Medieval Mouths in Context: Biocultural and Multi-Scalar Considerations of the Mouth and the Case of Late-Medieval Villamagna, Italy

Abstract

THIS PAPER EXAMINES THE CULTURAL FRAMEWORK and material evidence for teeth and oral health in later medieval Europe, using as a case study the bioarchaeological analysis of an excavated cemetery in central Italy (Villamagna). It proffers an alternative approach to the study of human skeletal material by reframing the questions that bioarchaeologists normally ask about mouths. Instead of stopping at, ‘how much disease?’ or ‘what state of health?’, here, ‘how did the mouth relate to individuals’ experiences of their world, and how might scientific information about health and disease provide insight into wider aspects of life, society and economy?’ is asked. This paper points to a range of cultural understandings around the mouth which were changing in the High and Later Middle Ages (c 1000–1400), namely: the Bible and changing explanations for the relationships between mouth, heart, confession and experience of the divine; an evolving understanding of medicine and medical principles; and new forms of saintly intervention involved in healthcare. Detailed osteobiographies of two adults from Villamagna illustrate shaped individual experiences and the ways in which oral condition reflects and use-patterns and lifeways common to such communities.

Résumé

Les bouches au Moyen-Âge dans leur contexte : considérations bioculturelles et multiscalaires de la bouche et le cas de Villamagna en Italie, à la fin du Moyen-Âge par Trent M Trombley, Caroline J Goodson et Sabrina C Agarwal

Ce papier examine le cadre culturel et les témoins matériels pour ce qui concerne la dentition et l’hygiène buccale dans l’Europe de la fin du Moyen-Âge, en prenant comme étude de cas l’analyse bioarchéologique d’un cimetière ayant fait l’objet de fouilles à Villamagna, dans le centre de l’Italie. Il propose une approche alternative pour l’étude des ossements humains en recadrant les questions que les bioarchéologues posent normalement à propos des bouches. Au lieu de poser seulement la question des « détériorations plus ou moins importantes » ou de « l’hygiène buccale », nous nous demandons ici « en quoi la bouche est liée à l’expérience vécue des personnes dans leur environnement, et quelles informations scientifiques concernant l’hygiène buccale et la détérioration de la dentition peuvent éclairer des aspects plus généraux de la vie, de la société et de l’économie ». Ce papier identifie une série d’interprétations culturelles de la bouche qui étaient en train d’évoluer au début et à la fin du Moyen-Âge (environ 1000–1400), à savoir : la Bible et les nouvelles explications concernant le rapport entre la bouche, le cœur, la confession et l’expérience du divin ; l’évolution des connaissances dans le domaine médical et des principes médicaux ; et les nouvelles formes d’interventions des saints guérisseurs dans le domaine des soins. Les ostéobiographies détaillées de deux adultes de Villamagna permettent d’illustrer de quelles manières l’état de la dentition reflétait les habitudes d’utilisation et les modes de vie communs à ces communautés et façonnait les expériences individuelles.

Zussamenfassung

Mittelalterliche Münder im Kontext: Biokulturelle und multiskalare Betrachtungen des Mundes und eine Fallstudie zum spätmittelalterlichen Villamagna, Italien von Trent M Trombley, Caroline J Goodson und Sabrina C Agarwal

Dieser Beitrag untersucht den kulturellen Rahmen und die materiellen Zeugnisse zu Zähnen und Mundgesundheit im spätmittelalterlichen Europa, wobei die bioarchäologische Analyse eines ausgegrabenen Friedhofs in Mittelitalien (Villamagna) als Fallstudie dient. Ein alternativer Ansatz für die Untersuchung von menschlichem Skelettmaterial wird geboten, indem Fragen, die Bioarchäologen normalerweise über den Mund stellen, neu formuliert werden. Statt es bei der Frage „Wie viel Krankheit?“ oder „Welcher Gesundheitszustand?“ zu belassen, wird hier gefragt: „Wie stand der Mund in Beziehung dazu, wie Individuen ihre Welt erfuhren, und wie könnten wissenschaftliche Informationen über Gesundheit und Krankheit Einblick in umfassendere Aspekte des Lebens, der Gesellschaft und der Wirtschaft geben?“ Im vorliegenden Beitrag wird auf eine Reihe kultureller Auffassungen über den Mund hingewiesen, die sich im Hoch- und Spätmittelalter (ca. 1000-1400) veränderten: die Bibel und die sich verändernden Erklärungen über die Beziehungen zwischen Mund, Herz, Beichte und Erfahrung des Göttlichen; ein zunehmendes Verständnis von Medizin und medizinischen Prinzipien; und neue Formen heiliger Intervention in der Gesundheitsfürsorge. Anhand der detaillierten Osteobiographien zweier Erwachsener aus Villamagna wird veranschaulicht, auf welche Weise der Zustand der Mundhöhle die in solchen Gemeinschaften üblichen Nutzungsmuster und Lebensweisen widerspiegelte und die individuellen Erfahrungen prägte.

