 It is my pleasure to introduce Trent Tomblay for today's talk and I believe everybody knows Trent. Would you like to say a few words? Do you want to introduce yourself? No, I know pretty much everyone here, I think. It's weird being on the other side. Let's put it that way. So, the title is from Saliva to St. Moram or Oram Hygiene in the Middle Ages and the case of Lake Medieval. Vilamana. Vilamanya. Please welcome Trent. Everyone see that okay? Okay, so thank you for that introduction. There's quite a bit to get through so I think I'm just going to jump right in largely because I want to make sure there's enough time for discussion and questions and answers. I'm looking for a lot of feedback or any sort of comments that you guys may have. So I'd like to start off by discussing the kind of context in which this work was conducted. This is a small side portion of a larger ongoing research project on the archaeological site of Vilamanya, Italy. It was originally established as an imperial state under the Roman Empire before converting to a monastery in the Middle Ages. The following presentation is part of the bioarchaeological analyses conducted under the Human Remains Project at Vilamanya, co-directed by Sabrina Agarwal and Patrick Boshane from the University of Michigan-Dearborn, as well as in conjunction with colleagues from Sapienza University in Rome and the University of College London. These bioarchaeological analyses are aimed in part to glean an understanding of daily life and well-being within the late medieval community of Vilamanya by analyzing the cemetery skeletal assemblage that was recovered from the site from excavations throughout 2006 to 2015. What I'm going to present today are the data encompassing oral pathologies, anti-mortem tooth loss, cavities or caries, abscesses, calculus or tartar, and periodontal disease. I will first detail a brief etiology of each of these oral pathologies before discussing how they fit into broader bioarchaeological debates. We will then examine the results for such pathologies from Vilamanya before expanding the discourse surrounding the mouth and examining the ways in which medieval people conceptualized, wrote and depicted mouths and oral pathologies throughout the Middle Ages. My goal is to use the rich ethno-historic context available to us as a point of reflection for rethinking bioarchaeological practice in order to build a biohistorical synthesis with the medieval mouth as its focus. So let us begin with a brief account of the oral pathologies examined and their etiologies. Anti-mortem tooth loss is one of the first oral pathologies we often look at in bioarchaeological skeletal samples. Anti-mortem tooth loss refers to teeth that have been lost or extracted prior to death in the individual. These teeth can be lost as a result of advanced cavities which penetrate the pulp chamber and weaken the ligament to their corresponding sockets, advanced dental wear, intentional extraction or from trauma. Bioarchaeologically, anti-mortem tooth loss is characterized by the resorption and remodeling or smoothing of bone surrounding the two sockets after loss. So this complete resorption and kind of bubbly texture we see here is indicative of anti-mortem tooth loss. Cavities or caries in the bioarchaeological literature are a multifactorial infectious disease whereby enamel surfaces of teeth are de-mineralized as a result of acedogenic bacteria within dental plaque. Dental plaque can adhere to the surface of enamel containing acid rich or acid loving and acid producing bacteria such as streptococcus and lactobacillus species. These bacteria then ferment dietary carbohydrates and sugars to produce organic acids which reduce the resting pH level of the mouth and create an acidic environment which causes irreversible damage to enamel structures. Cavities are scored bioarchaeologically by the absence of enamel alongside the presence of decay. So we can kind of see this pit or hole here is a classic kind of example of a pulp perperation cavity. Abscesses are the result of cavities that infect and penetrate the pulp chamber of a tooth then exit out the root. Infection of the pulp chamber can be caused either as a result of cavities penetrating the pulp chamber or from non-carious pulp exposure through significant wear as well as trauma. If severe, infection will become pyogenic which leads to a substantial inflammation and the formation of a granuloma or massive inundated inflammatory cells. This granuloma then stimulates osteoclastic activity right here which begins to resorb surrounding bone as the inflammation continues to expand. Calculus or TARDR is formed when salivary calcium phosphate minerals naturally precipitate out of the saliva resulting in partially calcified substrate that adheres to the surfaces of teeth. While innsipiate formation of calculus is not entirely understood, oral hygiene and the implementation of dentifrice technology such as tooth brushing appear to severely inhibit further accretions. Calculus is scored bioarchaeologically based on its presence, severity, and location within the oral cavity. So we can kind of see these chunks of almost cement looking structures adhering to the teeth here as calculus. Finally, periodontitis or periodontal disease is an advanced form of gingivitis or gum inflammation and bacterial infection resulting in degeneration of the gingival or gum margins. While gingivitis is a relatively benign inflammation of the gums and affects almost all adults who do not practice daily oral hygiene, periodontitis results in a malignant resorption and loss of irreplaceable bone that supports sockets for the dentition. In skeletal samples, periodontitis is often recognized by the marked porosity and kind of bubbles you see here, as well as exposed trabecular bone of the alveolar margin due to the resorption of the overlying bone. So essentially a recession where you could see the crown and the exposed root is often because this bone has been lost and dipped beneath where the crown meets usually the gums. The proximate causes of each of these pathologies are fairly well understood, yet their ultimate causes in relation to the ecology of the oral cavity is still an exciting frontier of research. Now, one of the most important factors regarding oral pathologies and oral homeostasis is saliva. This quote by salivary researcher Erwin Mandel laments to the fact that saliva is often underappreciated compared to other bodily fluids, despite its immense capabilities of effecting oral cleanliness, taste, and digestion. As we can see from these diagrams, saliva is crucial to the oral cavity. I'm only going to focus on the dental aspect here of teeth, this highlighted in blue, just to showcase how important saliva is. So we see that it's important in buffering, particularly with the result of phosphate proteins and bicarbonates. It protects against demineralization of the enamel surfaces, particularly with mucins. Remineralization with slathering and phosphates of particular importance, and then lubrication, so to make sure that the mouth is not too dry. Again, mucins play a huge role in this. The chart on the right depicts the particular role in which saliva aids in remineralizing enamel surfaces that have become demineralized, often as a result of cavities or acidic environments. It's part of what we usually call the remin-demin cycle, where phosphates and calcium are constantly cycling to protect against the kind of demineralized portions of cavities. Despite its importance, saliva's importance, bioarchaeologists and dental anthropologists have been slow to pick up on the magnitude with which saliva has affected the teeth they examine. Recently, a handful of scholars have underscored the