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Recording Dental Caries in Archaeological Human Remains, Hillson. 2001

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Recording Dental Caries in Archaeological Human Remains, Hillson. 2001

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International Journal of Osteoarchaeology

Int. J. Osteoarchaeol. 11: 249 – 289 (2001)

DOI: 10.1002/oa.538

Recording Dental Caries in Archaeological

Human Remains
SIMON HILLSON*
Institute of Archaeology, University College London, 31 – 34 Gordon Square,
London WC1H 0PY, UK

ABSTRACT Dental caries is an important condition to record in archaeological collections, but the way in
which recording is carried out has a large effect on the way in which the results can be
interpreted. In living populations, dental caries is a disease that shows a strong relationship with
age. Both the nature of carious lesions and their frequency change with successive age groups
from childhood to elderly adulthood. There is also a progression in the particular teeth in the
dentition which are most commonly affected and, in general, the molars and premolars are
involved much more frequently than the canines and incisors. Lower teeth are usually affected
more than upper, although the condition usually involves the right and left sides fairly equally. In
the high tooth wear rate populations represented by many archaeological and museum
collections, there is a complex relationship between the form of lesions and the state of wear,
which adds yet another range of factors to the changing pattern of caries with increasing age. In
the same populations, chipping, fracture and anomalous abrasion of teeth are also common, and
these contribute similarly to the distribution and forms of carious lesion observed. Amongst the
living, the pattern of ante-mortem tooth loss is important in understanding caries and, in
archaeological material, there is also the complicating factor of post-mortem tooth loss. Finally,
there is the question of diagnosis. There are diagnostic problems even in epidemiological studies
of living patients and, for archaeological specimens, diagenetic change and the variable
preservation of different parts of the dentition add further complications. For all these reasons, it
is difficult to define any one general index of dental caries to represent the complete dentition of
each individual, which would be universally suitable for studying a full range of collections from
archaeological sites or museums. Variation in the nature of collections, their preservation, tooth
wear, and ante-mortem and post-mortem tooth loss mean that when such a general index
appears to differ between sites, there could be many other reasons for this, in addition to any
genuine differences in caries incidence and pattern that might have been present. It is suggested
here that the best approach is instead to make comparisons separately for each tooth type, age
group, sex, lesion type and potential lesion site on the tooth. Copyright © 2001 John Wiley &
Sons, Ltd.

Key words: dental caries; recording schemes; epidemiology; periapical inflammation; dental
wear

Introduction alist lifeways (Lubell et al., 1994). In addition, it

is one of the few conditions which has been
Alongside the pattern of dental attrition and recorded unfailingly in almost all reports on
analysis of stable isotopes, dental caries epi- human remains from archaeological sites (Rose
demiology is one of the most important ways in et al., 1991). The difficulty is that methods used
which the diet of past populations can be recon- for diagnosis and recording dental status gener-
structed. It is fundamental to the understanding ally have lacked consistency, and also have
of transitions from hunter-gatherer to agricultur- often not provided enough detail to allow
proper interpretation. It is only in the last 30
years that such detail has been recorded in any
* Correspondence to: Institute of Archaeology, University College
London, 31 – 34 Gordon Square, London WC1H 0PY, UK. studies at all. A large step towards improving
E-mail: [email protected] the situation has been taken in the so-called
Copyright © 2001 John Wiley & Sons, Ltd. Received 27 January 2000
Accepted 3 March 2000
250 S. Hillson

Chicago Standards (Buikstra & Ubelaker, 1994)

for data collection which adopted the scheme of
Moore & Corbett (1971). Yet caries epidemiol-
ogy is difficult enough even amongst the living,
and there is a need for continued debate on
methods for recording and quantifying caries in
archaeology.

The natural history and different forms of caries

It has been common practice to record dental
caries simply as present or absent for each
tooth, but the condition may be initiated in
different positions on the tooth surface, to pro-
duce several classes of lesion with different
aetiologies: Figure 1. Carious lesion in the central fossa and distal fossa of
the occlusal surface of a lower first molar crown. The lesions
Coronal caries. Carious lesions initiated in the have progressed to the stage at which large cavities have
enamel of the crown surface can be grouped been formed, involving the underlying dentine and, probably,
together as coronal caries. As the lesions the pulp chamber. The cusps of the crown have been worn by
dental attrition to expose small areas of the underlying dentine,
develop, they involve the dentine, which so what appears to be active caries is co-existing with moder-
forms the main structure of the tooth under- ately severe tooth wear. This specimen (and those of all the
lying the enamel, and the character of the following figures) comes from the teaching collection of the
Institute of Archaeology, University College London.
lesion changes with this transition. Ulti-
mately, the pulp chamber may be pene-
trated, and in most cases, this results in an sides, but such lesions are usually along
inflammatory response from the pulp, which the cervix of the crown just above the
may in turn lead to periapical inflammation. line of the gingivae, particularly on the
Nowadays, a lesion that had progressed to buccal/labial side of the crown (Figure 3).
this point would usually be treated by ex- Root surface caries. Usually later in life, the
traction of the tooth, or a root filling. The roots of the teeth are exposed by continuous
original enamel lesion may be initiated in a eruption, or the recession of the gingivae
variety of locations on the crown: and underlying supporting tissues related to
– Occlusal caries. Many lesions are initiated periodontal disease. Carious lesions may
in the complex systems of fissures, fossae then be initiated in the cement of the root
and grooves that mark the occlusal sur- surface either along the cement –enamel
faces of molar and premolar crowns (Fig- junction (Figures 4 and 5), or further down
ure 1). Others start in the buccal pits at the root when this is exposed above the
the end of fissures on the molar crown margin of the gingivae. Root surface carious
sides, or in the pits which sometimes lesions usually develop slowly, but the thin
mark the lingual surfaces of upper layer of cement is soon penetrated to expose
incisors. the underlying dentine.
– Contact point or approximal smooth surface
caries. Lesions are frequently initiated on By far the majority of clinical studies have
the mesial and distal crown surfaces, just concentrated on dental caries in children from
below the contact point between neigh- industrialized countries with diets rich in sugar,
bouring teeth (Figure 2). and, relatively speaking, a high level of dental
– Other smooth surface carious lesions on the care, amongst whom coronal caries is much the
crown. Caries may occasionally be ini- most common form. One of the key features of
tiated anywhere on the other crown caries epidemiology since the 1970s throughout

Figure 2. Carious lesion at the contact point of an upper

second premolar, represented by a clear cavity just below the
point at which the tooth would have made contact with the
crown of its neighbouring first premolar. The lesion also in- Figure 3. Smooth surface carious lesion. A long irregular cavity
volves the cement– enamel junction at the cervix of the tooth. runs along the crown of this upper first incisor, just below the
Its form suggests that the site of initiation was, in fact, the point at which the gingivae would have been attached to the
contact point, but strictly speaking, it should be classified as a base of the crown.
gross contact point/cement–enamel junction lesion (see text).

in a population affected by caries. In all popula-

the industrialized world has been a striking
tions, there is an age-related trend line showing
decline in caries rates, whichever way they are a progressive rise in the average number of
measured. This seems to have little to do with lesions per person in successive age cohorts
availability of dental care, but more to do with from childhood to adolescence and early adult-
a less interventionist style of treatment, an even hood. The effect of the caries decline has been
greater relationship with fluoride toothpaste to decrease the slope of that trend line, making
and, most of all, with a range of changing social it flatter. These changes in average caries rate
factors which also seem to be linked to im- are superimposed over a clear hierarchy of sus-
provements in general health indicators (Shei- ceptibility in the tooth types and potential
ham, 1997). The decline is shown in the coronal lesion sites involved in the permanent
average number of carious lesions per person dentition (Sheiham, 1997). Left and right sides
(Decayed Missing Filled (DMF) scores —see be- are equally affected by coronal caries, and upper
low), and in the proportion of each age cohort cheek teeth about the same as lower cheek

Figure 5. Another lesion on the root, at the cement– enamel

Figure 4. Carious lesion on the root, at the cement–enamel junction, confined to the notch which characterizes the mesial
junction. A broad cavity runs around the root of this canine side of the upper incisor crown. Lesions of this type are
tooth, just below the base of the crown. amongst the most common forms in Medieval British material.

highest rates, the upper canines are affected.

teeth, but upper anterior tooth crowns are more This hierarchy appears to remain the same,
frequently involved than lower. Cheek teeth are regardless of fluorine in toothpaste and water,
far more susceptible than anterior teeth, and the and level of dental care.
occlusal fissures of first molars (the earliest Only quite recently have there been large
erupting permanent teeth) are generally the studies of caries in adults, including both coro-
teeth affected in the lowest caries rate popula- nal and root surface caries, and only rarely have
tions. At slightly higher caries rates, the occlusal there been such studies in communities where
sites in second molars are involved and, higher the level of surgical intervention seen in indus-
still, the approximal sites of the molar crowns trialized societies was effectively not available
(upper and then lower). At even higher rates, (Manji et al., 1991; Thylstrup & Fejerskov,
the occlusal sites of the premolars become in- 1994). For this reason, it has been difficult to
volved — initially the second and then the upper find modern examples which can be compared
first premolars —then the approximal upper in- directly with the majority of archaeological ma-
cisor sites, approximal premolar sites and oc- terial, and, on the contrary, archaeology may
clusal lower first premolars. Finally, at the provide an important opportunity for studying

the natural history of caries. There are now, lesions, the molars were the most frequently
however, a number of relevant studies of chil- affected teeth, although this was particularly
dren and adults from Kenya (Manji et al., 1988, marked in younger age cohorts (see above), and
1989a,b, 1990, 1991), West Africa (Matthesen et increasing numbers of incisors and canines were
al., 1990), and rural China (Luan et al., 1989a,b; affected in older age cohorts. Caries was slightly
Manji et al., 1991; Baelum et al., 1993). As with more common in the lower molars than the
the studies of children and young adults de- upper molars but, even though carious lesions
scribed above, one of the main features of caries were much less common throughout all age
in these groups of people was a clear progres- cohorts in first premolars, incisors and canines,
sion with age in successive cohorts from child- this group of teeth in the upper jaw were always
hood right the way through to elderly considerably more affected than those in the
adulthood. The proportion of an individual’s lower jaw. These general patterns of change
teeth affected by coronal or root surface caries with age have been to some extent confirmed
rose with age, as did the proportion of individu- by studies of older adults in modern Europe and
als in the study group affected (i.e. the preva- America, although here the position is compli-
lence of caries). At the same time, the caries cated by widespread dental treatment, diet and
experience of the members of such a study fluoride (Chauncy et al., 1989; Fejerskov et al.,
group was very varied, with only relatively few 1993; Fure, 1997; Fure & Zickert, 1997).
individuals having many teeth affected, or many Such studies may be of relevance to agricul-
lesions, in their mouths. As is seen in most turalist human existence in much of the past,
archaeological studies, women tended to have but probably differ markedly from the caries
more teeth affected than men, with a more epidemiology of hunter-gatherer existence.
strongly marked progression with age, although There have been some studies, mostly during
the difference was not great, especially in the the first half of the previous century and varying
younger age groups. The proportion of teeth considerably in detail, of living people who had
with lesions penetrating to the pulp chamber followed a relatively unaltered hunter-gatherer
rose gradually with age, as did the proportion of lifeway, at least during their childhood and
teeth missing because of caries. This was the early adulthood. P.O. Pedersen had a unique
most common cause of tooth loss/extraction in opportunity to examine the teeth of almost the
all age groups, followed by loss resulting from whole population of Angmagssalik in East
periodontal disease, and then trauma. Greenland (Pedersen, 1938, 1947; Davies &
In these studies, the pattern of lesions Pedersen, 1955). The scientific communities of
changed progressively with age as well. Lesions the western world were completely unaware of
confined to the enamel of the crown were the this isolated Inuit group until AD 1884, and,
most common form in teenagers and young even in 1937 when Pedersen saw them, most
adults, and, although they decreased after this, still lived on their traditional diet of meat and
they remained a common form of caries even in fish, with practically no carbohydrate. The
the oldest age groups. This means either that prevalence of caries was extremely low, with
some enamel lesions progressed very slowly, or just over 4% of people being affected, and
that new coronal carious lesions were initiated 0.3 –0.6% of permanent teeth (0.7 –0.8% of
throughout life. Coronal lesions involving the deciduous teeth) bearing a carious lesion. Most
dentine were uncommon in the youngest age of these lesions were found in the fissure sys-
groups, but increased into early/mid-adulthood tems of third molars, particularly in adult fe-
and then fell somewhat. Root surface caries was males. Third molar occlusal fissures were often
also uncommon amongst teenagers and young preserved into adulthood, because there was a
adults, but showed a steady rise with age in very marked wear gradient along the tooth row,
older groups. This rise, however, was not nearly with the highest wear rate in the anterior denti-
so marked as the age-related increase in root tion and the least in the most distal molars.
surfaces exposed by recession of the gingivae Overall, tooth wear was extremely rapid, even
and continuous eruption. For all types of carious in children, so that dentine was exposed in the