Riassunto

Le bocche medievali nel loro contesto: considerazioni bioculturali e multiscalari sulla bocca e sul caso della tardomedievale Villamagna, Italia di Trent M Trombley, Caroline J Goodson e Sabrina C Agarwal

Questo studio esamina il contesto culturale e la documentazione materiale per quanto riguarda i denti e l’igiene orale nell’Europa tardomedievale servendosi come studio analitico dell’analisi bioarcheologica di un cimitero riportato alla luce a Villamagna nell’Italia centrale. Qui si offre un modo alternativo di affrontare la questione relativa allo studio del materiale scheletrico umano impostando in modo diverso le domande riguardanti la bocca che di solito si pongono i bioarcheologi. Anziché fermarsi a “che grado di malattia?” o a “che stato di salute?”, qui ci si chiede: “Qual era il rapporto tra la bocca e le esperienze che gli individui avevano del proprio mondo e in che modo i dati scientifici sulla salute e la malattia contribuiscono ad accrescere la comprensione di aspetti più ampi della vita, della società e dell’economia?”. Questo studio mette in rilievo una serie di conoscenze culturali relative alla bocca che nell’Alto e nel Tardo Medioevo (1000-1400 ca.) si stavano evolvendo. Nella fattispecie si tratta della Bibbia e delle spiegazioni tra bocca, cuore, confessione ed esperienza del divino che stavano cambiando, così come la progressiva comprensione della medicina e dei suoi principi e le nuove forme di intervento dei santi riguardo alla salute. Le osteobiografie particolareggiate di due adulti di Villamagna illustrano come le condizioni della bocca abbiano rispecchiato usanze collettive e modi di vivere condivisi da tali comunità e abbiano formato esperienze individuali.

Everyone in the Middle Ages had a mouth, yet rather little is known about the cultural history of medieval mouths. The mouth, and accompanying dentition, were not simply an aggregation of utilitarian tissues, nor the sum product of quotidian activities such as speaking, breathing, eating, and kissing, but rather a fundamental interface between the embodied self and the world. While there is rich scholarship analysing the spiritual, metaphorical, and epistemological dimensions of medieval mouths (an attempt at which is briefly illustrated below; Walter 2018, 1) the material dimensions of medieval mouths, dentition, and the care that went into maintaining them have received comparatively less attention. There is much to glean from the larger cultural context surrounding medieval mouths and all their forms, but there is also much to learn about how individual mouths shaped and impacted daily life. There has been considerable bioarchaeological research on medieval dental remains (Garcin et al 2010; Pezo and Eggers 2012; McKenzie et al 2020). However, the scope of much bioarchaeological work (our previous work included) has been to elucidate patterns in oral pathological lesions, and hypothesise the etiological and biocultural pathways that might explain such patterning (pathogenesis; Hillson 1996, 2008). Notably, ‘hygiene’ and ‘cultural behaviors’ have often been offered as explanations for observed patterning of dental pathological lesions and proteomic diversity of oral microbiomes in medieval dental remains (Lopez et al 2012; Novak 2015; Stránska et al 2015; Jersie-Christensen et al 2018). Yet, few studies have deeply considered hygienic regimens and ideas about them in relation to the bioarchaeological record, though the approach is gaining traction (eg Colleter et al 2023).

Like other bodily tissues, mouths, teeth, and their associated aesthetics and values vary through time and space. In the Middle Ages people from various social standings spent a great deal of time thinking about, writing, and illustrating tooth pain and mouths. There is evidence, then, for the embodied experiences of these lesions and mouths, and the ideas and principles by which people sought to understand and treat them. Medieval mouths are potentially better understood in a holistic framework, acknowledging their symbolic and material dimensions in concert; medieval mouths were neither solely metaphorical nor biological objects. This paper suggests that a biocultural and multi-scalar framework, following ‘multi-proxy’ archaeology (Shillito 2017), can contextualise the material and social dimensions of medieval mouths, providing new vantage points on health, disease, and everyday experience.