importance of saliva in relation to cavities and oral pathologies observed in archaeological populations. This has helped to bring saliva within the fold of dental anthropology, but not without its challenges. Firstly, reconstructing saliometric and saliochemical profiles in archaeological samples is near impossible. There is no saliva that exists. And clinically, salivary content and salivary flow varies tremendously from person to person throughout the time of day, bodily position, and with stimulation such as food, as many of you are experiencing right now. Second, advocates for the salivary hypothesis have advanced their claims within a larger umbrella of reproductive ecology. Under this model, it is proposed that females are innately prone to higher frequencies of cavities and other oral pathologies due to hormonal fluctuations throughout the life course, particularly at events such as pregnancy. Such hormonal fluctuations are suggested to result in a decrease in salivary production, quantity, and chemical quality, ultimately failing to protect and buffer teeth against acidic bacteria and cavities. It is worth noting that the advocates of the salivary hypothesis have posed that increased female cavities is a near universal in bioarchaeological samples, oftentimes synthesizing bioarchaeological results alongside biomedical and clinical research in contemporary western women. Now traditionally, bioarchaeologists have subscribed to a different model, a dietary or behavioral model, whereby oral pathologies are explained in relation to subsistence practices, food ways, or other behaviorally centered actions. This view remains the predominant view in bioarchaeological practice, though has come with a potential cost of ignoring the importance of clinically demonstrated salivary research. If sex differences in oral pathologies are observed, they are often explained on the basis of gender differences in diet and subsistence. As such, if females are observed to have higher amounts of cavities in a bioarchaeological population, it is often explained as females having a higher reliance on starchy cultogens compared to their male counterparts. The opposition of these models should be met with caution, though their separation illustrates the difficulty with which bioarchaeologists have wrestled with biocultural models. We know that the proximate causes of cavities in oral pathologies quite well, rather the debate entails what are the ultimate causes. The decision of where to draw the line between biology and culture in relation to dental ideologies is one that often differs from researcher to researcher. Ultimately, this debate underscores issues in scale and what is considered more important within the biocultural spectrum. With this in mind, we can turn to the case of Vilimania and see what medieval dental tissues might reveal about our models. To give a brief context of the study, Vilimania was a large, around 17 hectare imperial estate located in the Sacco Valley of the Lazio region, approximately 65 km southeast of Rome. The site was initially established in the 2nd century as an estate under the Roman Empire, where it was frequented by young Marcus Aurelius prior to becoming emperor. After the fall of Rome, it was established as a monastery in the late 10th century before transforming into a castrum, or fortified village in the 13th and 14th centuries, though we aren't exactly sure where people were living during this time period. Archaeological excavations were carried out from 2006 to 2015 as part of a large international research project, which discovered a cemetery skeletal assemblage in the process of excavating the medieval monastery in San Pietro Church. Burials have been discovered from the late antiquity period up to the late medieval period. In particular, this project focuses on the remains from the late medieval chronology, given the smaller sample sizes in the preceding periods. A total of 113 individuals were analyzed, representing just under 3400 teeth, though I'm only going to focus on a sub-sample of adults as children are often tricky due to their varying levels of dental development as they grow. It is worth noting that the under-representation of older males, here, three, has forced us to collapse the 30-49 and 50-year age categories into one category for the purposes of statistical comparisons. Now to kind of talk briefly about some of the evidence we have for dietary subsistence in foodstuffs in Vilimania, it's consisted largely, looks like it consisted largely of serial cultogens and terrestrial herbivorous fauna. Documentary evidence from the central medieval period in the 9th and 11th centuries at Vilimania details records of produce and agrarian products tied to the monastic lands, such as wheat, barley, faba beans, and chickpeas. Subsequent zoarcheological analyses of the winery discovered vast evidence of terrestrial fauna, domesticists, typical of medieval agrarian context, such as sheep and goat, pigs, cattle, there we go, cattle, sheep, goats, pigs and cattle, there we go. Previous stable isotopic research conducted by niche at Vilimania has also revealed interesting dietary trends. Analyzing stable nitrogen and carbon from human bone collagen, niche discovered that not only did Vilimania have incredibly low values compared to other Italian sites, but that females in particular showed markedly low nitrogen values compared to their male counterparts. This niche suggested that the community that had monastic ties to Vilimania likely had a large reliance on C3 cultogens. Low female values could reflect reduced access to protein compared to their male counterparts, but could also suggest that female fasting is a form of religious observance. Or additionally the influence of crop manuring in male diets with increased nitrogen levels. With this brief context, let us see the results of the dental analyses at Vilimania. So again, I'm going to start with the anti-mortem tooth loss, and instead of presenting this in strict table format, I've decided to try to do more of a visual format with heat mapping. So essentially the more green, the more likely it is for a tooth to be present, and the more orange or red, the more likely it's to be absent. And so what we end up seeing is that posterior dentition for both females and males was lost at significantly higher portions than the front teeth, smiling teeth. But what's interesting to note is that women actually seem to lose quite a bit less teeth. On average, each individual lost three to four teeth before death, whereas males lost four to five. This is kind of surprising given a lot of the reproductive ecology model hypotheses, as well as clinical evidence of women typically losing teeth before death, much more than men. Now in terms of cavities or caries, there's two kind of ways to go about it. The traditional frequency essentially looks at taking the number of teeth with cavities and dividing by the total number of teeth present. This is just a kind of classic ratio, right? And when we do that and compare the males and females, we see no statistically significant difference. Now the stats that I'm using here are what's called a G-test or a likelihood G-test. It's a part of the chi-squared family distribution. It's essentially using observed and expected counts, much like you would a chi-squared. It's just more conservative because if you have large amounts of counts like you often do with teeth, upwards of 3,400 teeth, those results can often inflate the statistical significance, so I decided to go with a G-test instead of a chi-squared test. What's interesting though is if we use this corrected factor, which is proposed by Lukak's, the main proponent of the reproductive ecology model, we end up