involvement in economic life, resulting from the social role and status of men, e.g. predisposition to hard physical work, which ensured
easier access to food in comparison to women. However, the values of the Stloukal
index in other skeletal series compared in Table 4 (Sypniewo 11-12th cent., and
Wrocław 12–14th cent.), show a reverse trend. Many authors attributed the higher incidence of caries in women to, e.g. physiological stress caused by pregnancy, breast
feeding, hormonal changes, reduced secretion of saliva and nutritional habits, including the consumption of refined foods rich in starch [e.g. 4, 6, 11, 24].
32
Poland
Studies on the incidence of caries help to reconstruct diet, nutritional habits and
health-related behaviours in historical populations, while information on the oral hygiene of historical populations can be directly obtained based on the presence of mineralised deposits (calculus). In some cases, however, the assessment of calculus may
be biased by accidental mechanical removal of the deposit during the excavation of
the skeletal material [2, 16,18]. Calculus may also result from a protein-rich diet [2,10,
44]. In our study mineralised deposits were identified in 93% of the analysed teeth
and were more frequent in male than in female individuals (moderate and abundant
calculus). Greater incidence of mild calculus is usually identified in women [16, 35,
40]. Analysis of dentition from the medieval population of Prząsław supports this theory. Higher incidence of calculus in men, especially in the abundant form, may be
associated with their higher social status and, indirectly, better living conditions, including type of consumed food and better nourishment [e.g. 2]. The high incidence of
calculus in prehistoric and historical populations was indicated in other studies [e.g.
2, 35, 40]. Supragingival and subgingival calculus promotes the development of gingivitis and periodontitis, which in consequence may lead to the atrophy of dental alveoli and tooth loss for non-carious reasons [10,42].
CONCLUSIONS
Findings on the frequency of caries and level of oral hygiene in adult individuals
from medieval Prząsław, despite the limited amount of material available for the analysis, suggests that factors affecting the living conditions and, indirectly, health of the
population did not differ substantially from those identified in other medieval rural
and/or urban populations in Poland. Macroscopic examinations of all scoring stages
of the analysed features were possible due to the moderate wear of the crowns. Greater
overload of the masticator organ, reflected in severe wear of crowns was found in
male individuals. The incidence rate of caries in the analysed population (68%) may
indicate that diet and hygiene, and, indirectly, cultural and social relations, in Prząsław
were similar to those in other rural and/or urban medieval populations, but the epidemiological status expressed by the Stloukal index shows better health of the masticator
organ in the studied individuals from Prząsław when compared to urban populations.
The study revealed a lower level of oral hygiene and better nourishment in adult
males, as indicated by the scores for the dental calculus in the supragingival area.
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ABSTRACT
The aim of the study was to assess the incidence of caries and calculus in a population buried at a cemetery in Prząsław (11-12th cent.), Jędrzejów municipality,
Świętokrzyskie province, Poland. The analysis was carried out on 784 permanent
teeth (38 from juvenis, 577 from adultus and 169 from maturus individuals). Moderate
degree of tooth wear was most frequent (ca. 70%). Severe tooth wear was more frequent in males than in females (22% vs. ca. 16%; p<0.05). The incidence of caries
was 68%. Caries intensity in the population from Prząsław is lower (index E%+C%=
19%) in comparison to other medieval urban populations. In most individuals calculus
was in the moderate form. There was a statistically significant dimorphic difference
in the frequency of abundant calculus (20.6% in men vs. 14% in women).
STRESZCZENIE
Celem badawczym była ocena występowania próchnicy zębów oraz złogów mineralnych u ludności pochowanej na cmentarzysku w Prząsławiu (XI - XII w.), gmina
Jędrzejów, województwo świętokrzyskie, Polska. Przebadano łącznie 784 zęby stałe,
w tym 38 osobników w wieku juvenis, 577 osobników w wieku adultus i 169 osobników w wieku maturus. Najczęściej pojawiał się umiarkowany stopień starcia (
blisko 70%). Stwierdzono przewagę silnego starcia koron u mężczyzn w stosunku do
kobiet (22% do ok. 16%; p<0.05). Zapadalność na próchnicę wyniosła 68%.
Mieszkańcy Prząsławia charakteryzują się niższym stanem epidemiologicznym
próchnicy (wsk. E%+C%= 19%) w porównaniu do przedstawicieli innych średniowiecznych środowisk urbanistycznych. Kamień nazębny najczęściej występował w
37
średnio zaawansowanej postaci. Silnie rozbudowane złogi mineralne występowały istotnie częściej u mężczyzn ( 20,6%) niż u kobiet (14%).
Artykuł zawiera 31620 znaków ze spacjami
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Artykuł zawiera 31620 znaków ze spacjami

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