To begin, this paper considers epistemological, moral, and spiritual concerns surrounding mouths through the evidence of medieval texts. Medieval oral healthcare was both a spiritual and curative enterprise. Finding historical documents directly associated with the osteological remains of everyday people in medieval villages is practically impossible. Instead, this paper uses historical context here (literary accounts and medical treatises) to help develop a historical and cultural background to the ways medieval mouths might have been understood and treated. Then we turn to larger datasets on medieval dental remains to characterise some of the variation in oral cavities and dental pathologies in medieval mouths. In doing so, both the advantages and challenges of analysing dental tissues separately from the individuals to whom they belonged is shown. Finally, a case study of medieval mouths from the later medieval cemetery of Villamagna (Italy) is considered, which provides an example of an integrated biocultural analysis from both a community and osteobiographical perspective, situating teeth in terms of people and experience.

MEDIEVAL MOUTHS: EPISTEMOLOGIES

Throughout medieval Europe, mouths held metaphorical importance as places where matter entered as well as exited the body. Isidore of Seville’s Etymologies, a famous and influential encyclopedia written in the early 7th century and used throughout the Middle Ages, explains that the ‘mouth (os) is so called, because through the mouth as if through a door (ostium) we bring food in and throw spit out; or else because from that place food goes in and words come out’ (Isidore of Seville XI.i 49, 111; trans [English] 246). Isidore’s understanding of the mouth as a portal for matter, as well as words (and ideas) relies upon conceptions that were very ancient in his day, related to both philosophy and medical theory. In the Gospel of Matthew, Christ disputed with the scribes about food purity:

Do you not understand, that whatsoever entereth into the mouth, goeth into the belly, and is cast out into the privy? But the things which proceed out of the mouth, come forth from the heart, and those things defile a man.

(Matthew 15, 11–20, esp 18–20).

Late antique and medieval churchmen’s explanations of this passage focus on sources of corruption and the potential of a corrupt heart or mind, which might issue corrupt words out from the mouth (Glossa ordinaria). Food was hardly sufficient to corrupt a man, as food simply went in the body and then came out again; but the words which come out of the mouth might emit from a corrupt heart and spread filth. Mouths in the Middle Ages were critical vectors for food and nutrition (as expanded upon below) as well as ideas and moral values.

In the High and Later Middle Ages, as confession was increasingly scrutinised by churchmen, the mouth was understood as a vector for the purgation of sin and evil. 'Open your mouth through Confession so that God may fill it,’ wrote William of Auvergne (William of Auvergne, vol I, 491aC; Smith 1998). Miracle accounts often describe the mouth as a portal to permit or deny the passage of spiritual matter. For example, the vomiting of blood or bile at the moment of the miraculous healing of a blind and mute man (12th-century miracle of St Privat, Brunel 1912, 12–13, cf Arnold 2018, 25–6), or the mouth of a Jew which miraculously sealed shut, preventing him from chewing the Eucharistic host he had sacrilegiously taken in (Everett 2002, 914–20, trans [English]: Everett 2016, 220).

One recurring image in medieval Christian theological literature was the hellmouth, a monstrous zoomorphic being whose mouth was a portal to hell itself. The discourse of the mouth of Hell anchored spiritual and theological meaning in material and corporeal terms (Schmidt 1995, 165–78). Hellmouths were depicted in manuscripts, often around the Last Judgement and Christ’s triumphant descent into hell; and were even built into stage sets in vernacular theatre in later medieval England. The mouth of hell provided evocative and diabolical imagery as well being a universal idea that cut across otherwise prominent axes of social difference, where all manner of people from monks and peasants to kings and queens could enter eternal torment through a gaping mouth (Galpern 1977; Schmidt 1995; Rossmeisl 2012).