permanent first molars of most people by 30 mation and tooth loss (see section below). The
years of age, and secondary dentine in more situation was similar in museum collections of
than half the people over 50 years (Davies & aboriginal Australian skulls (Campbell, 1925).
Pedersen, 1955). In spite of this, pulp exposure The rise in frequency of lesions, therefore, ap-
by tooth wear was very rare (out of 6000 teeth pears to have been directly associated with
only 2 showed this, Hilming & Pedersen, 1940), increasing tooth wear in older adults, chipping
although large tooth fractures occurred fre- (Moody, 1960) and abrasion at the neck of the
quently and did often expose pulps (Pedersen, tooth by using the teeth as tools for a variety of
1947). Gingivitis was common, but bone loss in jobs (Campbell, 1925). The generally higher
the jaws resulting from periodontal disease was rate of caries amongst aboriginal Australians
practically non-existent. In no cases had any (compared with the Inuit described above) can
teeth been lost as a direct consequence of be put down to the availability of sources of
caries, and only rarely did tooth loss appear carbohydrate in the gathered plant foods ex-
related to pulp exposure by attrition or alveolar ploited by many groups in Australia. Such foods
bone loss resulting from periodontal disease. also formed a substantial part of the diet of the
These observations fitted well with the dental !Kung bushmen of South Africa (van Reenen,
condition of large collections of ancient Inuit 1964, 1966; du Plessis, 1986; van Reenen,
skulls in Denmark and the USA (Leigh, 1925b; 1992), who showed a remarkable similarity in
Pedersen, 1938), in which only 0.4 –2.5% of the pattern of dental caries before they were
individuals were affected by caries, with 0.08 – settled on farms.
0.35% of permanent teeth (and no deciduous These studies of the natural history of dental
teeth) bearing lesions, again mostly fissure le- caries, therefore, show that there may be strong
sions of little worn molars in adults. Other contrasts between different cultures and differ-
neighbouring Greenland Inuit settlements vis- ent modes of subsistence in the types of lesion
ited by Pedersen in 1930 had access to imported that occur, and their distribution. In order to
sugar and cereals, and had a considerably higher identify this, studies of archaeological material
rate of caries (Pedersen, 1966), associated with a need to differentiate between the various forms
much lower wear rate (Davies & Pedersen, of caries, different stages of development (par-
1955). Similar contrasts have been noted for ticularly of coronal lesions) different age groups,
Inuit in North America (Mayhall, 1970, 1977). males and females, and between different classes
The teeth of living aboriginal Australians of teeth. It is probably not necessary to distin-
were studied during several expeditions of the guish left teeth from right, because caries is
University of Adelaide during the 1920s and usually symmetical, but upper and lower denti-
1930s (Campbell & Lewis, 1926; Campbell, tions show consistent differences (Thylstrup &
1928; Campbell & Moore, 1930; Campbell & Fejerskov, 1994). Another important aim is to
Gray, 1936; Campbell, 1937, 1938a,c,b, 1939), recognize the possible effects of different pat-
and 1950s (Barrett, 1953; Campbell & Barrett, terns of tooth wear, chipping and fracture. If all
1953; Cran, 1955; Barrett, 1956; Cran, 1957, these factors are not taken into account, any
1959, 1960), and in association with the Ameri- apparent differences in the pattern of caries
can – Australian Scientific Expedition to Arnhem between populations, or archaeological collec-
Land in 1948 – 1949 (Moody, 1949, 1960). One tions of material, could be explained simply by
of the features of these dentitions was again differences in the nature and derivation of the
rapid tooth wear, associated with chipping of material studied.
the enamel around the edges of the worn sur-
faces. Caries was uncommon in children, but
showed a large increase in older adults —mostly DMF scores and percentages
lesions of the worn remnants of the molar
crowns, and not root surface caries (although Epidemiological studies of living people us-
little detail is available). The rise of caries with ually employ DMF scores to summarize an
age was paralleled by a rise in periapical inflam- individual’s caries experience (World Health

Organization, 1997). This idea was originally fissures in which the tip of a probe sticks. It
suggested by Klein et al. (1937, 1938) and, in its is necessary to ensure that like is being
simplest form, is a count of the number of compared with like in different surveys. In
permanent teeth which have a carious lesion addition, even the DMF-S variant is an un-
that are missing, or have been filled. The under- derestimate of carious lesions in some indi-
lying, but unstated, assumption is that the count viduals, because it is quite possible for one
is out of the total 32 permanent teeth normally surface to bear more than one lesion and an
present, even though the total may vary for overestimate in others, where one lesion
reasons which have nothing to do with caries. spreads over more than one surface. Finally,
Such a count of teeth is known as the DMF-T in their basic forms, DMF scores do not
score and, in many studies, the mean DMF-T allow the different types of carious lesion to
score for the study group has been used to be recorded separately.
express the rate of caries in the population. In 2. The M element; missing teeth or surfaces.
effect, this is the average number of teeth af- This is one of the biggest problems. When
fected by caries, per person. It is not (as has most studies involved caries in the young, it
was a fairly safe assumption that most teeth
sometimes been suggested) a prevalence for
that were missing had been lost as a result of
caries, which would be the number of individu-
a carious lesion which penetrated to the
als affected, expressed as a proportion of the pulp, and had resulted in an extraction,
total number of individuals in the population because tooth loss resulting from periodon-
(Waldron, 1994). The mean is also not a very tal disease is very uncommon in children
good way to summarize the distribution of and young adults. Even so, there would be
DMF-T scores in a population, because this some variation because of congenital ab-
distribution is usually strongly asymmetrical sence of teeth, trauma and variation in the
(Thylstrup & Fejerskov, 1994). A further diffi- sequence and timing of eruption. Studies of
culty of basic DMF-T scores is that they must adults have more problems because, al-
usually be an underestimate of caries severity, as though several studies have shown that
they take no account of the possibility that a caries is the most common reason for tooth
tooth might be affected by more than one extraction throughout life, a substantial
carious lesion. Many studies have, therefore, number are still lost to periodontal disease.
used a variant of the idea, in which tooth The ratio of caries to periodontal disease
surfaces are counted instead of teeth. Each tooth loss is likely to vary between popula-
tooth is reckoned to have five surfaces —oc- tions, especially with the large contrasts in
clusal, buccal, lingual, mesial and distal —to- diet and behaviour, which are often investi-
talling a possible 160 surfaces for a full gated in archaeological material. In studies
permanent dentition. For each individual, the of the living, patients can be asked about
number of such surfaces which are carious, miss- the clinical history of their missing teeth
ing, or filled is counted to give the DMF-S (Manji et al., 1989a). Carious lesions which
score. Again, the mean DMF-S score is used as penetrate the pulp and initiate periapical
an index for caries experience in the population, inflammation may cause great pain, but little
even though the distribution of such scores is bone loss or subsequent loosening. Peri-
once more highly asymmetrical. In any case, odontal disease rarely causes such pain, but
there are problems with each of the elements of involves bone loss, and one of the main
any DMF score: signs for diagnosis is mobility of the tooth
(MacPhee & Cowley, 1975). Even with such
1. The D element; decayed teeth or surfaces. additional evidence, it can be very difficult
The number of decayed teeth counted de- to determine the cause of tooth loss and, in
pends upon the diagnostic criteria used. archaeological assemblages it is not possible
Many surveys count only lesions in which a to reach any definite conclusions. To some
clear cavity is seen or felt, while others extent, it may be possible to form at least an
include stained or discoloured patches, or opinion about the likely cause of tooth loss

with archaeological material, as caries is of- rent discussion of DMF scores in the epidemio-
ten symmetrical and teeth still present on logical literature, and various adjustments and
the opposite side of the jaw may suggest statistical procedures have been proposed
pulp penetration by coronal caries. Simi- (Thylstrup & Fejerskov, 1994; Beck et al., 1997;
larly, bone loss resulting from periodontal Burt, 1997; Kingman & Selwitz, 1997; Spencer,
disease may be evident around other teeth 1997).
which survive in the jaw. For archaeological DMF scores are rarely used in archaeology,
material, it is also necessary to take into because the first priority is to develop a
account such factors as tooth wear and frac- methodology which is not affected by the pat-
turing, which cause parts of teeth to be tern of jaw preservation and post-mortem tooth
unscorable for caries and, therefore, effec- loss. With this in mind, most studies have ex-
tively missing, even when the rest of the pressed either the number of carious teeth as a
tooth is still present in the jaw. The most percentage of the surviving teeth, or the number
insuperable problem for archaeology, how- of individuals affected as a percentage of the
ever, is the post-mortem loss of teeth and total number of individuals in the collection.
parts of the jaw. It is very difficult to adjust Expressing caries as a percentage of teeth
DMF scores to take account of this (below). present has a big practical advantage for archae-
In any case, there is a final over-riding ology, in that isolated teeth can be included in
difficulty with the M element even in living the study, and these make up a considerable
populations —DMF-S scores have an inbuilt proportion of the remains at some sites. As
error because, if a tooth is missing, then all normally calculated, however, there are several
five of its surfaces are counted as missing. serious difficulties:
This means that all five are assumed to be
No distinction is made between tooth
carious, when it is much more likely that
classes. This makes it impossible to discern
only one or two surfaces were affected when
any patterns which relate to the distribution
the extraction took place. Some authors,
of caries through the dentition and, as has
therefore, advise that the missing category
been shown above, this is known to be
should be left out of DMF-S scores, to give
highly variable. In addition, the pattern of
DF-S scores instead (Thylstrup & Fejerskov,
post-mortem tooth loss has a strong effect.
1994).
Caries rates are much higher in cheek teeth,
3. The F element; filled teeth and surfaces. In
but anterior teeth are more likely to fall out
studies of living patients, this causes prob-
post-mortem, so that, in an archaeological
lems because one filling frequently overlaps
collection where preservation is good and
several surfaces, as a result of the need to
the anterior teeth survive, the caries rate is
give it a form which will be retained in the
inevitably depressed relative to a collection
tooth under heavy load. With one large
with poor survival of this kind.
filling, there is no knowing how many sur-
The percentages are likely to be underesti-
faces were originally involved with carious
mates of caries experience, where the bulk of
lesions (Thylstrup & Fejerskov, 1994). In
missing teeth were extracted ante-mortem as
archaeological material, even into the begin-
a result of caries because these, the most
ning of the 19th century, there is often little
strongly affected of all, are not taken into
evidence of dental work, so the F element
account.
causes fewer difficulties.
No allowance is made for the development
If all these difficulties are taken into account, of dental caries with age. The age-at-death
then the epidemiologist is left with only a D-T and sex composition of archaeological as-
or a D-S score. To allow for this, some studies semblages varies widely, and this could
now present scores for D-T, D-S, M-T, F-T and strongly affect the apparent caries rate.
F-S separately (Manji et al., 1989a, 1990, 1991). In most common usage, no distinction is
For all these reasons, there is considerable cur- made between the different forms of caries,
Copyright © 2001 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 11: 249 –289 (2001)
Recording Dental Caries 257

and there is no way in which the presence of proach has also been called the ‘I-CE’ (index of
two different forms of caries on one tooth caries et extractio; Caselitz, 1998). Procedures like
could be recorded. This must mean an un- this, however, make assumptions which are dif-
derestimate of caries amongst assemblages ficult to test and none address all of the prob-
(such as those of some native North Ameri- lems outlined above, so it seems timely to
cans) where both coronal and cervical le- re-examine the whole basis of recording carious
sions are important. In addition, the various lesions in archaeological material, and to look at
forms are differently distributed in anterior alternatives to the traditional percentage rates.
and cheek teeth with age, and are differently
affected by the contrasting wear patterns
seen in archaeological assemblages. Alternative caries recording systems in archaeology
With all these difficulties, it is unclear what the One possible alternative is the so-called Mou-
figure for percentage of teeth with caries in a lage System, which grew out of large plaster-of-
group of archaeological material actually repre- Paris models developed originally by P.A.
sents. Where, say, two assemblages are com- Lindström for teaching purposes in the Royal
pared, there are so many potential alternative School of Dentistry, Stockholm. In the first half
methodological explanations for any difference of the 20th century it was common practice to
between them that it is very difficult to prove a use models made from impressions (French mou-
real difference in caries rate. The depressing lage, moulded reproduction) of bodies and or-
conclusion of this is that most of the caries data gans for teaching anatomy and pathology.
painstakingly collected over many years, and Between 1940 and 1942, the teaching series was
presented as percentages of total tooth counts, developed into a recording scheme based on a
cannot reasonably be compared between studies series of 85 beautifully made models showing
of different collections. different types of carious lesion in varying de-
In some studies, corrections have been ap- grees of severity (Dahlberg, 1940). The models
plied to archaeological caries scores for the were numbered:
proportion of teeth missing ante-mortem, to
make them directly compatible with DMF in- 1–9 represented fissure caries.
dices in modern epidemiological studies (Costa, 11–16 and 91 –92 represented premolar
1980b). It is also possible to use the pattern of contact area caries.
lesions in surviving teeth to estimate the number 21–24 represented premolar combined fis-
of teeth lost because of penetration of the pulp sure/contact area caries.
by caries, and add these on to the number of 31–37 represented incisor contact area
carious teeth present in the jaw (Lukacs, 1995). caries.
Caries rate can then be calculated as the total 41–49 represented smooth surface caries at
number of teeth estimated to have had caries, the cervix.
51–59 represented cement –enamel junction
expressed as the proportion of the estimated
total number of teeth originally present (teeth caries.
61–65 represented pit caries.
in the jaw plus teeth lost ante-mortem). Erdal
71–76 represented cusp tip lesions.
and Duyar (1999) have proposed a further mod-
81–84 represented root surface caries.
ification to this corrected index, which allows
for the differential survival of anterior teeth and The models themselves were never widely avail-
cheek teeth. Another possibility is to include all able outside Scandinavia, but small photographs
teeth missing ante-mortem by adding their were published in a number of journal articles
count onto the number of carious teeth —the (Lindström, 1940; Rönnholm et al., 1951). When
‘DM’ index (Kelley et al., 1991) —and then to used for recording, carious lesions are matched
express this as a percentage of the total number with the models, and then the tooth involved is
of surviving teeth plus the number of teeth lost assigned the appropriate model number. This
post-mortem (Saunders et al., 1997). This ap- system was used in several epidemiological