seeing a statistically significant difference, but with males having more cavities than females. And what this correction factor does is essentially says that you take the number of teeth with cavities, but you add it to the number of teeth lost anti-mortem or before death with cavities. This is because in populations that have lost a lot of teeth before death, likely lost those teeth as a result of cavities, so you're accounting for these kinds of losses. And instead of just dividing by the total number of teeth observed or present, we're actually adding that to a total number of teeth lost anti-mortem as well. So it's essentially trying to create or correct for false positives. And so what we end up seeing is not only does the prevalence completely jump in almost 9%, 10% in the female, and even higher in the males, but this difference actually shows a statistically significant difference with males having more cavities, which I don't think Lukak's would be happy about. When we look at calculus, we see no statistically significant differences between the sexes. Teeth were heavily affected by calculus. About 65 to 70% of all teeth were affected by calculus or advanced tartar buildup. But generally speaking, for either age group, 18 to 29 or 30 plus years, as well as total, there's no significant difference between males and females. We observe a similar thing with abscesses. Abscesses don't often occur too frequently, but even when they do, we don't really see any large difference going on with either age groups or when they're totaled between the age groups for sexes. And so similarly with the calculus, we see no significant sex differences in abscesses. Now, when we look at periodontal disease, we do see something kind of interesting. So instead of using a GTS, I'm using what's called a relative risk ratio. This is a statistic commonly employed in epidemiology, and it's frequently used to compare different groups for risk of exposure to diseases. So what this number essentially tells you is the times likelihood of a group having the pathology compared to the other. In this case, males across the board are at higher risk than females, particularly in the 18 to 29 age group. Males are 1.35 times likely to have periodontal disease than their female counterparts. 1.13 times likely in the 30 age group. And if we total it all up, males in general have a 1.17 times likelihood of having periodontitis. Now, there's no real hypothesis test that we use for relative risk ratios. Instead, we use 95% confidence intervals. And if the confidence interval covers one, in other words, if the lower value and upper value overlap one, we usually say it's not statistically significant. But these are pretty close, 0.99. And so we do think that males have quite a bit more periodontal disease going on, which again is kind of surprising compared under the reproductive ecology model. So altogether, what are the results from the dental analyses at Vilimania Show? It shows that anti-mortem tooth loss affected both sexes similarly in terms of location, whereby posterior teeth were more likely to be lost before death. But that on average, on average for the entire population, 3 to 5 teeth were lost before death. But this loss appears to have affected males more particularly in the posterior dentition more than females. In terms of cavities, we see that males showed a higher prevalence of cavities when compared to females, which was surprising given the ethno-historic and isotopic analyses, which suggested that females had restricted access to proteins and an increased reliance on starchy cultogens. Finally, no significant differences were observed in terms of calculus or abscesses between males and females, though males did end up showing slightly higher values of periodontal disease. I think overall these results were surprising and call into question both reproductive and dietary models. For the reproductive model, we would expect far greater amounts of oral pathologies for females, particularly given the three times over-representation of older or 50-plus females compared to males. Similarly, the dietary model proposes that the ethno-historical and isotopic evidence of decreased female access to protein would preclude females as exhibiting higher amounts of oral pathologies, likely as a result of increased reliance on coarse cultogens. Our results support neither of these hypotheses fully but the error in debating something as complicated as cavities as an all-or-nothing mutually exclusive model. Furthermore, such debates reveal more about the researcher's stance in the field and less about the people who were actually studying. As such, to move away from this, I would like to reposition the analysis of dental tissues to include the people in which they were embedded and incorporate a variety of sources beyond disciplinary bounds to try and elucidate what such pathologies and tissues meant to medieval people. We do not have any documents relating to the oral hygiene specific to Villamigna, but we can draw more generally from continental Europe on medieval conceptions of the mouth and oral health care. The lack of sources is in part an issue in historiography, whereby the history of dentistry has largely been ignored prior to Pierre Fouchard and his seminal 1728 volume, Le churgeon dentiste. I'm not even butchering that. Pierre Fouchard is widely considered the father of modern dentistry, and as such has been celebrated in historiography for his separation from his seemingly backwards medieval forebears. What information we do have about pre-modern dentistry has actually not been examined by historians, but rather by modern dentists with historical interests. As such, what follows is a temporally and spatially broad exploration of the ways in which pre-modern dentistry and medieval mouths were conceptualized. Yet, one cannot begin to understand medieval mouths without first going back to classical notions upon which medieval conceptions were built. We begin with Hippocrates of Kos, the famous Greek medical philosopher and purported father of Western medicine. In his treatise on breaths, Hippocrates explains the importance of one's breaths. Now, bodies of men and animals generally are nourished by three kinds of nourishment, and the names that are of are solid food, drink, and wind. Wind in bodies is called breath, outside bodies is called air. It is the most powerful of all in all, and it is worthwhile examining its power. So great is the need of wind for all bodies while a man can be deprived of everything else, both food and drink for two, three or more days, and yet live. Yet if the wind passages into the body be cut off, he will die in a brief part of a day, showing that the greatest need for a body is wind. Aristotle similarly wrote of winds as the earthly exhalations of the cosmos. Some 500 years later, Galen of Pergamon, the famed surgeon of Rome, repositioned air as more internal to the body, articulated as Numa, the product of inhaled air that passes through the lungs and then into the left ventricle of the heart before being ignited with hot blood, resulting in the seat of the soul. Hot in this sense refers to the humoral theory of disease, whereby the four bodily humors, black bile, yellow or red bile, phlegm, and blood were associated with different temperatures, consistencies, and resulting temperaments. The tremendous impact of Galenohypocratic humoral theory in the Middle Ages was largely fostered by the 9th century translational movement into Arabic and distributed throughout the Islamic world and Christendom. Protervations in harmonious humoral faculties could be treated with humorally calculated dietary regimens. Remedies then were often dietetic, as different foods