Because mouths were portals for matter coming into and going out of the body, the metaphorical and physical mouths of humans and demons alike were core to ideas of disease in the Middle Ages. Disease and sickness could take on multiple etiological forms in relation to the mouth, particularly in relation to corruption, contagion, and epidemiological thought. The idea of pestilential air was rooted in Aristotelian, Hippocratic, and Galenic conceptions of pneuma. Whereas Hippocrates acknowledged internal air as a vital essence, he preferentially emphasised the power of winds and airs external to the body as having tremendous influence on health, wellbeing, temperament, and the environment (Hippocrates of Cos 1967, 233). Galen repositioned air as more internal to the body articulated as pneuma— the product of inhaled air that passes through the lungs, into the left ventricle of the heart before being ignited with hot blood (Temkin 1973, 155; Ballester 2002). It was broadly the Galenic tradition that informed medieval thinking on medicine, and in this sense the mouth was not just a bodily orifice, but a cosmological one as well. The Greco-Roman medical tradition positioned the breath as integral to the natural world and philosophy, drawing upon Hippocrates’ On Breaths, Aristotelian winds which were celestial and cosmological ‘earthly exhalations,’ and Galenic notions of pneuma. These ideas remained pervasive in medieval Europe, in part because of the biblical explanation of the Holy Spirit moving through breath, as in the Gospel of John on the Risen Christ (John 20: 23), ‘When he had said this, he breathed on them; and he said to them: Receive ye the Holy Ghost’ (compare to LA, ch 73 The Holy Spirit, [Latin], 496, [English] 303; [Latin] 493, 500, [English] 300, 302).

The idea that internal air was a vital life force or medium that could be corrupted in situ and then spread outwards through the mouth attests to a view of medieval epidemiology that worked, to quote Justin Stearns (2011, 93), ‘from the inside out, not the outside in’. Women were especially prone to internalising toxicity and pestilence, as their wombs, being the internal difference between the sexes, were thought to be humourally cold and moist, thereby tempering air that was breathed in and making it impossible to convert to vital pneuma (Cadden 1995; Dean-Jones 1996; Clark 1999; Walter 2014, 12, 15). This could prove disastrous for female temperament, particularly in older women as their bodily capacity for humoural heat was nearly extinguished. If not ‘purged’ regularly, the menses could rot, producing fumes and gases that would rise up through orifices and corrupt the eyes, breasts, and brain (and thereby psyche and temperament), as well as give the tell-tale sign of festering corruption and demons: foul breath (Walter 2014). In both pathogenic and linguistic concepts of contagion, the mouth reflected eschatological and moral anxieties, embodying illness, gender, and age, interwoven with moral underpinnings.

The mouth was such a key vector that it affected many interactions between people. Monica Green has reminded us that medieval bodies were ‘marked,’ and physiognomy and bodily visualisation were conceived in terms of corporeal ‘surfaces’ signaling social, legal, and moral positioning within medieval society (Green 2010, 159). Thus oral dynamics were intertwined with conceptions of gender as well. Medieval vernacular literature detailed anxieties regarding orality and gender. For instance, the old woman in the Roman de la Rose, a romance verse of the 13th century, warns that:

A woman ne’er should laugh with open mouth;

Her lips must cover and conceal her teeth;

For if too wide a gulf appears, it looks

As though her face were slit—it’s no fair sight—

And if she have not even, well-shaped teeth,

But ugly, crooked ones, she’ll be less prized

Should she let them appear in laugh or smile

(Jean de Meun, vv. 13350–66.; trans [English], 270)

The risks of seeing a woman’s wide-open mouth extended to seeing her genitalia, and both openings should remain hidden (Burns 1993, 204: Perfetti 2003, 8–9). In some social arenas, the medieval mouth was a high-stakes biosocial orifice: a potential void into sickness, moral slippage, contagion, and in the case of hellmouths, even hell itself.

