Dental caries and calculus in an early medieval population of Prząsław (11-12 th century), Jędrzejów municipality, Świętokrzyskie province, Poland

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1 CHAPTER II HEALTH AND WELLNESS 2/2015 WELLNESS AND SOCIETY 1 Department of Normal Human Anatomy, Wrocław Medical University, Wrocław, Poland Katedra i Zakład Anatomii Prawidłowej Uniwersytetu Medycznego we Wrocławiu 2 Department of Dental Anatomy, Wrocław Medical University, Wrocław, Poland Zakład Anatomii Stomatologicznej Uniwersytetu Medycznego we Wrocławiu PAWEŁ DĄBROWSKI 1, ZYGMUT DOMAGAŁA 1, WIESŁAW KURLEJ 2, BOŻENA KURC-DARAK 2, MICHAŁ PORWOLIK 1, SŁAWOMIR WOŹNIAK 1, RYSZARD KACAŁA 1, PIOTR CHMIELEWSKI 1, ALEKSANDRA KOTYLAK 1, BOHDAN GWORYS 1 Dental caries and calculus in an early medieval population of Prząsław (11-12 th 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

2 HEALTH AND WELLNESS 2/2015 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 (11-12 th 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 NW- SE 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

3 Paweł Dąbrowski, Zygmut Domagała, Wiesław Kurlej, Bożena Kurc-Darak, Michał Porwolik, Sławomir Woźniak, Ryszard Kacała, Piotr Chmielewski, Aleksandra Kotylak, Bohdan Gworys Dental caries and calculus in an early medieval population 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 11 th and 12 th 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

4 HEALTH AND WELLNESS 2/2015 Wellness and society 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 (11-12 th cent.) (after Dąbrowski et al. 2014) Sex Male Female Unidentified Total Infans I Infans II Juvenis Adultus Maturus 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

5 Paweł Dąbrowski, Zygmut Domagała, Wiesław Kurlej, Bożena Kurc-Darak, Michał Porwolik, Sławomir Woźniak, Ryszard Kacała, Piotr Chmielewski, Aleksandra Kotylak, Bohdan Gworys Dental caries and calculus in an early medieval population of Prząsław (11-12th century), Jędrzejów municipality, Świętokrzyskie province, 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

6 HEALTH AND WELLNESS 2/2015 Wellness and society 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 STATIS- TICA 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]. 28 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

7 Paweł Dąbrowski, Zygmut Domagała, Wiesław Kurlej, Bożena Kurc-Darak, Michał Porwolik, Sławomir Woźniak, Ryszard Kacała, Piotr Chmielewski, Aleksandra Kotylak, Bohdan Gworys Dental caries and calculus in an early medieval population of Prząsław (11-12th century), Jędrzejów municipality, Świętokrzyskie province, 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 (11-12 th cent.) Degree Sex of wear Male Female Total 1 no wear % P* % % 2 - mild % 1***,3***, P** % 1***,3*** % 1***,3*** 3 - severe % 1**,2***, P* % 1**,2*** % 1***,2*** Total 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 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 (11-12 th cent.) Sex Male Female Incidence % 15/22 13/19 (68.18%) (68.42%) NS difference not statistically significant Total 28/41 (68.29%) Male vs Female 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). NS 29

8 HEALTH AND WELLNESS 2/2015 Wellness and society Table IV. Intensity of caries in adult individuals from medieval Prząsław (11-12 th cent.) vs other urban populations Wrocław St. Elizabeth s Compo- Church (13-14 cent.) Prząsław (11-12 cent) Sypniewo (11-12 cent.) nent of the and Wrocław Ołbin index of (12-13 cent.) caries Sex Male Sex Sex intensity vs Female Male Female Male Female Total Total Male Female Total A E %E NS 12.88% % % % % % % % % Z C %C % NS 25.48% % % % % % % 16.74% %E + %C % p= % % % % % % % 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 (11-12 th cent.) and cemeteries in Wrocław: St. Elizabeth s Church (13-14 th cent.), and Ołbin (12-13 th 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 (11-12 th cent.) Calculus Sex Male Female Total Degree % 2***,4***, % 2**,3***, 2***,3***, % P** 4*** 4*** Degree 2 1 3***,4***, 50.39% 96 P* % 3***,4*** % 3***,4*** Degree % 4***,P* % 4* % 4*** No calculus % P* % % Total 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<