studies in the living, including the famous

Vipeholm study (Gustafsson et al., 1954), and in
the ground-breaking archaeological study of
Swärdstedt (1966). The results were presented
as frequencies for the different categories of
moulage, and could be combined in a variety of
ways.
The main advantage of the Moulage System
is that it counts the different types of lesions at
various caries sites, rather than affected teeth. Figure 6. ‘Gross gross’ carious lesion, in which only the apical
As originally described, it makes no provision to part of the root remains. The cavity exposes the open root
count the non-carious sites and, therefore, does canal in its floor, and there is no real evidence remaining which
might suggest where this lesion was initiated.
not allow lesions to be expressed as a propor-
tion of ‘sites at risk’, although this could easily
be remedied. The models make an excellent The prevalence of caries was calculated in a
shorthand for describing caries, and a good number of ways, but the real innovation was an
teaching aid, but are a little too cumbersome for index which expressed the number of carious
routine use in archaeological material. Another teeth as a percentage of ‘teeth at risk’ of devel-
difficulty is that the original large plaster models oping caries. In addition, indices were tabulated
are not widely available, and the published pho- separately for different tooth classes and differ-
ent age groups. These ideas were an important
tograph is too small for ease of use. In any case,
advance in recording dental caries for archaeo-
the system needs to be used imaginatively be-
logical material, and have formed the basis of
cause real carious lesions do not necessarily
most detailed studies since (Lunt, 1974; Whit-
match any model exactly. Furthermore, archaeo-
taker et al., 1981; Kerr et al., 1990; Varrela,
logical teeth are often much more worn than 1991). They have been recognized as a standard
those of modern people, and this gives rise to for anthropological recording (Buikstra & Ube-
lesions which are not included in the system. laker, 1994), but can be applied in a variety of
Another alternative was proposed by Moore ways, and the methods proposed in the present
and Corbett (Moore & Corbett, 1971, 1973, paper have developed out of them.
1975; Corbett & Moore, 1976) in their study of
the history of caries in Britain from the Iron Age
to recent times. They recorded carious cavities
General problems of recording and
at three groups of lesion sites:
presentation of results
(A) Occlusal. Fissure caries. Cuspal caries.
Gross (below) occlusal caries.
(B) Interstitial. Contact area caries. Cement – The progressive nature of caries
enamel junction caries (distinguishing
where possible between lesions initiated in The cavities which make the most visible ex-
enamel and those initiated in cement). pression of dental caries are in fact a rather late
Gross interstitial caries. stage of the disease. In coronal caries, the initial
(C) Buccal. Fissure caries. Cement –enamel demineralization of enamel takes place under an
junction caries. Gross buccal caries. apparently intact surface layer, and the changes
can only be seen in microscope sections (Dar-
Lingual sites were involved so rarely that they ling, 1963; Jones & Boyde, 1987). Some time
were not presented in the results. ‘Gross caries’ later, the first outward sign may be a very small
is the term used to describe a lesion that has white or brown spot in the otherwise translu-
grown to the point that it includes several cent enamel, which still has a smooth and
possible sites of initiation, and, therefore, its glossy surface. It requires very careful examina-
original site cannot be determined (Figure 6). tion of the surface, preferably with a low-power

microscope, to see the first stages of such white abscess, but these are once again not usually
or brown spot lesions. The localized demineral- painful, and would mostly be noticed by the
ization often does not show itself as a radiolu- foul-smelling discharge which emerges via a
cency in a dental x-ray until much later and, in channel through the gingivae or into the nose.
any case, the ability to demonstrate enamel Chronic periapical inflammation of these kinds
lesions varies greatly with their position on the may persist for a long time, and is maintained as
tooth crown. Gradually, the spot lesion may long as the open root canal provides a route for
increase in size until it is readily visible to the micro-organisms to enter from the mouth.
naked eye. Eventually, the hitherto smooth In most cases, even coronal caries, as de-
enamel surface may become roughened (tradi- scribed above, is a slowly progressive disease
tionally detected by feel, using a fine-pointed (Pine & ten Bosch, 1996), although a proportion
probe), and finally breaks down to produce a of modern children show what is known as
cavity. The lesion may then progress into the ‘rampant caries’, where newly-erupted and not-
dentine, and then into the pulp. This opens the fully-matured crowns are covered in thick
pulp up to an infection by a broad spectrum of plaque deposits, and the child eats sugary snacks
micro-organisms from the mouth, and may re- all day. In most other cases, it can take years for
sult in pulp inflammation. Ultimately, the pulp surface-visible signs to develop, and the lesion
usually dies (although some parts of the pulp in progresses irregularly, with faster development
a multi-rooted tooth may continue to survive), interspersed by quiescent phases (Pine & ten
and inflammation passes down the root canal, so Bosch, 1996). Even when a cavity has formed,
that either the micro-organisms or the products the lesion does not necessarily proceed to expo-
of inflammation emerge from the apical foramen sure of the pulp and it may remain stable for
and initiate inflammation in the supporting tis- years, or even remineralize. Penetration of the
sues around the apex of the root. Pulpitis and pulp chamber itself can be delayed for a long
acute periapical inflammation are painful, and time by the deposition of secondary dentine,
the affected teeth are sensitive to cold, heat and which seals off the pulp, and inflammation of
pressure. Nowadays, teeth that have reached the pulp can be very localized and slow to
this stage are usually treated by extracting them develop. Chronic pulpitis of this kind some-
or by root canal treatment, or sometimes by times does not lead to pain and may be unrec-
removing part of the pulp. Extraction is the ognized for years —it may even heal. Similarly,
simplest and surest treatment, and this operation periapical inflammation may be virtually symp-
has a long history (Hofman-Axthelm, 1981). tomless for much of the time, and often devel-
Most people in the world today probably have ops very slowly. All of these features and
recourse to basic treatment of this kind, even if consequences of caries show a gradual progres-
it is from non-professional surgeons, and it is sion with age, and the mouths of people who
also likely that many groups of archaeological are susceptible to caries accumulate more cari-
material include jaws from people who were ous lesions, more lesions which penetrate into
treated in this way. In the absence of treatment, the dentine, more exposed pulp chambers, more
it is not clear that acute periapical inflammation teeth affected by periapical inflammation, and
inevitably leads to loss of a tooth, and many more teeth lost by extraction. Root surface
cases progress much more slowly anyway. The caries develops even more slowly, and shows a
most typical form of such chronic inflammation similarly strong pattern of development with
is a periapical granuloma (below), usually associ- age.
ated with a small smooth walled cavity within From this, it is clear that dental caries has no
the bone of the alveolar process. These are precisely defined fixed points at which a diag-
virtually symptomless, and involve very little nosis of ‘carious’ or ‘non-carious’ can be made. It
loss of tooth support, even though they may is a continuous development, which typically
look striking in archaeological jaws. In some proceeds slowly and irregularly, so that any
instances, such granulomata may develop by the diagnostic criterion is arbitrarily selected,
accumulation of pus into a chronic periapical and there has been recent discussion in clinical

literature about the best criteria to use (Ie & hidden occlusal caries (van Amerongen et al.,
Verdonschot, 1994; Thylstrup & Fejerskov, 1992; Espelid et al., 1994) because of the convo-
1994; Lussi, 1996; Pine & ten Bosch, 1996; Burt, lutions in the enamel in this part of the crown,
1997; Ismail, 1997; Nyvad & Fejerskov, 1997; but they are more useful for approximal caries,
Pitts, 1997). One issue is the inclusion of ‘pre- and still act as a useful additional diagnostic
cavitated’ lesions (sometimes called incipient le- tool. Newer techniques include fibre-optic tran-
sions) in epidemiological surveys. It has been sillumination (FOTI), with a narrow beam of
known for some time that enamel lesions in light that shows up dentine lesions as dark
which an opaque spot or roughened surface is shadows, laser fluorescence where lesions fluo-
seen, without a cavity being apparent, are much resce differently to the intervening enamel, and
more common than cavitated lesions (Ismail, electrical resistance which is reduced in carious
1997). Most surveys to date have however only lesions because they are more porous and, thus,
recorded carious cavities (usually penetrating imbibe more fluid than intact enamel. Of these,
the dentine) about which the examiner was electrical resistance seems to be one of the more
absolutely certain, because this reduces prob- promising approaches, but even this is not
lems of variability between dentists, particularly widely used for clinical purposes. Most dentists
in situations where the facilities for examination continue to use direct examination by eye and
are not optimal. It is recognized that such explorer, supported by radiography. Simple vi-
procedures will underestimate the prevalence of sual examination, in fact, does not perform
caries, but consistency is usually considered badly for lesions hidden under occlusal surfaces,
more important (Burt, 1997). It has recently particularly when modest magnification can be
been suggested that recording of precavitated used to examine extracted teeth carefully (Tveit
lesions is not necessarily as unreliable as had et al., 1994; Ekstrand et al., 1995; Lussi, 1996).
been believed when carefully trained and cali- This latter situation is easy to duplicate in
brated examiners are used to conduct the survey examination of archaeological material, where
(Ismail, 1997), although some other studies have jaws can be held under a low-power stereomi-
shown less encouraging results (Lussi, 1996). A croscope with optimum illumination, teeth are
related issue is the use of a dental explorer or already dry and clean, and can often be tilted
probe to feel for roughened enamel surfaces, or and manipulated in their sockets to show the
fissures in which the tip sticks, to help detect approximal area better. The main additional
precavitated lesions. In the first place, it is now difficulty for archaeological material is the pos-
suggested that sharp probes damage tooth sur- sibility of diagenetic change, which may pro-
faces and, second, that they are not a very duce staining and even cavitation (Poole &
effective aid to diagnosis (Penning et al., 1992; Tratman, 1978) under some circumstances. This
Thylstrup & Fejerskov, 1994; Ismail, 1997). An- can be checked by simple sectioning (see be-
other issue is so-called ‘hidden caries’, in which low), through the presence of a secondary den-
a lesion can be demonstrated in a section of the tine reaction underneath.
tooth to have affected the dentine, but is either A more serious problem, even in clinical stud-
not apparent at the crown surface, or the surface ies, is that varying practice between different
manifestation gives no clue that the lesion is so surveys and the contrasting nature of carious
extensive. This is particularly a problem of oc- lesions in different populations make it difficult
clusal caries (see below), and numerous labora- to ensure that like is being compared with like
tory studies of extracted teeth have been carried when surveys are compared. Furthermore, most
out (van Amerongen et al., 1992; Tveit et al., surveys of caries in the living, and all archaeo-
1994; Ekstrand et al., 1995), together with trials logical studies, are cross sectional. They record
of various traditional and novel methods of caries in a group (not necessarily contemporane-
examination (Ie & Verdonschot, 1994; Pine & ous) of people of various ages, and it is neces-
ten Bosch, 1996; Huysmans et al., 1998a,b; Eg- sary to infer the longitudinal development of
gertsson et al., 1999; Lussi et al., 1999). X-rays caries throughout these people’s lives from a
are not a very reliable basis for diagnosing snapshot of the group as a whole. Caries does

not affect everyone equally, and the bulk of to create a deep and steep-sided cavity. In other
large carious lesions and tooth loss are found in teeth, opacities, staining or small cavities may
only a quarter or less of the study group (see become visible in the grooves, fossae and fis-
above). This uneven distribution makes it partic- sures. These features are usually a reasonably
ularly difficult to infer a lifetime’s development good indication that there are carious lesions
of caries from cross sectional studies, although underneath, but it can be difficult to relate them
modern clinical studies have shown that, at the directly to the extent of that lesion, or group of
level of the population as a whole, it is possible lesions. Penning et al. (1992) found that 94% of
to extrapolate. Added to this is the fact that a extracted teeth with stained fissures showed
collection of archaeological material from a caries when they were sectioned and, on aver-
large cemetery is by no means a random sample age, there were 2.3 lesions per tooth. Tveit et al.
of all ages, sexes and conditions of people in the (1994) similarly found that 90% of molars and
original living population. The group of people premolars with opaque or discoloured patches
that die each year is itself not a random cross in occlusal fissures or pits, but no cavity, had
section, because it is generally those who are histological evidence for caries in the underly-
susceptible and succumb to disease, and the ing enamel (and in 23% of the teeth in the
people buried in the cemetery would be drawn dentine also). All those teeth which had even a
from such death assemblages over some years — small cavity, with or without an opaque or
maybe even hundreds of years. The collection discoloured patch, were carious on histological
that eventually reaches the anthropologist’s examination, although lesions involved the den-
work-bench has also been subject to a whole tine in only 77% of them. Ekstrand et al. (1995)
series of (probably) non-random factors of found a high correlation between the surface
preservation and recovery. Caries is common appearance of occlusal lesions and their progress
enough in most archaeological material to make into the enamel and dentine when they used a
it the most profitable palaeopathological condi- very detailed set of criteria for examination
tion to study, but all the problems involved with under a low-power stereomicroscope. In sum-
determining prevalence in ancient, once-living mary, it seems that staining and cavities in the
populations need to be borne in mind (Wal- occlusal surface can suggest a good deal about
dron, 1994). the progress of caries underneath, even if there
are difficulties in interpretation.
In modern clinical practice, diagnosis of fis-
Occlusal caries and its diagnosis sure caries is still augmented by the use of a
sharp explorer or probe (see above). These
Caries frequently develops in the complex of instruments are run along the line of a fissure/
sloping cusp sides, grooves, fossae and fissures groove and, where they stick or catch slightly,
that make up the occlusal surface of the crown. caries may be suspected even if there is no other
The fissures in the occlusal surfaces of molars sign. Penning et al. (1992) tested the efficiency
and premolars are often very deep, and reach of the explorer method against an examination
down almost to the enamel –dentine junction. of serial sections through the crown, but only
The initial stages of fissure caries may take place 17% of carious lesions within the fissure systems
deep inside them, without being apparent at the were detected in this way. Another possibility is
surface. Within a complex fissure system in a to use radiography. The difficulty here is that
large molar, lesions may be initiated at several the deep fissures of the occlusal part of the
separate points and, in any case, caries may crown are all superimposed over one another in
spread rapidly through the whole complex of the image on the x-ray film, so that it is impos-
fissures and fossae. In some cases, the lesion has sible to disentangle details of the enamel. A
reached the enamel –dentine junction, and is carious lesion in this area shows only as a
undermining the enamel before there is any sign radiolucency when the dentine underneath is
at the surface, which may result in a sudden substantially affected. In a study by Espelid et al.
collapse of a large area of the occlusal surface, (1994) of 84 extracted teeth, a panel of ten