Despite their potential for harm, corruption, and diabolical imagery, medieval mouths could also be loci for healing, salvation, and peace. Early Christian theology noted the importance of kissing for its transmission of the Holy Spirit and pneuma (Perella 1969, 19). Afterall, it was the divine breath that created mankind from dust, as stated in Genesis 2:7, ‘And the Lord God formed man of the slime of the earth: and breathed into his face the breath of life, and man became a living soul’ (cf Job 33:4 ‘The spirit of God made me, and the breath of the Almighty gave me life’). Aside from their importance in betrothal ceremonies, kisses in the Middle Ages not only performed a bringing together of differing bodies and pneumatic souls, but also enacted and performed peace and unity, through the physical act of mouths coming into contact with one another (Perella 1969, 23, 40–2). This can be seen in the proliferation of the ‘kiss of peace’ from the Christian Church context into peace negotiations in the later medieval West (Petkov 2003). The bishop’s kiss also helped mark the importance of transmission of divine breath in Christian initiation rites, including catechism for neophytes (Perella 1969, 19; Kelly 2004). Priestly breaths and exsufflation onto catechumens had roles in both cleansing and demonic exorcising (Kelly 2004, 88, 113, 117). Beyond kissing, mouths provided an interface between physical and spiritual phenomena. One major recurring emphasis in medieval Latin texts is the description of the sensation of ‘sweetness’ (dulcis, suavis, dulcedo, suavitas; Carruthers 2006, 999). Mary Carruthers (2006 demonstrates how taste, and sweetness in particular, was heavily interwoven with knowledge acquisition, persuasion, and healing practices. To know God was, in part, to taste him, as Bernard of Clairvaux (d 1153) eloquently stated, ‘Jesus is honey in the mouth, melody in the ear, a jubilee in the heart’ (Bernard of Clairvaux, Leclercq et al 1996–2007, 15.6, I, 86; Carruthers 2006, 1000). Psalm 33 is a particularly sensorial passage in which the psalmist instructs the reader to keep the lips and tongue from issuing evil, to keep the praise of the Lord in the mouth, and to taste to know that ‘the Lord is sweet’ (Frank 2001, 619–43; Fulton 2006, 169–204), speaking to the value of spiritual senses (Caseau 2014) and what archaeologies of senses may entail (Hamilakis 2013). Contrary to our ‘post-Enlightenment ocular centrism,’ medieval sensory experience may well have privileged the mouth, tongue, and taste (Fulton 2006 20). The double-edged nature of sweetness (in excess, bitterness) also bolstered its relationship with persuasion, as suavis appears to be a cognate with suadeo and persuadeo, to where persuasion is, literally, ‘to sweeten’ (Carruthers 2006, 1003, 1010). Finally, taste and sweetness served both spiritual and practical means in healing, not only through oration, but in humoural balance and calibration (eucrasia). The humoural composition of sweetness (warm, moist) helped to temper humoural compositions, and acted as a prescriptive means of alimentary treatment (Carruthers 2006, 1010; Fulton 2006, 197–9). In this sense, the dietetic nature of prescriptions placed the mouth as the ultimate receptacle for healing. The power of the mouth and its associated sensorial phenomena (such as breath) could thus go both ways—it had the potential for contagion, pestilence, and corruption but also healing, purification, and cleansing. The medieval mouth may well have acted like a dialectical pendulum, with the potential to swing between sickness and healing, contaminating and cleansing.

MEDIEVAL ORAL HEALTHCARE AND REMEDIES

Given the centrality of mouths in nutrition, disease, and morality, it is not surprising that there is considerable evidence for medical advice on oral healthcare. The tremendous impact of classical Galeno-Hippocratic humoural theory on the Middle Ages came in part through enduring theoretical treatises, and subsequent incorporation and popularisation in Arabic scholastic works (Temkin 1973; Pormann and Savage-Smith 2007; Nutton 2013, 236–53). The pervasiveness of humoural theory had ramifications for ideas about the mouth. Briefly, Galen held that the elements cold, hot, dry, and moist were phenomena embodied physically as the four anatomical humours: phlegm, blood, black bile, and yellow bile. Ill health was conceived, in part, due to a humoural imbalance, a perturbation in harmonious humoural faculties (Garber 2008). Remedies, then, could be dietetic, as different foods held different humoural compositions and therefore could be mobilised as prescriptions to recalibrate humoural imbalances. Galenic principles 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 humours (Niebyl 1971; Burns 1976). The dietetic nature of food in humoural theory situated the mouth then as a crucial entry point for medicinal care. Galen’s suggestion that a healthy life was ‘a moral obligation’ is furthered by the hygienic and dietary regimens that accompanied it, and the oral cavities that processed such culinary medicaments.

Medieval recipes provide some evidence for what ailments people suffered and what cures they attempted, whether using humoural remedies or others. They also attest the transmission of ancient ideas about health into the Middle Ages. Dental healthcare recipes could vary in their degree of specificity and focus. In analysing a large corpus of manuscripts of early medieval recipes (n = 4,335), a recent study by Claire Burridge (2020) found 229 ailment recipes related to tooth problems and oral healthcare. The majority of these recipes (n = 186, 81%) were highly specific in their treatments, with nearly half of the remedies concerning toothache (dentium dolorem) and numerous other recipes also concerned with tooth loss (ad dentem cauum), mouth sores and ulcers (ulcera), putridity (ad putridinem oris), and cosmetic concerns such as tooth whitening (ad albos dentes/ad dentes candidos; Burridge 2020, 40–2). Notably, Burridge found a subset of recipes which specifically detailed the treatment of molars (ad dentes molares), perhaps unsurprising given the cariogenic patterning in posterior dentition observable in bioarchaeology, as discussed below. Burridge’s work (2020, 43) makes a case that oral healthcare and toothache was a major concern for early medieval communities, particularly in the Carolingian world.