9 Paweł Dąbrowski, Zygmut Domagała, Wiesław Kurlej, Bożena Kurc-Darak, Michał Porwolik, Sławomir Woźniak, Ryszard Kacała, Piotr Chmielewski, Aleksandra Kotylak, Bohdan Gworys Dental caries and calculus in an early medieval population of Prząsław (11-12th century), Jędrzejów municipality, Świętokrzyskie province, 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 11 th and 15 th centuries (Tab. 6). 31

10 HEALTH AND WELLNESS 2/2015 Wellness and society Table VI. Incidence of caries in selected urban and rural populations between the 11 th and 14 th cent. in Poland 32 Period (century) Site N n Incidence % 11-12* Prząsław % 13-14** Wrocław, St. Elizabeth s Church % 12-13** Wrocław, Ołbin % 13-15** Wrocław, St. Jacob s Church % 15-16** Wrocław, St. Christopher s Church % 14-18*** Kołobrzeg, Collegiate Church % 11-12* Tomice % 15-16* Pawłów % 11-13* Sypniewo % 13-15* Gródek n. Bugiem % * - 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 th cent., and Wrocław th 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].

11 Paweł Dąbrowski, Zygmut Domagała, Wiesław Kurlej, Bożena Kurc-Darak, Michał Porwolik, Sławomir Woźniak, Ryszard Kacała, Piotr Chmielewski, Aleksandra Kotylak, Bohdan Gworys Dental caries and calculus in an early medieval population of Prząsław (11-12th century), Jędrzejów municipality, Świętokrzyskie province, 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. REFERENCES 1. Acsădi G., Nemesceri J.: History of Human Life Span and Mortality. Akademia Kiado, Budapest Belcastro G., Rastelli E., Mariotti V., Consiglio C., Facchini F., Bonfiglioli B.: Continuity and discontinuity of the life-style in central Italy during the Roman 33

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15 Paweł Dąbrowski, Zygmut Domagała, Wiesław Kurlej, Bożena Kurc-Darak, Michał Porwolik, Sławomir Woźniak, Ryszard Kacała, Piotr Chmielewski, Aleksandra Kotylak, Bohdan Gworys Dental caries and calculus in an early medieval population of Prząsław (11-12th century), Jędrzejów municipality, Świętokrzyskie province, Poland 42. Vodanović M, Brkic H, Šlaus M, Demo Z.: The frequency and distribution of caries in the mediaeval population of Bijelo Brdo in Croatia (10th 11th century), Archives of Oral Biology, 2005, 50: Walker A., Hoeck H. N., Perez L: Microwear of mammalian teeth as an indicator of diet, Science, 1978, 201, White D. J.: Dental calculus: recent insights into occurrence, formation, prevention, removal and oral health effects of supragingival and subgingival deposits, European Journal of Orthodontics, 1997, 105: White T. D., Folkens P. A.: The Human Bone Manual, Elsevier Academic Press, Oxford, Zoll-Adamikowa,H.:Wczesnośredniowieczne cmentarzyska szkieletowe Małopolski, Cz. II Analiza, Polska Akademia Nauk. Oddział w Krakowie. Prace Komisji Archeologioznej, 1971,11. 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

16 HEALTH AND WELLNESS 2/2015 Wellness and society średnio zaawansowanej postaci. Silnie rozbudowane złogi mineralne występowały istotnie częściej u mężczyzn ( 20,6%) niż u kobiet (14%). Artykuł zawiera znaków ze spacjami 38