dentists failed to diagnose enamel fissure caries demineralization and the dentine reaction very
in 77% of the specimens, and fissure caries clearly, and is also an excellent means of distin-
affecting a small area of dentine in 38% of guishing diagenetic changes (Boyde & Jones,
specimens. They also falsely diagnosed caries in 1983; Jones & Boyde, 1987). The resin can be
12% of the teeth that had normal fissures, but removed afterwards by dissolving it in acetone,
they did diagnose correctly all those fissure and the cut halves of the tooth are still available
caries lesions which affected a large area of the for study, with relatively little material lost in
underlying dentine. Lussi (1996), on the other the sectioning process.
hand, found that the number of cavitated cari-
ous lesions detected in radiographs was about
the same as those detected visually, and that Cement– enamel junction and root surface caries
diagnosis in radiographs was somewhat better
than visual examination for precavitated lesions. Carious lesions initiated on the surface of the
A combination of the two methods gave the cement which coats the roots create a number
best results. of difficulties for archaeologists. Clinical studies
What can be suggested from such studies of living people record caries as present when
when methods for studying occlusal caries in an area of the root surface is discoloured or
archaeological material are to be developed? stained, sometimes with a surface that is soft to
First, there seems little point in using an ex- the explorer, and sometimes with the formation
plorer on potentially delicate archaeological of a cavity (Fejerskov et al., 1993). Such cavities,
specimens, but the use of a low-power stereomi- however, are not like those of the enamel in the
croscope seems well worthwhile, particularly crown, where the sides are usually steep and the
when fibre-optic lamps can be used to adjust outline clearly marked. Root surface caries cavi-
illumination precisely. Radiography of archaeo- ties instead tend to be shallow depressions that
logical specimens is easy to accomplish, and spread around the cervix in a band, and are
high quality x-rays can be produced by the long difficult to recognize in archaeological material.
exposure times that are possible, but they are Most archaeological studies, in fact, show a
only likely to be of limited use in studying early considerably higher frequency of cement –
occlusal caries because lesions do not register as enamel junction caries than cement caries of the
radiolucencies until they involve the dentine. root surface itself (Moore & Corbett, 1971).
Where possible, however, they should be used This may be because they are difficult to diag-
alongside visual examination under a micro- nose on ancient root surfaces. It is also possible
scope. Recording of precavitated occlusal le- that diagenetic changes in archaeological teeth
sions clearly produces variable results, but many may mimic the discolourations used to diagnose
lesions involving the dentine may well be the condition in the living and, for this reason,
missed if they are not recorded. It therefore discolouration should either be excluded from
seems best to record opacities and discoloura- the criteria used in archaeology (noting only
tions in occlusal fissures, grooves and fossae as a definite cavities) or be recorded as a separate
separate category which can be tabulated sepa- category. In addition, considerable care needs to
rately to cavitated lesions. be taken in distinguishing post-mortem erosion
If specimens can be sectioned, then it is of the root surface from, particularly, the cavi-
possible to check the diagnosis by examining ties of cement –enamel junction caries (Moore &
the underlying dentine. A minimally destructive Corbett, 1971). Whilst in coronal caries it may
approach is to avoid grinding a thin section of be relatively easy to confirm the status of the
the tooth, but instead to embed the tooth in lesion histologically by identifying a patch of
methylmethacrylate resin, make a single cut, reparative secondary dentine lining the pulp
polish one side of it and then examine it either chamber, root surface caries typically occurs in
under a reflected light microscope, or in a older individuals who often (in archaeological
scanning electron microscope, using backscat- material) have much more worn teeth, with a
tered electron mode. This shows the changes of pulp chamber and root canal already filled in by

secondary dentine. This means that the tell-tale

patch of reparative secondary dentine, which
might prove that the demineralization occurred
during life, cannot be distinguished.

The role of tooth wear and fracturing in caries

The prevalence of fissure caries tends to be low

in populations that have a high rate of occlusal
attrition. Amongst some rural Africans today, it
has been noted that caries occurs at a lower rate
in first molars than in second molars, which is
the opposite way round to most studies of
town-dwelling people. It is suggested (Manji et
al., 1990) that this is a result of the higher fibre
content and abrasive quality of the diet, pro-
moting rapid wear which would remove the
fissures of the earlier erupting first molar before
they became carious (although it could also be a
result of a change from childhood to adult
diet — A. Sheiham, personal communication). In
heavy wear populations, such as recent hunter- Figure 7. Gross carious lesion, bridging the whole mesial side
gatherers or early agriculturalists, wear in molar of an upper first incisor. It involves the heavily worn occlusal
teeth could theoretically obliterate fissures, even surface, the contact area and the cement– enamel junction.
Apart from being able to say that the lesion was initiated on
in the young, and might therefore remove cari- the mesial side of the tooth, it is not possible to determine the
ous tissue, but it would have to be very rapid site of initiation with any certainty, although, in Medieval British
indeed to outstrip the type of caries develop- material, this type of lesion commonly seems to result from a
cavity of the type shown in Figure 5.
ment deep in the fissures, which is seen in many
populations today. It might also be expected
that approximal attrition (between neighbouring inal Australians, caries seems to have been posi-
teeth in the same jaw) could remove carious tively related to attrition, and was a disease
tissue in contact area lesions (Kerr et al., 1990). particularly of the worn molars in older adults
Once again, however, caries often proceeds (Moody, 1960; van Reenen, 1964, 1966). This is
rapidly to a deep cavity in this region, and because increasing attrition predisposed to chip-
approximal attrition is relatively much slower ping of teeth, ranging from small chips to more
than occlusal. Indeed, one of the main areas for major breaks, and creating traps for dental
initiation of contact area caries is along the plaque to accumulate, as well as exposing lines
cervical edge of an approximal attrition facet, of weakness for the extension of a carious le-
which must represent a discontinuity in the sion, or exposing areas of dentine. In worn
protective surface layer of enamel. Similarly, it teeth, where all the enamel of the occlusal
is not uncommon in archaeological material to surface had been removed so that the enamel of
find a carious lesion in quite heavily worn teeth the sides stood up as a raised rim above the
(Figures 1 and 7), or even involving the dentine softer dentine in the centre, small chips of
in the middle of a large attrition facet. enamel flaked away under the powerful forces
An alternative view is that, far from having a applied to the teeth (Turner II & Cadien, 1969;
protective effect against dental caries, the rapid Milner & Larsen, 1991). These areas of exposed
attrition of hunter-gatherers was intimately in- dentine were particularly susceptible to caries in
volved in the development of carious lesions. older adult aboriginal Australians (Campbell,
Amongst the recent !Kung bushmen and aborig- 1925, 1937; Moody, 1960), and this would be

expected, because the demineralization of den- tion —the exposed pulp chamber may be
tine does not require such a low pH as that stained and it can sometimes be difficult to be
needed to demineralize enamel (A. Sheiham, sure that it is a simple open chamber rather than
personal communication). Another effect of a poorly defined carious cavity. Carious lesions
heavy wear was to create approximal spaces in develop slowly over time, with arrested and
which food could be trapped, and thus encour- active phases, and the actual exposure of the
age plaque accumulation. These factors may pulp might have occurred during a period when
also be at work in the natural history of caries there was an active lesion in the occlusal sur-
amongst those other primates that regularly eat face. Further attrition could remove evidence of
sugars. In the wild great apes, for example, the original site of the lesion. It is also possible
dental caries is most common in the approximal (although perhaps less likely) that the dentine
region of the incisors, rather than the molars, above the pulp chamber area might have
but also seems to develop in association with cracked and fractured away under load, expos-
increased attrition. Thus, in the chimpanzee, ing a trap in which plaque might accumulate.
orang utan and gorilla, it is mostly a disease of There are many possibilities and practically no
the worn incisors of older individuals (Miles & data for the way in which very worn teeth may
Grigson, 1990; Kilgore, 1995). be involved in caries and behave mechanically.
Root surface caries is also related to wear, but How can a ‘pulp chamber exposed by attrition’
in a different way. Rapid occlusal attrition may be positively diagnosed? It is surely better to
lead to rapid exposure of root surfaces, over and record what is actually seen —the stage of attri-
above exposure resulting from periodontal dis- tion, the exposure of an open pulp chamber
ease. Teeth continually erupt throughout life, as whose sides and floor can clearly be distin-
part of a mechanism by which the dentition and guished, the exposure of an apparently open
jaws adjust and remodel in response to the root canal, the presence of secondary dentine,
changing height of the tooth crowns, and alter- the presence of discolouration or of any clearly
ations in the form of the occlusal plane (Levers defined carious cavity, fracturing or cracking, or
& Darling, 1983; Whittaker et al., 1990). In a the existence of bone loss around the apex of
rapid attrition population, it might be expected the root. Anything else is an interpretation
that this eruption could expose roots to carious rather than an observation, and should be kept
attack at an earlier age than a population with separate.
lower attrition rate (Kerr et al., 1990). There The heavy attrition seen in many archaeolog-
may also be other factors at work in cervical ical collections, therefore, creates difficulties in
caries. Campbell (1925) noted that almost all defining the best way to record carious lesions,
carious lesions in aboriginal Australian skulls because the usual recording schemes have been
were associated with ‘erosions’ worn in the defined for the much less worn teeth of modern
cervix on the mesial and distal sides of many of Europeans and Americans. The marked attrition
these teeth. Similar features are well known of archaeological material and recent hunter-
from Middle Pleistocene hominid fossils, as well gatherer groups exposed rather different sites
as later archaeological material, and are often for the initiation of caries. How should a carious
referred to as approximal or interproximal cavity in the middle of the dentine of a large
grooves (Frayer, 1991; Milner & Larsen, 1991; occlusal attrition facet be recorded? It cannot be
Bermudez de Castro et al., 1997). There is eth- assumed that the lesion was originally initiated
nographic evidence that they were caused in the fissure system, before it was worn away,
amongst aboriginal Australians by stripping fi- because it may just as well have been initiated in
bres between the teeth (Brown & Molnar, 1990), the worn surface —for example, along the edge
but a variety of other explanations is possible of one of the remaining patches of enamel
for archaeological material. which mark some of the intermediate phases of
Some cases of pulp exposure (see below) wear. There is also the question of interaction
might also be the result of carious lesions devel- between attrition and caries. Attrition exposes
oping in combination with advancing attri- vulnerable tissues, and caries itself weakens

those tissues and potentially renders them liable It is thus clear that the presence of a calculus
to more rapid attrition. At the risk of further deposit on a tooth surface is no guarantee that
complication, it seems best to include separate the surface underneath is caries-free. Such sur-
categories of caries in relation to attrition facets. faces should be recorded as ‘no information’
In addition, it is clearly necessary to make some rather than ‘non-carious’.
record of both occlusal and approximal attrition,
not only for the purposes of age estimation (see
below), but also to relate the surfaces exposed The relationship of caries with hypoplasia and
in the attrition facets to the pattern of dental fluorosis
caries. For similar reasons, in heavy wear groups,
it is also necessary to record tooth chipping and Enamel hypoplasia is a defect of enamel matrix
fracturing as a separate category of potential site formation that may (very rarely) be inherited, or
for the initiation of carious lesions. (much more commonly) results from a disrup-
tion to development, such as a childhood fever
Calculus and caries or a dietary deficiency. Developmental defects
of this latter kind form a band around the
Dental calculus is mineralized plaque, which circumference of the tooth crown, representing
frequently builds up around the cervix of the the interval during which the growth disruption
tooth crown (supragingival calculus), or coats occurred. The bands of defective enamel can be
the exposed surfaces of roots as a thinner layer traced from tooth to tooth across the dentition,
(subgingival calculus) when they are exposed in so that one disruption marks several teeth, each
a periodontal pocket by the development of in a different place relating to differences in the
periodontal disease. As calculus is formed ages at which particular teeth form. It has long
through mineralization, and caries involves a net been known that these bands form a line of
demineralization, it is not surprising to find an weakness, along which enamel can be preferen-
inverse relationship at the population level be- tially demineralized, and, therefore, they predis-
tween the two conditions. A population with a pose to caries (Mellanby, 1927, 1929, 1930,
high caries rate is likely to have less frequent 1934, 1941). It is essential to take account of
calculus deposits, and vice versa (Manji et al., them but, as they occur at intervals during the
1989b). The relationship, however, is not a development of the teeth, only some initiation
strong one, and does not apply at an individual sites for carious lesions on particular teeth will
level. It is quite common to see calculus deposits be affected. Similarly, depending upon the tim-
on a tooth with a well developed carious lesion, ing of growth disruption, different sites on dif-
and not only can arrested or remineralizing ferent teeth will be involved. A further difficulty
lesions be covered with calculus (Thylstrup et is that the prominence of defects produced by
al., 1989), but active lesions may continue un- one growth disruption varies between teeth, in
derneath a calculus deposit (Jones, 1987). A relation to the geometry of crown formation.
number of factors may be involved. The chem- Any relationship between prominence of defect
istry of dental plaque changes greatly between and the vulnerability of the crown surface to
adjacent regions of a plaque deposit and shows, initiation of a carious lesion is not at all estab-
for example, a strong gradient with depth. lished, but the effect of hypoplastic defects will
Caries involves very localized changes in the only be serious for the statistics of caries preva-
chemistry of the plaque, and so it is quite lence if there are common features in growth
possible to imagine active caries proceeding in disruption for all children in a particular popula-
one region whilst calculus mineralization occurs tion. It used to be thought (Massler et al., 1941)
in an adjacent region. Dental caries also in- that the development of the dentition could
volves cycles of both demineralization and rem- be divided into a number of phases, character-
ineralization, so that calculus deposition could ized by a different ‘quality’ of enamel which
well be part of the long term development of a rendered particular parts of the dentition either
lesion. more or less vulnerable to carious attack. This