held different humoral compositions and therefore could be mobilized as prescriptions to recalibrate humoral imbalances. Galen articulated nutrition as one of the three natural faculties of man and food as one of the six non-naturals, or hygienic regimens external to the body that could impact internal humors. The dietetic nature of food and humoral theory situated the mouth then as a crucial entry point, the foyer for medicinal care. Galen's suggestion that a healthy life was a moral obligation is furthered by the hygienic and dietary regimens that accompanied them, and the oral cavities that processed such culinary medicaments. In this sense, the mouth was not just a bodily orifice, but a cosmological one as well. A portal for the soulful breath and medicinal care. The Greco-Roma tradition, drawing from Hippocrateses on breaths, Aristotelian winds as celestial and cosmological earthly exhalations, and Galenic notions of Numa positioned the breath as integral with the natural world and philosophy. However, the internalization of air as a vital life force meant that it could be corrupted in situ and then spread outwards through the mouth should the humors be improperly aligned. Breath that was corrupted was no longer soulful Numa, but rather miasma, a notion that contagion and illness were spread through bad air. Justin Stearns' work on medieval conceptions of contagion and disease suggests that diseases were conceived endogenously, from the inside out, not from the outside in, with the mouth as the ultimate place of contagion and contraction. In this sense, the oral cavity acts as both a receptacle and a vector for disease and illness. And so we can see this kind of famous sermon in the top quote here, that the heavenly bodies are through some mixture of elements from which a corrupting smell is emitted. We receive this air through the mouth, and after a man has been corrupted, all the air that he inhales and exhales is corrupted by the corruption that he carries within him. And this image on the left here is from a famous Latin manuscript, the Omnibonum. And while we don't exactly know what's going on in this image, we have essentially a practitioner of what might be a dentist with extraction irons, trying to extract teeth, a snaky black figure with all the teeth attached to it, probably indicating something like miasma. Yet the means by which disease could spread via the mouth could vary. While a number of disease and illnesses were thought to be spread through respiratory pestilence, conceptualized as airborne pathogens, diseases could also spread through language. In a 15th century Salamanca manuscript, a Castilian preacher suggested that leprosy was a disease of the mouth, whereby those who spoke ill of others resemble nothing as much as lepers whose mouths also stank. The preacher suggested to keep sinful speakers at a distance and follow Christ's advice to keep one's mouth clean of foul speech. Leprosy in this case was likened and contracted to sinful speech acts rather than airborne pathogens. It had a potential repercussions for physical proximity to others. Bodily visuals, surfaces, aesthetics, and odors were particularly important medieval social relations. And as such it may be no surprise that they would be laden with moral and religious underpinnings. Such corruption did not affect all equally and oftentimes pestilence was associated with gender conceptions of the female body. The medievalist Brenda Gardner-Walter suggests that the famous lines fair is foul and foul is fair hover through the fog of filthy air and the witches behavior depicted in Shakespeare's Macbeth was actually drawing on earlier medieval notions of witch physiognomy and humoral theory. Women were especially prone to the toxicity in pestilence as their wombs, conceptualized as the one internal difference between the sexes were thought to be humorally cold and moist. Thereby tempering respiratory air and beyond the possibility of ever achieving a vital soulful Numa. This could prove disasters for female temperament, particularly in older women as their bodily capacity for humoral heat was thought to be nearly extinguished by old age. Finally, if not purged regularly, the menses could rot, producing fumes that would rise up through the orifices, corrupt the eyes, the breasts, the brain and thereby psyche and temperament and as well give the tell-tale sign of festering corruption and witchcraft, foul breath. Thus, witchcraft and its associated physiognomy were predicated on moral and biological explanations of aged and gendered bodies drawing on a longer tradition of oral vapors, heirs, and their phenomenologically associated odors. In both pathogenic and linguistic concepts of contagion with which physiognomy here, the mouth reflects larger religious and moral anxieties about the finality of the soul embodying illness, gender and age. As such, given the gravity with which gendered conceptions of physiognomy were associated with mouths and their odors it's no surprise then when Catherine Crocroft, an English literature scholar specializing in medieval theological concerns of the mouth and lying states silence, the closed orifice is most often encouraged as the best ornament of a woman in the Middle Ages. Now the power of mouths could actually reach beyond humans as well in a critical assessment of Revelations 917-919 and the Four Horsemen of the Apocalypse Beatis of Lebanah states by these three was the third part of men killed by fire and by the smoke and by the brimstone which issued out of their mouths because the power of horses is in their mouths and in their tails. Another recurring image in medieval Christian theology was the depiction of hell mouths monstrous beings whose mouths were the entrance of hell itself. These depictions were common in a variety of media but were often associated with the last judgment or Christ's triumphant descent into hell in Christian theology. We see a couple examples of illuminated manuscripts here and there's also the example from the opening title slide. Perhaps one of the most interesting forms of the hell mouth could take was in the form of a prop in medieval theater. We see here the depiction of a hell mouth uses a prop which would not only scare the audience but also act as a trap door and the reason actresses could enter and exit the stage through the grisly symbolism of a monstrous theological mouth. I chose this image not only for the depiction of a hell mouth prop not working, kind of working but also the obvious foreground. We see here a woman tied down by a number of men with a particular individual here poised with long extraction irons extracting her teeth. This is St. Apollonia, the patron saint of dentistry and toothaches. In this small church of San Bernardo of Monte Carrasso in the Italian side of Switzerland we see in the upper right corner a 15th century mural once again depicting the forced extraction of St. Apollonia. She was originally a deaconess of Alexandria and Egypt when an uprising and riot against Christians in 249 resulted in her capture. She was then tortured by having all of her teeth extracted one by one before escaping her captors and self-immolating. Her martyrdom helped her to become canonized by Pope John XXI in the 13th century as the patron saint of dentistry. She's often depicted with forceps gripping a tooth, often times a molar as well as the palm of the martyr as we see here. And in other images or iconography she's depicted with a book symbolizing her educated life in Alexandria. In his early 14th century manuscript Rosa Anglica, John of Gadinson wrote extensively on treating toothaches for medieval people and was likely well-read among non-professionals. In one prescription John writes that anyone