Copyright © 2001 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 11: 249 –289 (2001)
266 S. Hillson
Table 1. Parts of different permanent tooth crowns in which the formation times overlap

Upper and lower Lower Upper Canines Premolars First Second Third
first incisors second second molars molars molars
incisor incisor

Occlusal – – – – Occlusal – –
Contact Occlusal – – – Contact – –
Lower crown side Contact – Occlusal – Cervical – –
Cervical Cervical Occlusal Contact Occlusal – Occlusal –
– – Cervical Lower crown side Contact – Contact –
– – – Cervical Cervical – Cervical –
– – – – – – – Occlusal
– – – – – – – Contact
– – – – – – – Cervical

Following this table, for example, a hypoplastic enamel defect level with the contact point area of the lower first incisor crown
would be expected to match with a defect in the occlusal (incisal edge) part of the lower second incisor, and in the contact point
area of the first molar. If this defect decreased the resistance of the enamel to development of carious lesions, it could affect
all these teeth in those particular regions of their crowns. Data from Table 6.3 in Hillson (1996).

interpretation has not stood the test of time, centrations near to the pulp chamber, and falls
but the general idea of relating caries to off steadily through the thickness of the den-
enamel structure warrants serious consider- tine towards the enamel –dentine junction. Flu-
ation. An index of dental enamel defects has orine has a considerable effect on dental
been defined for clinical purposes (Commis- caries. Enamel that contains fluorine is pro-
sion on Oral Health, 1982), but it is not re- tected because it is less soluble and, therefore,
ally suitable for the present purpose, and the resistant to demineralization, and the presence
simplest way to take account of hypoplastic of fluorine in food and drink has a further
defects is to create a table of the dental devel- protective effect in inhibiting plaque micro-
opment sequence, in relation to the various organisms and enhancing the remineralization
sites of initiation for potential carious lesions of carious lesions. The relationship of fluorine
on different teeth (Table 1). Distributions of in water to the epidemiology of caries has
caries and hypoplasia can then be tabulated long been recognized, and the introduction of
together, so that relationships between them fluoridation to water supply, together with
can be recognized. Even so, there are varying fluoride toothpaste, are today major factors in
types of hypoplasia, some more prominent the control of dental caries. It is clear that
than others (Hillson & Bond, 1997), and it is fluorine should be taken into account in any
not in any way clear that all types predispose study of caries, archaeological or otherwise,
to caries in the same way. but its effect can be difficult to establish.
Fluorine is found naturally in varying con- Large concentrations of fluorine in the water
centrations in the water of different regions, supply can cause enamel defects of a charac-
depending upon the local geology. The partic- teristic type, which usually involves a pattern
ular fluorine analysis of a given region, there- of opacity, called fluorosis (Møller, 1982; Fe-
fore, characterizes not only the drinking jerskov et al., 1988). There are rare reports of
water, but also any food plants and animals fluorosis in archaeological material (Lukacs et
raised on it, and it is passed on into the hu- al., 1985), but it is difficult to distinguish
man body. Fluorine is absorbed into the them from potential diagenetic effects, and, in
bloodstream, from which it is taken up by any case, it does not make a very precise
mineralized tissues as they develop. Within marker of fluorine concentrations in water.
enamel, it typically shows highest concentra- Similarly, analysis of fluorine in teeth is un-
tions near the surface of the crown, with likely to be helpful, partly because the distri-
much lower values underneath (Weatherell et bution of fluorine in enamel and dentine is
al., 1977). In dentine, it occurs in highest con- complex anyway, and partly because fluorine

levels change markedly after burial as a result of lars remain in the socket, because another
interaction with ground water. Instead, it may line of weakness runs along the base of the
be best to examine the water catchment of crown.
different sites studied, obtain water analyses,
and consider possible derivation of drinking
water in the past. Reckoning with teeth that never erupted
One or several of the expected 32 permanent or
The problem of post-mortem missing teeth (and 20 deciduous teeth may never have appeared in
the mouth, and, therefore, must be reckoned
parts of teeth) in archaeology
out in calculating caries statistics. There could
be four possible reasons for this:
Teeth, or parts of them, may be have been lost
post-mortem from archaeological jaws for a va- 1. Congenitally absent teeth. A proportion of
riety of reasons. Each has different implications people in most populations have some teeth
for the recording of caries: which are missing because they never devel-
oped. Most commonly, this involves the
1. Tooth and socket missing. A whole segment
third molars (up to one third of people may
of jaw may have broken away, taking the
have one or more missing), followed by the
sockets and teeth with it. In such cases,
upper second incisor, second premolars,
nothing can be recorded about caries, attri-
lower first incisor and first premolars. In
tion or the bone of the alveolar process.
jaws where there has been significant bone
2. Tooth missing, socket present. In archaeo-
loss (below), it may be difficult to decide
logical material, teeth may fall out of the
whether or not teeth were originally there.
jaw, leaving an empty socket. This particu-
2. Impaction of teeth within the jaw. There are
larly affects the single-rooted incisors, ca-
many different anomalies of dental eruption,
nines and premolars. Study of such
and some teeth (often the third molars
specimens involves much fitting of isolated
again) never emerge from their bony crypts.
teeth into the correct sockets, but many
Radiography is required for detection.
teeth may simply have been lost. In such
3. Teeth not yet erupted in young individuals.
cases, although caries and attrition cannot
The permanent teeth erupt between 5 years
be recorded, any alveolar or periapical bone
and the early 20s in three phases —first
loss can still be detected.
molars and incisors, then canines/premolars/
3. Part of the tooth broken away during burial,
second molars, and finally, third molars.
excavation or laboratory work. Archaeologi-
DMF scores rise through childhood and into
cal teeth have a number of lines of weakness
early adulthood, simply because more teeth
(Hillson, 1996) which cause them to break
gradually arrive in the mouth to become
up, particularly when they dry out after
carious. As each new tooth erupts, a succes-
cleaning. The main line of weakness in in-
sion of sites for the accumulation of plaque
cisors, canines and lower premolars divides
appear.
the crown along a buccolingual plane,
4. Exfoliation of deciduous teeth. As they are
whereas molars tend to break into quadrants
replaced by their permanent conterparts, all
along the lines of the main fissures. In post-
information about caries in the deciduous
mortem fractures, the broken surfaces are
teeth is lost. Those people who died in
usually clean and sharp. Again, these frag-
infancy, and, therefore, preserved their de-
ments may be present in the bottom of a
ciduous teeth, may not be representative of
skull box and can, therefore, be re-fitted, but
caries experience amongst the healthier peo-
they may be lost altogether. Where this has
ple that survived to an older age.
happened, it may be possible to record
caries in some initiation sites, but not others. These difficulties are minimized when caries
Frequently, the root trunk and roots of mo- statistics are kept separately for each tooth type.

Mechanisms of ante-mortem tooth loss mm from youngest to oldest age groups at the
Romano –British site of Poundbury, compared
Once erupted, permanent teeth are lost only with 2 –3 mm at Spitalfields), and the root
when they are removed mechanically through surface of the teeth is progressively exposed. It
injury or surgery, or when so much supporting is this shortening of the socket as wear pro-
bone is lost through remodelling of the alveolar gresses down the roots that apparently resulted
process that they can no longer be sustained in in the loss of teeth amongst recent aboriginal
position. This remodelling takes place in rela- Australians and Inuit (above). In very worn
tion to continuous eruption, the changing oc- teeth, where only a fragment of root is left, this
clusal relationships between teeth resulting from may be housed in such a shallow socket (or
attrition, periodontal disease, and periapical practically no socket) that the tooth becomes
bone loss relating to exposure of the pulp to loose and can be pulled out simply in the
infection. fingers —‘The teeth of the old people are gener-
After the initial establishment of a tooth in ally worn down by attrition and when loose are
occlusion, continued eruption takes place generally removed by themselves’ (Cran, 1957,
throughout adult life at a slow rate. The 18th/ p 280) and ‘Excessive use results in loosening
19th century crypt at Christ Church, Spital- the teeth only when the roots have become so
fields, in London, contained a much-studied shortened by attrition at one end and by root
group of people whose age-at-death is known absorption from the other that only short
from parish records. There was a steady increase stumps not surrounded by bone are left’
(Pedersen, 1947, p 731).
with age in the vertical distance between the
In addition to this gradual upward migration
inferior mandibular canal (chosen as a reference
of the tooth sockets through the alveolar pro-
point inside the body of the mandible) and the
cess, there is also a change in their position
root apices, cement –enamel junctions and oc-
relative to one another, and to the outer com-
clusal surfaces of the molars (Whittaker et al., pact bone plates of the alveolar process. This
1990). At the same time, the distance from the results partly from ‘mesial drift’ of the teeth in
canal to the crest of the alveolar process re- response to approximal wear (Begg, 1954; Kaul
mained relatively constant with increasing age, & Corruccini, 1992), but the supporting bone is
so the roots of the teeth appear to have been known to respond by remodelling to a whole
progressively exposed. The Spitalfields people, range of changing forces acting on the dentition
like several other groups of post-Medieval Lon- (MacPhee & Cowley, 1975). In some cases, the
doners, had very little occlusal wear, and so the alveolar bone lining the socket comes very close
net result was that the overall height of the face to the labial/buccal compact bone plate at the
in older individuals was greater than in younger surface of the process. Remodelling may remove
individuals. Continuous eruption thus occurs part of the bony covering of the root, so that it
whether or not the teeth are worn rapidly is covered only by the gingivae and, in dry
(Clarke, 1990) but, in people where the rate of skulls, this is seen as a notch known as a
attrition is more rapid, it is thought that the rate dehiscence, or window-like opening, known as a
of continuous eruption may be increased to fenestration (Muller & Perizonius, 1980; Clarke
compensate (Danenberg et al., 1991). The infe- & Hirsch, 1991). Even if an opening was not
rior mandibular canal to occlusal surface mea- present during life, the surface bone may have
surement in earlier groups of archaeological been so thin that it fractures away easily in
material remains relatively constant for increas- archaeological specimens and exposes the root
ing wear (Levers & Darling, 1983; Whittaker et (Brothwell, 1981). It is important to be able to
al., 1985), as does the distance to the crest of recognize this post-mortem effect by the sharp
the alveolar process. This implies that the wear edge exposing different coloured bone at the
rate is at least partially balanced by the eruption edge of a pseudo-fenestration.
rate. By contrast, the distance to the root apex It may be difficult to disentangle the root
and cement – enamel junction increases (by 10 exposure of continuous eruption (and other

remodelling of the alveolar process) from active rapid occlusal attrition. Whatever the mecha-
bone resorption, which relates to inflammatory nism of pulp exposure, a broad spectrum of
conditions. The most common condition of this micro-organisms initiates an inflammatory reac-
kind is periodontal disease. This involves an tion in the pulp. In some cases, this produces
irregular inflammatory response to the presence few symptoms, whereas in others there is pain,
of micro-organisms and antigens in the plaque, sensitivity to cold and pressure. The pulp may
in the supporting tissues of the teeth, through- contain the infection and recover, but is more
out life. It progressively disrupts the periodontal likely to die and the bacteria, their products, or
ligament, which binds the root into the socket, the products of the inflammatory process pass
and this results in loss of the alveolar bone down the root canal, to emerge through the
lining the socket, starting at the crest of the apical foramen. This initiates an inflammatory
alveolar process. This is seen first of all as a response in the bone around the apex of the
porosity and then as a deep, narrow trench roots (periapical inflammation). Even at this
around the root as the thin alveolar bone lining stage, the infection may be contained, but it
of the socket is resorbed (Kerr, 1991), followed often settles down to a chronic (slowly develop-
by a more generalized remodelling of the alve- ing) inflammation, typically a periapical granu-
olar process which reduces its height as a loma (Soames & Southam, 1993; Dias & Tayles,
whole. The distinguishing feature of bone loss 1997). This is seen initially as a small radiolu-
relating to periodontal disease (in contrast with cency (typically less than 15 mm across —
general remodelling of the jaw, continuous Whaites, 1992; Goaz & White, 1994) in a
eruption and periapical inflammation) is the dental x-ray, as bone is resorbed to accommo-
trench-like nature of the defect in the alveolar date a growing mass of granulation tissue. The
process in its early stages, around the roots of radiolucency represents a cavity within the
each tooth. The amount of general bone loss bone, extending a few millimetres radius around
gradually increases with age so that the roots of the apex of the root, and with a smooth, com-
the teeth are progressively exposed. Patterns of pact bone wall. In some tooth roots, there are
bone loss are variable, but it generally involves lateral canals which branch off to the side from
a whole segment of the dentition together and, the main root canal (Carlsen, 1987), and these
in recent populations, is more marked around may in a few cases give rise to a granuloma at
the molars and premolars than anterior teeth the side of the root instead (Clarke, 1990; Dias
(Watson, 1986). Eventually, so much support is & Tayles, 1997). Most periapical granulomata
removed that teeth are lost. Today, periodontal cause little pain or other symptoms. In dry bone
disease is an important cause of tooth loss in specimens, as in the jaws of living people, many
older adults. It also seems to have been common require radiography for detection, but general
in, for example, 19th century Londoners remodelling of the alveolar process (see above)
(Molleson & Cox, 1993), but evidence for it is may reduce the distance between the periapical
rare in Medieval and earlier human remains region and the surface of the bone to the extent
(Alexandersen, 1967b), and it appears to have that the side of the cavity is exposed at the
been uncommon amongst the recent Greenland surface in a fenestration (above). The edges of
Inuit, aboriginal Australians and !Kung Bush- the opening are formed by delicate wafers of
men. It is related to the presence of long-stand- thinned bone from the buccal plate of the
ing plaque deposits, so some of the conditions alveolar process, and are often damaged in ar-
that predispose to caries must also predispose to chaeological specimens. In a small number of
periodontal disease, but the connection with cases (possibly one quarter to one third), the
diet is not clear. granuloma may develop into a periodontal cyst,
The micro-organisms of the mouth may gain through the replacement of the granulation tis-
access to the pulp through a rapidly developing sue by fluid, and an increase in size of the
carious lesion, a narrow crack which opens up in cavity. It still has a smooth bony lining and, as
the tooth crown (and may leave little surface it starts to bulge out the periosteum which
evidence), a more extensive fracture or, perhaps, covers the surface of the bone, a thin shell of