who prays to St. Apollonia on February 9th, her feast day would likely have their toothaches cured. While she's been depicted in medieval churches throughout England with an extension of 55 representations in the Isle alone St. Apollonia appeared to carry a tremendous following throughout medieval Europe given her artistic depictions in varying forms of media from stained glass to tapestries and even to screen panels. A particular concern here is the church covenant that was constructed in her name in the late 16th century in the Trastevere district of Rome purportedly holding much of her bodily relics though the church was destroyed in the 19th century and no longer exists the adjacent Piazza de Santa Apollonia where the church faced remains a toponymic remnant of its past and her power. Now perhaps the most famous relics of St. Apollonia her famed ablated teeth housed in the Seide de Porto in Portugal down here and the Cathedral of Assumption of Virgin Mary in Robcrucia up here. The former represented by what appears to be a lower molar and this by a premolar. Pilgrimages to Apollonia's relics were likely common throughout the late medieval period underscoring the importance of what things like toothaches and dental pain could drive people to move across vast distances. However, Apollonia's bodily relics appeared to have been employed so much circulation by the 15th century that their authenticity came under question. Concerned with the abundant circulation of dental relics in 15th century England King Henry VI ordered all relics to be gathered likely for authentication purposes. What resulted was over a ton of teeth that were collected in the central plaza and leading the 17th century chronicler Thomas Fuller to write were her stomach proportionate to her teeth a country would scarce afford her a meal. Now apocryphal as these tales may be such tales reveal fascinating insight into medieval oral health care. While a number of medievalists have thoroughly researched the circulation and commodification of relics such a tale begs the question where would these purported dental relics of Apollonia i.e. the ones that certainly did not belong to her come from? The removal of remains after death seems unlikely except for the cases of the recently deceased in the Middle Ages. Thus were individuals complacent and the intentional ablation or extraction started to be marketed or commodified as relics. We may never know answer to such questions and although highly improbable I found it certainly entertaining to think of our bioarchaeological colleagues working on anti-mortem tooth loss in medieval British remains might be in part caused by the intentional extraction for reliquary purposes rather than the cause of cavities or oral pathologies. Interestingly much of what we know about the medieval extraction of teeth comes from art historical analysis of St. Apollonia herself by seriating a large number of artistic representations of Apollonia in a variety of media from paintings to relief carvings. José de Piva Baleo argues that the iconographic depiction of Apollonia's extraction irons correspond to temporal understandings of dental anatomy. The extraction irons are the iconic prime identifier for St. Apollonia so it must be disclosed that they're often depicted in larger scale than they would have normally occurred. Nevertheless seriation of iconography shows early depictions of having long rods leading to bulky C-clamp clasps. The breadth and bulkiness of the claws can only grasp so far as the cemento enamel junction basically the tip of the crown here. This paired with the long straight rods suggests that teeth during the Middle Ages were pried in a motion similar to how nails are extracted with the back of a hammer. The process was likely disastrous as the inability to grasp the root and failure to understand how roots were curved with a prying motion meant that the fracturing or complete breakage of a tooth crown from its root was common. Extraction iron morphology unfortunately did not systematically change until the 18th century like we see here whereby large C-clasps were replaced with finer what we call longer bird beet clasps to get far down to the roots as possible and the rods were shortened and curved to allow for smoother extractions. Such changes in technology corresponded directly with understandings in dental anatomy particularly noting how tooth roots were curved and not straight like nails in a board. Changes in extraction technology were slow and as such is likely that many people throughout the Middle Ages experienced painful extractions or dental procedures. It is no surprise then that late medieval dentists were portrayed as charlatans or quacks. So this is Lucas van Leiden's kind of famous painting or engraving the dentist in which we have a dental professor or professional here extracting a tooth and the dental assistant is pickpocketing the man. Dentists were not enjoying a very good career throughout the Middle Ages. Similarly, in the case of Hyronomus Bosch's beautiful Haywain Triptych, we see at the bottom of the center plant panel here a depiction of a quack dentist in a semi-dence cap with a string of teeth around his neck the sign of a traveling dentist or vagabond. Behind him on the table are a variety of curiosities but in particular is a small depiction of a worm. Now the famed 10th century medieval Arabic physician Al-Razi seemed to be intensely concerned with separating himself from charlatan dental practice and his famous example of critiquing charlatanism focuses on dental health care and extraction practices. In his book of medicine for Al-Mansur he describes a folk petty treatment whereby the charlatan or dentist would secretly place a worm into someone's mouth and then remove it so that the patient could visually see that it had been removed from a cavity thus relieving toothaches. Despite a number of medieval physicians detailing such apocryphal examples the etiology, the etiological conception of worms as the cause of cavities might have been more widespread that anticipated. Drawing on multiple sources from throughout medieval Europe David Garabek suggested the etiological conception of tooth worms was not systematically questioned until the 18th century with once again Pierre Fouchard's Le Cheres M. Dentease. Rather the conception may become popularized by the first century Roman physician Scrobonius Largus who stated that after fumigating the mouth with henbane and a rinsing of water small tooth worms will fall out in the process thus relieving toothaches and cavities. Other scholars had similarly argued that tooth worms were a widespread idea throughout Europe reinforced by famous physicians such as Ibn Sina and Paracelsus though with regional differences such as the Germanic reference to Zanwem throughout the 9th and 10th centuries. Medical treatment could vary from the direct extraction of worms with pincers to rinses that would chase the worm out of the cavity or abscess. Fumigations appear to have been particularly popular whereby herb poultices would be ignited and the patient would inhale the resulting smoke to chase out the worm. Aside from henbane prescriptions of Tansi also appear to have been prevalent due to their ability to destroy worms. Interestingly worms could also be medicinally prescribed as a means of accelerating the removal of teeth that was aching. The famous 11th century Arabic physician Ibn Sina and his canon of medicine details that cabbage caterpillars could be placed on a plainful tooth so that they may eat away the tooth fully. Finally, seen in this 18th century image here taken from the manuscript 256, we see the presence of worms within a cross-section of a tooth altogether and this survives up