bone may grow out beyond the alveolar process not typically marked by bone loss, that is pain-
(usually only a few remnants of this shell survive ful, and has, for centuries, been treated by
in archaeological material). Periodontal cysts extraction (thereby causing tooth loss). Periapi-
look very impressive, but are relatively uncom- cal bone loss is therefore unlikely in most cases
mon in archaeological jaws and are likely to to have been a direct factor in ante-mortem
have been practically symptomless in life. tooth loss. It may, however, have been a con-
Another type of periapical inflammation in- tributing factor in jaws with extensive bone loss
volves the accumulation of pus. This is a peri- resulting from periodontal disease, or remod-
apical abscess, and produces much more elling in relation to continuous eruption of
noticeable symptoms than the granuloma. An teeth. Clarke (1990) maintained that many cases
acute (rapidly developing) periapical abscess is of localized bone loss adjacent to the side root
marked by the rapid build up of pus around the are a result of inflammation of pulpal origin
root apex, with little bone resorption, to invade which occured in relation to a lateral canal,
the spaces within the bone and emerge into the rather than periodontal disease.
overlying soft tissues and form a swelling which The cause of the initial pulp exposure may
bursts. It is very painful and usually associated not always be easy to determine. Often, there is
with a fever. By contrast, a chronic (slowly a large carious cavity in a tooth which has
developing) periapical abscess is not usually periapical bone loss. Sometimes, however, there
painful and, in most cases, does not make the may be a gross carious lesion which has re-
patient feel ill, but does produce an unpleasant moved most of the crown, but no surface sign of
discharge from a channel or sinus into the periapical inflammation (although there may, of
mouth or nose. It may produce its own rough course, be an undetected granuloma inside). It
walled small cavity at the blind end of the sinus has long been noted that periapical inflamma-
within the alveolar process at the tooth apex, tion can be found in association with the expo-
but a larger cavity with rough walls is more sure of the pulp chamber in a large occlusal
likely to represent an abscess which has devel- attrition facet, without clear signs of a carious
oped in a pre-existing granuloma. Dias and lesion, so that it has seemed reasonable to
Tayles (1997) have pointed out that chronic suppose that the pulp was exposed by rapid
abscesses with a proper sinus are considerably attrition (Campbell, 1925; Leigh, 1925b,a, 1928;
rarer than most anthropologists suppose, and Brothwell, 1963; Alexandersen, 1967b; Costa,
that most small bony cavities in archaeological 1980b,a; Clarke & Hirsch, 1991; Lukacs, 1995).
jaws are probably periapical granulomas, ex- The evidence that this actually happens, how-
posed by thinning of the overlying buccal plate ever, is not very clear. Secondary dentine is
of the alveolar process. deposited in the pulp chamber as a reaction to
For the purposes of this paper, the distinction disruption of the overlying enamel covering,
between granulomas, abscesses and cysts may and it seems unlikely that attrition could pro-
not matter much, but the loss of bone involved ceed so fast that the rate of secondary dentine
does, because of its possible relationship with deposition was outstripped (see plates in Camp-
ante-mortem tooth loss. Chronic periapical in- bell, 1925). In the Greenland Inuit, there was
flammation on its own is unlikely to cause little evidence of pulp exposure by wear, even
sufficient bone loss in archaeological jaws to though attrition was the most severe seen in any
destabilize a tooth. Exposed cavities in the alve- group of people, archaeological or recent
olar process are common in many collections, (Pedersen, 1938; Hilming & Pedersen, 1940;
but they are usually small and limited to the Pedersen, 1947; Davies & Pedersen, 1955). On
area of the apex (or occasionally at the side of the other hand, Elvery et al. (1998) noted, in a
the root in relation to a lateral canal; above). radiographic study of jaws from a low caries/
Similarly, the chronic forms of inflammation heavy wear aboriginal Australian group, that
which produce such bony changes are not usu- teeth with associated periapical bone loss were
ally painful, and are less likely to have resulted more often heavily worn than teeth without
in tooth extractions. It is acute inflammation, such bone loss. They also found, however, that

the same teeth frequently had pulp chambers It should, however, be possible to recognize the
which were almost completely filled by sec- site of such a fracture, unless it has been exten-
ondary dentine deposition and, in such cases, it sively remodelled.
could hardly be said that the pulp was being Even in living people, information about the
exposed by attrition. Other factors must have distribution of caries may also not be recordable
been at work. for some parts of a tooth which is actually still
On occasion, periapical bone loss may be present in the jaw. So far as the compilation of
unaccompanied by any sign of a carious lesion caries statistics are concerned, these parts of the
or exposure of the pulp chamber in the occlusal tooth are effectively missing ante-mortem:
attrition facet. In such cases, it is reasonable to
Wear. Occlusal and approximal attrition may
assume that there is a crack in the crown. The
remove large parts of the tooth, and it is not
heavy loads applied to teeth of hunter-gatherers
possible to make any assumptions about
might create fine cracks, through which micro-
their history in relation to caries.
organisms could still infect the pulp (Pedersen,
Dental fracture. Ante-mortem breaks in the
1938; Alexandersen, 1967b), as well as large
tooth may be recognizable by their worn
fractures right through the tooth, especially
and rounded appearance, and, again, may
when the softer dentine was exposed at the
remove caries initiation sites.
centre of the occlusal surface. ‘Extensive frac-
Calculus. Some parts of the tooth may be
tures exposing the pulp are rather frequent’
covered with calculus deposits, and no as-
(Pedersen, 1947, p 729) in recent East Green-
sumptions can be made about caries in the
land Inuit. In some very worn teeth, the roofless
underlying enamel.
pulp chamber or open root canal is exposed in
Caries. A gross carious lesion itself removes
the attrition facet, but this does not in itself
evidence of where it was initiated.
prove that the pulp was originally exposed by
rapid attrition. Populations in which teeth wear It is, therefore, clear that ante-mortem missing
rapidly often also commonly chip and fracture teeth and missing surfaces need to be consid-
their teeth, and it is rather more likely that such ered very carefully in archaeological studies of
fractures are responsible for the pulp exposure caries. In view of their place in a whole network
(see above), as well as contributing to the rapid of factors involved in the pattern of caries, it is
loss of the crown during wear of that tooth. probably just as dangerous to ignore them as it
Similarly, there is no reason why the initial is to put them into caries scores and indices.
exposure should not have occurred during the
development of an earlier carious lesion which
was arrested and then worn away. In some Conclusion: desiderata for a caries
archaeological groups, it is not uncommon to
find an exposed pulp chamber, associated with recording scheme in archaeology
dark staining, in the centre of a very worn
tooth. With all this in mind, what is needed for
One possibility that should not be forgotten recording archaeological caries?
is ante-mortem tooth loss resulting from trauma 1. There seems little advantage in trying to
to the jaw itself. Most jaw fractures track along arrive at a recording scheme which attempts
the tooth sockets and, thus, communicate with to be compatible with the mean DMF com-
the oral cavity so they are, in effect, compound monly used to summarize caries experience
(Alexandersen, 1967a; Banks, 1991). The infec- in epidemiological studies of the living.
tion and inflammatory reaction involve the bone There is currently debate about the validity
around the roots, and the processes of fracture of DMF scores in any case (see above), and
consolidation and remodelling also affect the the only studies with which archaeological
alveolar process. All this may remove support collections are directly comparable use
for the tooth, so that it is eventually evulsed, variants that quantify caries for individual
even if it was not lost at the time of the fracture. tooth classes, and give separate figures for

different categories of caries, for filled and which would lead to artificial contrasts be-
for missing teeth. These are closer to the tween archaeological sites where there was
figures which can be produced from frag- differential preservation of juvenile and
mentary archaeological material, in which young adult remains versus older adults.
there is no possibility of estimating a reliable There is, however, a difficulty with archaeo-
mean DMF-T or DMF-S. logical material, because the best age estima-
2. In view of the particular difficulties of post- tion methods for adults are based upon
mortem archaeological tooth loss, it would occlusal attrition of the teeth. Attrition is
be best to carry out an analysis of missing strongly related to the pattern of dental
teeth separately from the tabulation of data caries in adults so, without care, it is possi-
on caries. Figures for missing teeth in mod- ble to enter a circular argument in which
ern populations normally relate to extrac- dental caries shows apparent trends with age
tions by dentists, so it is not clear that which are actually trends with attrition. Al-
ante-mortem archaeological tooth loss ternative age estimation methods based
would follow similar patterns. In any case, upon the pubic symphysis, auricular surface
the roles of such factors as tooth wear and and sternal articulation of the rib should be
fracture and periodontal disease may well used instead (or as well) where possible. If
have been very different. Careful records these alternatives are not available, it is
need to be made of the pattern of attrition, better to abandon any attempt to define ‘age
pulp exposure, discolourations and carious groups’ and, instead, to make explicit defini-
cavities on attrition facets, and loss of alve- tions of groups in terms of dental develop-
olar and periapical bone. Caries also needs ment and occlusal attrition scores. In this
to be reckoned in relation to the preserva- way, it is immediately clear what is being
tion of sites on the teeth that would be compared with what.
capable of registering the different types of 6. The dentitions of men and women should
lesions. In other words, the scheme needs to be recorded separately, because there are at
take account of the fact that parts of teeth least some differences between the sexes in
may be missing in archaeological material, the pattern of caries development with age.
as well as whole teeth. Most archaeological studies in which the
3. The scheme needs to take into account the sexes have been separated show that women
much higher rate of occlusal and approximal are more frequently affected by caries than
attrition in archaeological material relative men. Thus, the differential survival of the
to modern populations. This gives rise to sexes on many archaeological sites will po-
different potential sites of caries initiation, tentially create differences in caries statistics
and a different pattern of lesion develop- between sites if they are not kept separate.
ment. It is also important to take into ac- 7. It is necessary to consider the effects of
count such factors as crown chipping and hypoplasia, because the dental enamel de-
fractures, together with abrasions on the fects seen at some archaeological sites are
crown sides and at the cervix. very strongly marked and would almost cer-
4. Different tooth classes must be recorded tainly have had an effect on the progress of
separately, because of their different patterns carious lesions. The difficulty lies in defining
of caries and differential survival in archaeo- a method which takes into account the ir-
logical material. This is particularly true of regular distribution of hypoplastic defects
anterior teeth versus cheek teeth. Upper over the different potential caries initiation
teeth should, similarly, be recorded sepa-
sites of different teeth.
rately to lower teeth. There is no substitute
for separate statistics on different teeth. It is not possible to arrive at a single index of
5. Different age groups need to be recorded caries prevalence that expresses the true com-
separately, because of the clear development plexities of the condition, or is not affected by
with age of caries in living populations differential preservation of different tooth
Copyright © 2001 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 11: 249 –289 (2001)
Recording Dental Caries 273

classes, parts of teeth, age groups and sexes. Contact area caries lesions as percentages
Instead, it is best to make separate tabulations of the total numbers of mesial and distal
for the different categories of carious lesions, contact points surviving —two per tooth.
at the different sites where they may be ini- Gross contact area/occlusal caries as a per-
tiated on different teeth (it is possible to centage of the number of mesial and distal
present these quite compactly as graphs — crown elements surviving —similarly, an in-
Luan et al., 1989a; Fejerskov et al., 1993). tact tooth would have two of these.
If counts of the various categories of lesions Gross coronal caries as a percentage of the
need to the expressed in relation to the sur- number of tooth crowns with any part
vival of those parts of the tooth capable of surviving.
showing the different initiation sites, then the
site totals, out of which percentages or pro- At the cervix, it is often possible to see that a
portions are calculated, are likely to be differ- root surface carious lesion was initiated either
ent for each category. Each total will relate at the cement –enamel junction, or on the
not only to be survival of whole teeth, but to root surface nearby, but in archaeological ma-
the loss of parts of them as a result of frac- terial, it is usually not possible to distinguish
ture, wear and the development of carious le- between the two initiation sites. It is, there-
sions themselves. A large lesion removes all fore, more practical to combine the two as
signs of its original initiation site just as effec- ‘root surface caries’, as in clinical studies
tively as heavy occlusal wear or fracture. It is, (Fejerskov et al., 1993). In some groups of ar-
therefore, necessary to record such large le- chaeological material, it is common for mesial
sions in a way that makes no assumptions or distal lesions to overlap the root surface,
about their original initiation site. This leads cement –enamel junction, and the contact area
to various categories of gross caries, which or cervical crown side. Further, where there is
recognize the range of possible initiation sites pronounced occlusal wear, there may be one
that might have been involved. On the crown, single gross mesial or distal carious lesion run-
it is possible that a carious lesion might have ning from the root surface up the crown to
been initiated in the enamel of the occlusal the edge of the attrition facet. In such cases,
fissures, grooves or fossae, in a buccal or lin- it is not possible to determine the original site
gual pit, or at either the mesial or the lingual of initiation. It is, therefore, necessary to rep-
contact point. If the lesion has progressed far resent root surface lesions as a number of sep-
enough, it may not be possible to tell whether arate percentages:
it was initiated in the occlusal surface at all, Root surface caries as a proportion of the
or at the contact point, and, in some cases, it mesial, distal, buccal and lingual sites, for
may only be possible to say that it was ini- which the cement –enamel junction or root
tiated on the crown. For coronal caries, there- surface is present or visible.
fore, it is necessary to present the frequency Gross cervical caries (where the lesion is
of caries as a number of different percentages: so advanced that it is not possible to tell
Occlusal fissure/groove/fossa caries as a whether it was initiated in the cervical
percentage of the total number of fissure/ enamel, along the cement –enamel junction,
groove/fossa complexes with any part sur- or in the cement) as a percentage of the
viving — it is only practicable to count just number of teeth with any part of the root
one complex per tooth because there are surviving on mesial, distal, buccal and lin-
often several lesions hidden deep in fis- gual sides.
sures. Gross contact area or cervical caries (where
Pit caries as a percentage of the total num- a carious cavity bridges the cement –
ber of buccal pits (in the case of molars) enamel junction and the edge of the ap-
and lingual pits (in the case of incisors and proximal attrition facet) as a percentage of
canines) surviving. the number of mesial and distal cervix
Copyright © 2001 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 11: 249 –289 (2001)
274 S. Hillson

elements surviving —an intact tooth would, Appendix A: Caries recording

therefore, have two of these. scheme
Gross mesial or distal caries (where a cari-
ous cavity bridges the entire crown side
from the cement –enamel junction to the Dental features related to caries
edge of the occlusal surface, or occlusal
and approximal attrition produced a similar Caries and attrition are most easily recorded per
outcome in combination with the cavity) as tooth on recording forms (Appendix B). If the
a percentage of the number of mesial and records are to be entered into a computer data-
distal cervix elements surviving (Figure 7). base, then it makes sense to use the Fédération
Dentaire Internationale (FDI) system of tooth
In addition, it is necessary to have two further numbering (Fédération Dentaire Internationale,
categories, to cope with all the possibilities: 1971), as given on the forms shown in Ap-
Occlusal attrition facet dentine caries as a pendix B. Each row of the form is numbered
percentage of the total number of teeth and these row numbers are referred to below in
with attrition facets that expose dentine (at the titles of each section. The different cate-
the early stages, there may be fissures and gories of observation are noted as number
grooves remaining at the centre of the codes, which can be entered into the forms.
facet and these may still be scored sepa-
rately). General
Occlusal attrition facet enamel edge chip-
ping and caries, in populations where this Row 1. Presence/absence of tooth, and score for gross
occurs. gross caries
Gross gross caries (where there is no indi- Some aspects are recorded for the whole
cation where the lesion was initiated) also tooth, rather than particular sites on it. The
as a percentage of the number of teeth numbering of this category has deliberate gaps
with any part surviving. in it, to match the numberings of other cate-
A scheme for recording caries, together with gories.
all the essential related information about attri- BLANK=missing post-mortem and jaw with
tion, remodelling of the alveolar process, hy- socket missing too.
poplasia, ante-mortem and post-mortem tooth 0=tooth present, without gross gross caries.
loss, is proposed in Appendix A. It incorpo- 7=gross gross carious cavity, involving the
rates the principles outlined above, and is be- loss of so much of the tooth that it is not
ing tested on a variety of projects. possible to determine whether the lesion was
initiated in the crown or root.
8=gross gross carious cavity, involving the
Acknowledgements loss of so much of the tooth that it is not
possible to determine whether the lesion was
I am most grateful for the detailed comments initiated in the crown or root, and there is a
of Dr Tony Waldron (Institute of Archaeol- clear opening into an exposed pulp chamber
ogy, University College London), Dr Helen or root canal.
Liversidge (St Bartholomews and the Royal 10=tooth missing, leaving an empty socket
London School of Medicine and Dentistry, in the jaw without any sign of remodelling.
Queen Mary and Westfield College, London) 11=tooth missing, leaving an empty cavity
and Professor Aubrey Sheiham (Department of in which there are signs of remodelling, but
Epidemiology and Community Medicine, Uni- the bone is not fully remodelled to a level
versity College London). Any errors or omis- contour.
sions in the final draft are, of course, my own 12=tooth missing, with full remodelling of
fault. the jaw to leave a level contour.

13 = no evidence that the tooth has ever incisors (rarely canines). It would be uncommon
erupted (as a result of young age, impaction for there to be more than one pit site per tooth,
or agenesis). but it may happen.
14 = tooth partly erupted (crypt communi-
BLANK=pit site not present or not visible
cating with crest of alveolar process, or tooth
(for any reason).
not yet in wear).
0=site or sites present, but enamel is
15 = anomalous eruption, so that the tooth
translucent and with a smooth surface.
has not reached its normal position in the
1 =white or stained opaque area in enamel
tooth row.
of pit, with smooth glossy or matte surface.
2=white or stained opaque area, with asso-
Occlusal crown lesion sites ciated roughening or slight surface
destruction.
Row 2. Occlusal surface caries in premolars and 3=small cavity, where there is no clear evi-
molars dence that it penetrates to the dentine.
Fissure system, groove and fossa sites. Count the 5 =larger cavity, which clearly penetrates
whole occlusal fissure system of premolars and the dentine.
molars as one site, when any part of it remains 6=large cavity, which was clearly initiated
and can be seen unobscured. Score the deepest in a pit site, within the floor of which is the
lesion, if there is more than one. open pulp chamber, or open root canals
7=gross coronal caries, involving a pit and
BLANK= sites missing for any reason, or
the occlusal crown surface (Row 2 above).
fully obscured.
8 =gross coronal caries, defined as in score 7
0 =sites present but enamel is translucent
above, within the floor of which is the open
and with a smooth surface.
pulp chamber, or open root canals.
1 =white or stained opaque area in enamel
of fissure/groove/fossa, with smooth glossy or
matte surface. Row 4. Occlusal attrition score
2 = white or stained opaque area, with asso- The Smith (1984) system is simplest to use.
ciated roughening or slight surface BLANK=occlusal surface not present, or ob-
destruction. scured, for any reason.
3 = small cavity, where there is no clear evi- 1–8=Smith attrition stage.
dence that it penetrates to the dentine. 10=tooth fractured, leaving a surface which
5 = larger cavity, which clearly penetrates shows some wear.
the dentine.
6 = large cavity which was clearly initiated in
a fissure/groove/fossa site within the occlusal Row 5. Occlusal attrition facet dentine caries and
surface (it does not involve the contact ar- pulp exposure
eas), within the floor of which is the open Count whole facet as one site, and record the
pulp chamber, or open root canals. most severe lesion if there is more than one.
7 =gross coronal caries, involving the oc- BLANK=worn dentine surface, either not
clusal crown surface and contact area or pit. yet exposed, missing or obscured (for what-
8 =gross coronal caries, defined as in score 7 ever reason).
above, within the floor of which is the open 0=dentine exposed in occlusal attrition
pulp chamber, or open root canals. facet, but without any stained areas, or
cavitation.
Row 3. Pit sites in molars and upper incisors 4=stained area of dentine and/or enamel,
Count each discrete pit present. Not all denti- which may or may not be a carious lesion.
tions have them, but there is often one buccal 5 =clear cavity in dentine.
pit on molars and, sometimes, a lingual pit 6 =pulp chamber, exposed in the attrition
tucked in above the lingual tubercle of upper facet, which is stained or appears to have

been modified by the development of a 4 =occlusal attrition has proceeded down

cavity. into the roots of the teeth, so that there is no
8 = exposed pulp chamber in which there is longer any contact between neighbouring
no sign of either staining or irregular forma- teeth.
tion of a cavity.
Rows 8 and 12. Mesial and distal contact area caries
Row 6. Occlusal attrition facet enamel edge chipping BLANK=contact area missing, or not visi-
and caries ble, for any reason.
This category may only be important in 0=contact area present, but enamel is
some collections —particularly hunter-gatherer translucent and with a smooth surface (and
groups. Count the enamel rim of the attrition any exposed dentine is unstained and not
facet as one site. cavitated).
1=white or stained opaque area in enamel,
BLANK= worn enamel rim not yet exposed
with smooth glossy or matte surface (or
at any point on the perimeter of the occlusal
stained patch in dentine).
surace, missing or obscured (for whatever
2=white or stained opaque area of enamel,
reason).
with associated roughening or slight surface
0 =enamel rim of occlusal attrition facet ex-
destruction.
posed at any point, but intact with no
3=small enamel cavity, where there is no
chipping.
clear evidence that it penetrates to the
1 =chipping which appears to be post-
dentine.
mortem in origin.
4=discolouration in exposed dentine of an
2 =chipping which appears to be ante-
approximal attrition facet.
mortem, but is not affected by caries.
5=larger enamel cavity which clearly pene-
3 =chipping associated with carious lesion.
trates the dentine (or clear cavity in dentine
7 =gross carious lesion (scores 7 or 8 in
of approximal attrition facet).
Rows 2, 3, 8, 12, 15, 18), involving the
6=large cavity, clearly initiated in the con-
enamel rim of the occlusal facet, but not
tact area or approximal attrition facet, within
clearly associated with any chipping.
the floor of which is the open pulp chamber,
8 =gross carious lesion, as defined in score 7
or open root canals.
above, involving the enamel rim, within the
7=gross cavity in the contact area or ap-
floor of which is the open pulp chamber, or
proximal attrition facet, which involves
open root canals.
neighbouring occlusal sites (Rows 2 or 6)
and/or root surface sites (Rows 9 or 13).
8=gross cavity, defined as in score 7 above,
Mesial or distal side lesion sites within the floor of which is the open pulp
chamber, or open root canals.
Rows 7 and 11. Mesial and distal approximal
attrition score Rows 9 and 13. Mesial and distal root surface caries
BLANK=contact point missing (for what- Count one site per mesial or distal surface. The
ever reason). site may run into a buccal/labial or lingual site.
0 =no attrition facet around contact point. BLANK=no part of mesial/distal root sur-
1 =approximal attrition facet confined to the face or cement –enamel junction preserved,
enamel. or at least not visible if present.
2 =approximal attrition facet exposing den- 0=root surface/cement –enamel junction
tine at its centre. present and visible, with no evidence of stain-
3 =approximal attrition facet exposes den- ing or cavitation.
tine all the way down to the cement –enamel 1=area of darker staining along cement –
junction. enamel junction, or on root surface.

5 =shallow cavity (stained or unstained), fol- 5 =larger cavity, which clearly penetrates
lowing the line of the cement –enamel junc- the dentine.
tion, or confined to the surface of the root. 6=large cavity, which has exposed the open
6 =cavity involving the cement –enamel pulp chamber, still without involving the
junction, or root surface alone, within the cement –enamel junction.
floor of which is the open pulp chamber, or 7=gross cavity, which involves neighbour-
open root canals. ing occlusal sites (Rows 2 or 6) and/or root
7 =gross cavity, including the cement – surface sites (Rows 16 or 19).
enamel junction or root surface, which in- 8=gross cavity, defined as in score 7 above,
volves the neighbouring contact area site within the floor of which is the open pulp
(Row 9 or 13), occlusal sites (Row 2) or chamber, or open root canals.
occlusal attrition facet sites (Row 6).
8 =gross cavity, defined as in score 7 above, Rows 16 and 19. Buccal/labial and lingual root
within the floor of which is the open pulp surface caries
chamber, or open root canals. Count one site per buccal/labial or lingual sur-
face. The site may run into a mesial or distal
Rows 10 and 14. Mesial and distal root exposure site.
Maximum vertical measurement (to the nearest BLANK=no part of the buccal/labial/lingual
millimetre) from cement –enamel junction to root surface or cement –enamel junction pre-
alveolar bone lining socket, using a graduated served, or at least not visible if present.
periodontal probe. Do not take the measure- 0=root surface/cement –enamel junction
ment if there is evidence that the alveolar pro- present and visible, with no evidence of stain-
cess has been damaged post-mortem. ing or cavitation.
1=area of darker staining along cement –
enamel junction or on root surface.
Buccal/labial or lingual side lesion sites
5=shallow cavity (stained or unstained), fol-
lowing the line of the cement –enamel junc-
Rows 15 and 18. Buccal/labial and lingual enamel tion, or confined to the surface of the root.
smooth surface site 6=cavity involving the cement –enamel
One site, just above the margin of the gingivae junction, or root surface alone, within the
in life. Count as present only when it is clearly floor of which is the open pulp chamber, or
separate from the cement –enamel junction. open root canals.
Only score if the lesion clearly does not involve 7=gross cavity, including the cement –
the cement – enamel junction, the fissure system, enamel junction, or root surface, which in-
a pit or any worn occlusal attrition facet. Rare in volves the neighbouring crown side (Rows 15
archaeological material, and may not be worth or 18), occlusal or pit sites (Rows 2 or 3) or
recording. occlusal attrition facet sites (Row 6).
BLANK= site not present or not visible (for 8=gross cavity, defined as in score 7 above,
any reason). within the floor of which is the open pulp
0 = site present, but enamel is translucent chamber, or open root canals.
and with a smooth surface.
1 = white or stained opaque area in enamel, Rows 17 and 20. Buccal/labial and lingual root
with smooth glossy or matte surface. exposure
2 = white or stained opaque area, with asso- Maximum vertical measurement (to the nearest
ciated roughening or slight destruction of the millimetre) from cement –enamel junction to
enamel surface. alveolar bone lining socket, using a graduated
3 = small enamel cavity, where there is no periodontal probe. Do not take the measure-
clear evidence that it penetrates to the ment if there is evidence that the alveolar pro-
dentine. cess has been damaged post-mortem.