into the 18th century. Altogether the varying successes of tooth worms as an ideological explanation for medieval dental pains suggest that an attack on charlatanism might have been more exceptional and further helps to historically contextualize the health care and hygiene of the Middle Ages without rendering worm etiologies as backwards. Finally, even today St. Apollonia carries a degree of significance in relation to dental care depicted in Catholic prayer cards. The prayers allude to earlier medieval forms of worship in her name which often include a passage along the lines of O'Glorious Apollonia, Patronate of Dentistry and Refuge to all of those suffering diseases of the teeth. I consecrate myself unto thee. What's even more interesting is that in these prayer cards, processions and recognitions as well as venerations of relics are still practiced in parts of Europe to honor St. Apollonia. In the Belgian city of Turnai, a procession takes place during the month of September every year whereby the silvered reliquary arm and relics belonging to St. Apollonia are paraded. In the Flemish region of Belgium an old tradition of celebrating St. Apollonia's feast day on February 9 is accompanied by the special baked good Goetzlingen or pancakes which are supposed to help provide your long immunity to two fakes. I bring these up not only to highlight the vibrant ways in which St. Apollonia is still worshiped today but also to underscore issues in bioarcheological analyses. I do indeed think that we should heed S. C. Humphrey's warning that it is all too easy for the social anthropologists or the historian to produce examples of burial forms or artifact patterns of which the archeologists would never guess the meaning without help from the archeologists would deduce in their right mind that a pastry laden with carbohydrates and sucrose would be mobilized as a form of oral health care. Such morsels illustrate that two fakes, cavities and all manner of oral pathologies are not mere biological pathologies with etiological pathways to trace but rather they embody social acts a means of coming together to bake, to celebrate, to pray and to prevent. Though this is not to say that bioarcheology cannot contribute immensely to such investigations the arrival and art historical evidence on what medieval mouths were like necessitates bioarcheological analyses a rather crude and macabre example will illustrate. While none could deny the pain that St. Apollonia had to endure with the forced extraction of her teeth a bioarcheologist could inquire as to how many teeth she had left in the first place particularly since she was purportedly of older age. Furthermore, bioarcheologists have the potential to research forms of oral hygiene and health care at a local level using techniques such as pyrolysis gas chromatography mass spectrometry may be informative. Such an analysis reveals the carbonized remains of plants that were inhaled to smoke which in the context of medieval Europe and the aforementioned conceptions of toothworm may lead more credence to the fumigation techniques as a widespread and physically embodied practice rather than a fringe or folk remedy as is often been claimed. Similarly, which teeth were lost or cared for throughout the oral cavity available to historical documents or artistic imagery? While the loss of rear teeth before death likely corresponds to mechanical and dietary demands of coarse cultogens how might the retention of front teeth affect daily life? What might the retention or loss of smiling teeth reveal about medieval aesthetics? Given the importance of oral pathologies in facilitating halitosis or bad breath bioarcheologists are relatively poised to comment on such conditions and explore their social ramifications. What might one's breath reveal about the condition in society or even physical proximity to one another? The medieval mouth was likely a daily topic of conversation and if not, it certainly was an aspect of daily life capable of receiving care, spreading disease, entangling itself in academic debates and ingesting the classical soul. The medieval mouth and its accompanying dentition, if anything, seems to be a vital place to start scholastic dialogues. It seems only right to consider such a biosocial orifice in the confines of disciplinary lines and reposition ourselves to not only analyze teeth for their biological information but understand them as biosocial tissues embedded with meanings to the people whom they belonged. Thank you. Fantastic. Questions. Laurie. I'll have more for later, but given the whole idea about bodies being hot and cold and machines being hotter with implications in some society for the teeth and I wonder if there's any consideration in terms of differences of male and female isotopes and whether there may be a correlation between hot food, cold food, and more seen as more appropriate for the human being to balance their health? No, it's a great question. In the case of Willimania and the isotopic research done there I think that Niche did a good job of contextualizing her findings in relation to fasting and this in part comes out of Carolyn Bynum Walker's work with Holy Feast Holy Fast and talking about the ways in which fasting for women might be a form of religious observance and so she says it might not be that men are controlling all the resources or protein it might be actually a form of religious expression. In terms of humors and at least in terms of I think isotopes directly tied with humors it hasn't it's quite been explored yet which is interesting because most of the medical practice was dietary and it was dietetic and it was partially because you were trying to recalibrate your humors based on different dietary regimens and so yeah, it's humeral like capabilities exactly and so it's something that I think the humoral the delving into the historiography of humoral theory is like something I'm still trying to kind of scratch at I think it has huge ramifications for things like isotopic results huge, but I haven't quite seen it discussed I think fully yeah, Maureen so this was fascinating thank you, and it was great to see the visuals too, I would say the same visual and the medieval images you have and wondering in terms of explaining this greater incidence among males whether it might be a by-product of more access to certain medicinal and a little bit of sugar because I mean I only have I have a little bit of a fairly modern list of like apothecary bills for the artificial Florence in the 16th century it's just a sugar so I don't know what's been done but I would guess it might be differential access to like expensive medicines like sugars and whether sugar could therefore be more used by men for other, like to treat other things but in fact not this result yeah, I think that's one of the things that I think that's a really good point in terms of sugar and its direct impact in like the social currency of sugar in the middle ages right I think it gets back to the kind of I think frustration I often have with the adaptationist kind of view that some people who look at dental tissues will interpret it as more cavities he means they were doing something silly or wrong and not really contextualizing it in terms of the social currency of say sugar and I was trying to kind of hint at that with the pancakes right, like this kind of sucrose carbohydrate-laden thing was actually a form of like oral healthcare and is in a way and so I think I think the in terms of Vilimania explaining the kind of differences there's a lot going on and I think the cleavage of these kind of models that we've seen at least in biology needs to again be met with caution and I think acknowledging the kind of biological forces of