Defects of dental enamel 0 =appropriate surfaces present, but enamel

surface smooth, or with only minor
Row 21. Defects in the occlusal region, above the undulations.
contact area 1= furrow-like defect follows around the cir-
Score defects in the region of the cusp sides, cumference of the crown.
occlusal fissures, fossae or pits, or mamelons on 2=band of pitted defects follows around the
the incisal edge of anterior teeth. circumference of the crown.
3=plane-form defect, in which there is a
BLANK=appropriate surface missing from prominent step running around the crown.
the present tooth or corresponding surfaces
from other teeth in the dentition (refer to
table in Appendix B). Bone remodelling in the alveolar process which
0 =appropriate surfaces present, but enamel may provide evidence for the progress of caries or
surface smooth, or with only minor the causes of ante-mortem tooth loss
undulations.
1 =furrow-like defect follows around the cir- Changes to the alveolar process are not so
cumference of the crown. easily codified into a series of scores, and are
2 =band of pitted defects follows around the mostly recorded by descriptions for areas of the
circumference of the crown. jaw, rather than necessarily per tooth. The
3 =plane-form defect, in which layers of recording sheets included here (Appendix B)
enamel matrix are missing from the tips of consist of a diagram of the alveolar process and
the cusps, and a prominent step runs around teeth which can be annotated, together with
the edge. boxes for scoring bone loss using the Karn et al.
(1984) and Kerr (1991) systems (see below).
Row 22. Defects involving the contact area Dehiscences, fenestrations and cavities within
Score defects on the crown side that may pre- the alveolar process can be drawn on the dia-
dispose to caries in the contact area. grams, and the positions of dental radiographs
BLANK=appropriate surface missing from marked. They are drawn roughly twice life-size,
the present tooth or corresponding surfaces but the variation in size, shape and internal
from other teeth in the dentition (refer to organization means that they can only work as
table in Appendix B). an approximate guide.
0 = appropriate surfaces present, but enamel
surface smooth, or with only minor General thinning of buccal and lingual plates
undulations.
1 = furrow-like defect follows around the cir- The process of remodelling for continuous erup-
cumference of the crown. tion and occlusal adaptation leads to thinning of
2 = band of pitted defects follows around the the buccal and lingual cortical plates of the
circumference of the crown. alveolar process. The changes are usually more
3 = plane-form defect, in which there is a pronounced in the buccal plate than the lingual
prominent step running around the crown. plate. There are no published standards for
describing them, but a range of terms is com-
Row 23. Defects below the contact area or involving monly used.
the cervical crown
Score defects on the crown side that may pre- Thinning of the buccal plate
dispose to caries in the cervical region. The buccal plate remodels around the tooth
BLANK=appropriate surface missing from sockets to create depressions between them, so
the present tooth or corresponding surfaces that the bone above the roots appears to bulge
from other teeth in the dentition (refer to outwards. In advanced cases, the whole outline
table in Appendix B). of the roots can be clearly made out through

the thin ‘skin’ of bone. The sockets of some tween. As alveolar bone is lost through peri-
roots are, in any case, normally prominent, such odontal disease, the crest of the approximal wall
as in the upper canines and incisors, but their first becomes porotic, and then irregularly re-
level of prominence becomes much greater. At moved, to create a gap between the teeth. Use
the same time, the bone around the cervix of number scores from Kerr (1991) to record the
the tooth shows wafer thin against the root, profile of the top of the approximal wall, poros-
rather than making a stout edge. ity and destruction (see also Hillson, 1996).

Dehiscence
A dehiscence is a ‘V’ shaped opening in the Deformities of the alveolar process
alveolar process, extending down a root from
the alveolar margin at the cervix of the tooth Bone remodelling associated with periodontal
(Muller & Perizonius, 1980; Clarke & Hirsch, disease causes gross changes to the alveolar
1991). The edges of a dehiscence are usually process. The characteristic change is a selective
wafer thin. Care must be taken to distinguish removal of the thin alveolar bone lining to the
the dehiscence from post-mortem damage (look socket, either just along one side of the root or
for a sharp edge with a different colour to the around several sides to make a trench-like defor-
surrounding bone surface), and from irregular mity. The buccal and lingual plates of the alve-
defects of periodontal disease (look for involve- olar process may be involved as well, to produce
ment of the alveolar bone in other parts of the a more general deformity. Use letter scores (C,
tooth socket). T, R, P, CR and RC) from Karn et al. (1984) to
describe changes from normal morphology in
both jaws (see also Hillson, 1996).
Fenestration
A fenestration is similar to a dehiscence, but is a
circumscribed opening, further down the root Periapical/periradicular bone loss
(Muller & Perizonius, 1980; Clarke & Hirsch,
1991). It may expose a granuloma and, in such Both direct observation and x-rays should be
cases, it is important to distinguish it from the used to look for periapical bone loss, or similar
sinus of an abscess (see below). loss at the sides of a root in relation to a lateral
canal. The record should distinguish between
Hypercementosis different ways in which the area of bone loss
Hypercementosis, and irregular over-production has been exposed to view, or otherwise de-
of cement on the root surface, is common in the tected. Strictly from the point of view of a
jaws of people with heavily worn teeth. The caries study, differential diagnosis of granuloma,
irregular swelling of the roots is accommodated cyst or abscess is not a large issue because,
by resorption, and they may be exposed in a when associated with a carious lesion, all three
fenestration or dehiscence. Hypercementosis imply that the pulp has been exposed. Similarly,
can be detected in x-rays as a swollen and their role in ante-mortem tooth loss is unclear,
irregular root outline. although a granuloma or cyst may cause enough
bone loss to contribute to the loss of tooth
stability, in combination with continuous erup-
Defects of the approximal wall between sockets tion and periodontal disease.
Periodontal disease is an important alternative
cause of tooth loss. It is most easily monitored Visible cavity within the alveolar process
by examining the wall of bone which separates
neighbouring sockets in the same jaw (the ‘ap- Bone loss resulting from a granuloma or cyst is
proximal wall’), consisting of the thin layer of seen as a cavity in the bone around the apical
compact alveolar bone lining each socket, with foramen at the apex of the root, or occasionally
a thin zone of trabecular bone sandwiched be- around a lateral foramen at the site of a root.

Record different roots in multi-rooted teeth Sinus

separately. Defined as a well-demarcated tube or canal,
whose blind end is at the side or apex of the
root, and whose open end emerges at the sur-
Visibility of cavity face of the alveolar process, maxillary sinus, or
Visible through an ante-mortem opening in nose. To be sure, it should have substantial
the thinned buccal or lingual wall of the walls and a well-defined opening, distinct from
alveolar process (i.e. a fenestration or dehis- a fenestration fringed by delicate wafer-like
cence, rather than a sinus). bone (see above). Most apertures around the
Seen through a sinus (definition below). apex in archaeological specimens are probably a
Seen on extracting a loose tooth from its fenestration, rather than a sinus, and care also
socket. needs to be taken to recognize an opening
Seen through a post-mortem break in the made or enlarged by post-mortem damage.
bone (look for a line of different coloured Where there is a clear indication that it is a
bone along the break) —a post-mortem sinus, however, the nature of the opening
break may enlarge a pre-existing should be recorded:
fenestration. Through the buccal/labial or lingual plate of
the alveolar process.
Location Through the angle of the palatine process of
the maxilla into the floor of the nose.
At the apex of one or more roots. Into the maxillary sinus.
In relation to a lateral canal part way up the Onto the buccal or lingual aspect of the
root. mandibular body.
In the cervical part of the root, or the root
trunk of a multi-rooted tooth (Clarke & Interpretation
Hirsch, 1991). Dias & Tayles (1997) have defined a periapical
To buccal, lingual, mesial or distal of the
granuloma as a small cavity (B3 mm radius as
root, or centrally under the apex. measured above) with smooth walls, and a
radicular cyst as a larger cavity of the same
Size type. It is, however, possible for a granuloma to
Measure radius with a graduated probe, and be larger and a cyst smaller. An acute abscess
make allowance for the root protruding into the developing in a granuloma or cyst may show as
cavity. a slight roughening of the wall of the cavity. A
chronic abscess is recognized by its sinus, which
Less than 3 mm radius (from the side of the may have no real cavity at its blind end near the
root to the wall of the cavity). tooth root. A large cavity with rough or ragged
More than 3 mm radius.
borders, especially in the cheek tooth region of
It is also possible to estimate the overall maxi- the mandible, is distinguished as chronic os-
mum diameter, including the root (see radiolu- teomyelitis, and may show the classical signs of
cencies below). multiple cloacae, sequestra, and involucrum.
More than 15 mm diameter.
More than 25 mm diameter. Periapical radiolucency
The size and appearance of the radiolucency
Wall of cavity depends on the projection of the image (orien-
Smooth and well-demarcated. tation of specimen, x-ray source and film), and
Slightly roughened. may be explained by normal features, such as
Clearly roughened, with a ragged the maxillary sinus, incisive foramen, mental
appearance. foramen and mylohyoid line, as well as the

presence of a zone of bone removal within the Secondary dentine infilling of pulp chamber and root
alveolar process. Detailed descriptions of nor- canal
mal radiographic anatomy are given in Whaites Primary and secondary dentine cannot be dis-
(1992), Goaz & White (1994) and Wood & tinguished radiographically, but the pulp cham-
Goaz (1997). The same texts give details of ber/root canal size is reduced by secondary
the usual projections used for clinical work, dentine deposition, starting at its roof (infilling
and the terminology used below follows theirs. the horns first), followed by more general re-
duction in width. The chamber/canal may ap-
Normal pear to be infilled completely, but there is
The root and apex are outlined by a narrow often a thread-like radiolucency running down
radiolucent band, which represents the space the root, so it cannot be assumed that the
occupied in life by the periodontal ligament, tooth is dead.
and outside this is a thin, clearly demarcated
line of radio-opacity (the lamina dura) repre-
senting the alveolar bone lining the socket. Interpretation
Between adjacent sockets, and within the body Circular or pear-shaped radiolucencies centred
of the alveolar process, an irregular, dense on a root (usually the apex) are usually inter-
granular texture is created by the trabeculae. preted as granulomata or cysts. The over-
whelming majority in modern clinical practice
Lamina dura are granulomata. Size may help to distinguish
As alveolar bone is resorbed, there is local loss them, as very few granulomata give a radiolu-
of the lamina, often apparent without a wider cency over 25 mm in diameter, whereas most
area of radiolucency. It may, however, be diffi- radicular cysts are larger than 15 mm in diame-
cult to discern, and sometimes the lamina is ter, but in many cases the radiolucency is
poorly defined even in normal jaws. smaller than 5 mm. With reference to dry
bone specimens (see above), it should be noted
Radiolucent area that the measurement on a radiograph includes
A radiolucency of varying size and shape may the root within the total area of radiolucency,
be apparent within the trabecular texture sur- whereas the direct measurement on the speci-
rounding the lamina dura. It may be circular to men is made from the side of the root and,
pear-shaped, and centred on the apex or side therefore, is a smaller value. Cysts usually have
of a root, or it may be more widespread. It a well-defined radio-opaque border, but granu-
may be diffuse, without clear margins, or lomata may not do so. A periapical abscess
sharply demarcated by a clear radio-opaque may not give rise to any radiographic features,
line. The approximate diameter can be mea- but may be associated with a radiolucency cre-
sured on the radiograph, but factors of magni- ated by a pre-existing granuloma or cyst. Scle-
fication and distortion need to be taken into rosis is taken to indicate chronicity of the
account (Whaites, 1992; Goaz & White, 1994). condition. Osteomyelitis is seen as a much
larger, diffuse, ragged radiolucency of ‘moth-
Sclerosis eaten’ appearance, and is almost always con-
Sclerosis is a thickening of trabeculae, and defined to the cheek tooth area of the mandible.
position of isolated areas of denser bone.
These are seen as isolated radio-opacities
within the trabecular texture of the jaw, either
as a diffuse area of opacity, or more sharply Appendix B: Recording forms for
defined. It may occur right next to the lamina caries
dura, or outside the margin of a radiolucency.
Occasionally, sclerotic patches occur adjacent The columns of the forms are numbered ac-
to teeth which do not have any evidence of cording to the FDI system and the rows are
pulp exposure —the cause is unknown. numbered, as explained in Appendix A.

Appendix C: Diagrams for recording the condition of the alveolar process. The out-
morphology of the alveolar process line of the alveolar crest is drawn as a black line,
and the approximate line of the alveolar crest
Only diagrams for the permanent dentition are relative to the roots can be drawn onto the
given here, as the changes described in the text diagram. Similarly, the relative amount of
are less relevant to the deciduous dentition. The crown/root worn away can be indicated, with
teeth are numbered according to the FDI system the positions of periapical bone loss, fenestra-
(see Appendix A) and the boxes are for adding tions and dehiscences. The same diagrams are
scores for pathological changes according to the also useful for noting post-mortem changes to
Karn et al. (1984) and Kerr (1991) systems (also the alveolar process, with the positions of x-rays
in Appendix A). Space is provided for notes on and other details.

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Recording Dental Caries in Archaeological Human Remains, Hillson. 2001

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Recording Dental Caries in Archaeological Human Remains, Hillson. 2001

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International Journal of Osteoarchaeology

Int. J. Osteoarchaeol. 11: 249 – 289 (2001)

Recording Dental Caries in Archaeological

Introduction alist lifeways (Lubell et al., 1994). In addition, it

Chicago Standards (Buikstra & Ubelaker, 1994)

The natural history and different forms of caries

Figure 2. Carious lesion at the contact point of an upper

in a population affected by caries. In all popula-

Figure 5. Another lesion on the root, at the cement– enamel

highest rates, the upper canines are affected.

studies in the living, including the famous

secondary dentine. This means that the tell-tale

The role of tooth wear and fracturing in caries

The prevalence of fissure caries tends to be low

elements surviving —an intact tooth would, Appendix A: Caries recording

been modified by the development of a 4 =occlusal attrition has proceeded down

Defects of dental enamel 0 =appropriate surfaces present, but enamel

Record different roots in multi-rooted teeth Sinus

References imaging of dental tissues. Anatomy Embryol 5: 145 –

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