a lot of what I'm interested in is kind of mechanical force and the actual rate of attrition and teeth adhering to one another particularly as you start to lose teeth it puts more force on other teeth to occlude and so that's something that we're looking kind of more like a biomechanical way but in terms of dietary impact I think that there was probably differences in diet at Vilimania between males and females but we don't really know exactly what those are yet it's something that I think we might work with Carolina a little closer because a lot of the central medieval documents at least are detailing more on what the actual food and domestic goods and products were but I'm not sure at that level Christine Thank you very much three quick things one the higher protein might be males doing different things for example hunting having access to hunting so if you looked at the faunal remains there might be some evidence to talk about the domestic goods but they're still living off demand so you might look at the faunal remains to see about that which would explain the higher faunal two is there any evidence in the teeth oh you mentioned pressure or fancy work but teeth grinding and I mean in theory you should be able to see that and that might lead to not only increased inventive disease but also tension and strife of individuals whether they're male or female I don't know if that's it and then the thing I just want to say really quickly is Chaucer talks a lot about the math so I've got a few quotes I had this great one from Martin Luther which is a different context and I was told that it's a very different context but it's a great quote on how all poisons and diseases are spread by the mouth and it's breathing it's really just the act of people breathing on one another and their sins are what's spreading all this disease which is just awesome and interesting to me in terms of the kind of things going on with protein you know I do think I didn't talk about wear dental wear and that's because it's its own bear and I could go at length about how dental wear is scored and everything like that and the other thing is that males seem to show in the younger age group more wear and then females in the older age group have more wear than the males so it's kind of flip flopped which is interesting because it's why would you have young men with such heavy amounts of wear if they're having access to meat and proteins which typically don't think at least bioarcheologically cause wear and so I do think it could be grinding the influence of manure crops and whether the increased nitrogen would potentially result in these kind of coarse cultogens that might be masking might be simulating something like protein consumption but it's actually just coarse cultogens yeah and legumes that's something we don't yeah I think originally a lot of increased nitrogen values in a lot of parts of isotopic research in Italy are often interpreted in terms of resources which is great but I think we don't quite know what the influence of marine resources are at the La Mania you can separate that with some new techniques but the other thing is again looking at the fauna remains if you find no seashells whatsoever I'll probably not bring those in yeah absolutely a lot of the kind of ways I've been trying to work through the prevalence of cavities and caries and stuff in males has been interesting and what I ended up mainly finding out is a lot of the kind of clinical research that's advocated by the reproductive ecology model has very very small sample sizes and it's based on modern like pregnant women like 16 women or less 8 women in some cases and so I don't know and a lot of times they'll even chalk it up to things like snacking or cravings and things like that yeah and so I think imposing that on any sort of as a bias or an expectation on the dental research is problematic and so unfortunately I think if you find when males have been found to have higher prevalence it's just written off as an exception there are exceptions and that's about it and so I'm trying to kind of at least trying to still tinker with the ways in which how did males show these increased kind of prevalences and almost across the board in every oral pathology so Nancy was one of the yeah Nancy is a really well known abortivation and it's interesting they could be getting treated for deep things with something that could also be an abortivation there's a lot on I didn't go too much into it here but there's a lot on like poultices and like receipts or recipes and quite a bit on some of the on the plants that were particularly used and there's been some interesting follow-up research with the kind of pharmacological properties of a lot of those plants well in some of those too at the time are going to be made into pills and options and syrups and if there's syrups they're going to have the high sugar so you might also be getting something at what the properties being employed were of the plants and they had different nuance and what they could be used for and how they were treated and the preparation techniques yeah the preparation techniques is a complete bear of a thing that I'm still trying to figure out the fumigations yeah with the sugar do you know the ways in which I guess the sucrose like the sugars where were they refined from or were they referenced of course like bricks or something okay yeah other references yeah it's a great idea okay that's great thanks marine yeah, Sabrina typically yeah there's something that's got it but the sugar, straight sugar is not going to do nothing when it's got the carbs something like an alcohol or a beer or something that's got the carb with the sugar it's much more problematic so it's going to be a mixture not just straight again with the dental wear stuff is really interesting the cavity really the big thing is looking at how these oral pathologies link together right and I think wear typically corresponds a lot with cavities in a way because the coarse cultogens are basically exposing different parts of the tooth and dentin if you get to the point where you've worn the enamel completely down to dentin that's going to really expose the pulp chamber which is why you start to see so many abscesses and teeth lost before death but it's hard yeah no sugar I think has to be contextualized because it's not straight karyogenic it's typically in relation with texture yeah yeah Kent so you may have covered this but did you talk about in terms of the basic maintenance of the mouth and the teeth in terms of when brachin comes in is there gender and status differences and when does that come in and does that really have any kind of effect in terms of what you're seeing yeah I think yeah a lot yeah a lot yeah a lot yeah it's a mouthwash pocket no it's a good question I think I didn't go too much into it in the beginning in part because we especially with things like brushing teeth we don't know a ton until again after this 18th century volume is published and that's because dentists get really kind of excited when that volume is published look he's doing real science and he's separated himself from the kind of medieval people so it means anything that kind of goes before him we're still learning a lot about and again historians and historians of medicine in particular have not really been interested in dentistry it's more on things I think like social history but also plague and so dentistry is already kind of underappreciated and so what has been done in terms of that kind of research is often just dentists who maybe work with a historian or go to the archives on the weekend in a way which is good and bad we've learned a lot but we still have a lot of gaps in the case of medieval like brushing techniques the only real evidence we have is thick linen so really coarse linen and you would brush until you're supposedly you're supposed to brush until your gums bleed severely yeah that was the prescription written and which is interesting because then how would something like that affect periodontal gum disease all these kinds of things at Vilomania we have such heavy amounts of calculus Sabrina's laughing because she's seen all these teeth on the front I mean what's kind of interesting here as you can see this kind of lip right because that's where the gums would have been so there's so much gum inflammation going on that your bone has almost completely receded a couple millimeters typically two millimeters is what we use as a standard and so if that starts to recede it means that calculus starts to build directly into the gums there was so most of where the calculus was in Vilomania was what we call inter proximally in between the teeth which means flossing was not probably practice floss your teeth but it's unfortunate because I'm really interested originally I was basically just came across an article that was talking about oral hygiene in medieval Britain and I was kind of interested in that and they had this talk yeah and they had this discussion on linen as a form of like a toothbrush but that was it and since then I haven't really found much else on what people were doing and it's just I don't think it's written about and particularly in the middle ages dentists are it's not the greatest profession and they don't enjoy the best portrayal even in the middle ages particularly later like us we tend to relegate them as kind of quacks or charlatans which has its issues yeah exactly exactly and it's partly because a lot of what we think about medieval medicine is built on these kind of classical notions of you needing to be like a medical philosopher you need to tie in things like philosophy and the cosmos to daily life in medical practice that's why Hippocrates, Galen and all these really famous Arabic scholars like Alrazi and Ibn Sina becomes more prominent is because they're writing about philosophy and how it relates to health now it's interesting and I didn't get to go into it here but I definitely want to look into it for potential dissertation research in Iberia Iberia even though it is Arabic starts to wholesale reject Arabic medicine in a way and you see written prescriptions from there's a copy of one of these big philosophical medical volumes received in Spain and the Arabic practitioner says I'm not so taric and theory heavy I'm just going to rip the edges and use them as prescriptions for my patients so it's kind of interesting to see how those things translate throughout throughout Europe and there's a lot of variability Chris two questions yeah one I was wondering you talked about the different styles of tube extraction is there is there any evidence that can be matched with a method of tube extraction on the things that you're looking at and then I guess more generally is there a way to tell if teeth were either removed with long handled long forceps or if there are other things that are knocking people brawling, pugilists that's a good question I would say I think for the first question I don't know and I think it's in part because if depending on how long ago it happened if it's happened like let's say ten years before death that's basically going to completely smooth over to where we have something more like this whereas there are some I was at the Western Bioreg group conference there was a particular person who's working on whether the holes that we see say like can't get this work but let's say at the top of the screen we have some of the teeth missing but they're not resorbed we typically score those as post-mortem loss, tephanomic curation issues and she's arguing well how might that be related how do you know what if they lost it right before death and again it goes into these things of what if people were using them and they were suddenly deceased you extract a couple teeth and pawn them off as relics and we would not necessarily know if it's anti-mortem or post-mortem because it hasn't had time to do this bony change that we recognize I'd venture to say with trauma if they died shortly after you could maybe know but it's hard to know and it's partially because we don't have the teeth that are extracted 16-year-olds and more like this this whole thing and you can see it's like a dip that's because it's basically completely smoothed over this happened a long time ago that those teeth were lost what is interesting I think is just thinking about these kinds of heat maps and how it fits in there what's interesting is how much the first molars are lost and I think using this is kind of a check for a way that we assume how teeth look or should work or look in modern western, particularly American society is being all there straight clean white is interesting because you don't really have crowding going on in these mouths like we do with wisdom teeth in part because the first molars get lost and so you end up freeing up space for other teeth to come in which is kind of interesting they're all green yeah exactly so one of the things I was mentioning to Maureen right before and I gave a version of this talk in Lisbon and one of the scholars was saying well it's very interesting that you're doing all this but you know like America has quite a reputation for how their mouths look and how obsessive you guys are with the cleanliness and I was like that's a good point and it's kind of thinking about do we assume then are these anti-mortem tooth lost it's like oh they lost it's a pathology or is that just part of normally what happens and we're just kind of fixated on keeping everything there and cleaning pristine so those are some of those things that I think larger ideas I'm trying to still think through Nico hmm that's a great question so one of the things I'm not sure about naturally occurring you'd probably have to do some more like I'm guessing like semi-hydrological research or at work at a landscape scale which would be great one of the things I am particularly interested in potentially for my dissertation research is to look at the impact of what's called Miswak which is basically the toothbrush plant part of the Salvadora persica tree that is prescribed in hadiths by the holy prophets of Islam as a form of religious expression and moral obligation to keep your teeth clean by brushing them with this toothbrush plant and pharmacologically has very high levels of fluoride and it's actually been studied by the World Health Organization for its ability to be used in areas where there aren't access to dental care particularly in northeastern Africa and in the peninsula and so that's one potential aspect like I guess a pharmacological aspect of a particular plant species that I would be interested in looking at but I'm not sure in terms of fluoride I don't know if it's been fully discovered yet So you can get that from hydrology Yeah, I think hydrological I don't think it's an area of fluoride but different springs will have it doesn't go up naturally in this part of the Soco region I'm not sure A lot of work's been done now particularly with things like the World Health Organization they use this metric that's used all over the world called the DMFT score to give each country and each little region a score based on how many teeth are basically worn, trauma filled or decaying and so that score has been used all over the world in almost every country and so they've started to kind of use that in correspondence with modern fluoride geology and hydrology but in terms of medieval I'm not sure but that's a really good question That it? Oh Maury