Oral healthcare, whether inherited from ancient authors or newer medieval efforts, involved the application of remedies or poultices, fumigations made from herbs, minerals, or animal products, and in extremis, surgical interventions. The Chiurgia, a 12th-century Latin treatise written by Roger Frugard in Italy and widely circulated in Latin and vernacular languages, details a variety of oral healthcare techniques and prescriptions (Frugard 1914; Hunt 1994, 5, 6, 19, 20). Frugard prescribed poultices of wine, honey, and a number of herbal ingredients such as mullein (Verbascum thapsus), pellitory (Anacyclus pyrethrum) and ginger (Zingiber officianalis) in order to treat oral illness (Frugard 1914, 178–81). He also prescribed a fumigatory recipe to treat gum pain and toothaches, whereby henbane (Hyoscyamus niger) and leek (Allium porrum) seeds were burned and the smoke was to be applied to the patient’s tooth (Frugard 1914, 180–1). In another collection of 13th-century prescriptions for oral healthcare, the Compendium medicinae of Gilbertus Anglicus, dentifrice technologies employing herbs such as elecampane (Inula helenium) and sage (Salvia officinalis) or even strips of linen were prescribed in order to keep teeth clean and white (and presumably disease free) (Gilbertus Anglicus, 1510, 111; Getz 1991, 89–97; Pughe 1993, 344; Anderson 2004, 420). Teodorico dei Borgognoni (d 1296) was an Italian-born surgeon whose treatise Cyrurgia (c1267) detailed maxillo-facial surgery procedures. In cases where the mandible had been fractured, he recommended to, ‘bind the teeth thus separated and displaced to one another with gold or silver wire or with silk, holding them firmly so they cannot be distracted’ (Borgognoni; trans [English] in Campbell and Colton 1995, 183). He further detailed the importance of stints, linen dressings, bandages, various salves, and liquid diets to accompany surgical procedures and proper healing of the mouth (Campbell and Colton 1995, 203–4). Similarly, the Trotula, a late 12th-century Latin collection of medical prescriptions for women, detailed the importance of dental hygienic regimens. Originally compiled in Salerno, it was widely circulated throughout Europe by the 15th century after its translation into vernacular. The second and third treatises, ‘On Treatments for Women’ (De curis mulierum) and ‘On Women’s Cosmetics’ (De ornatu mulierum), detail various dental prescriptions:

For black and badly coloured teeth, take walnut shells cleaned of the interior rind, which is green, and we rub the teeth three times a day, and when they have been well rubbed, we wash the mouth with warm wine and with salt mixed in if desired.

(Trotula, ch. 182, 142; trans [English] 143).

For whitening black teeth and strengthening corroded or rotted gums and for bad-smelling mouth, this works the best. Take some each of cinnamon, clove, spikenard, mastic, frankincense, grain, wormwood, crab foot, date pits, and olives. Grind all of these and reduce them to a powder then rub the affected places.

(Trotula, ch. 237, 111; trans [English] 112)

For pain of the teeth and for strengthening them if they have moved. Take eleven drams of ammonium salt, fourteen drams of costmary, 14 drams of black pepper, and two drams of clove…Put the salt and [some] bran in a pot until they turn to charcoal. And when this has become cold, grind it with the remaining spices and reduce it into a very fine powder, and rub the teeth and ulcerous places with it.

(Trotula, ch. 239, 164; trans [English] 163; ch 230, 164; trans [English] 165).

The Trotula and other similar collections contain numerous prescriptions and recipes specific to oral healthcare, whether for palliative, curative, or cosmetic purposes. The extent of these recipes and instructions suggests, as did Burridge’s (2020) census of early medieval recipes, an abiding medieval concern for caring for and curing mouths. Remedies, whether folk or academic, thus played an important role in mediating dental ailments, diseases, and pain, as well as oral aesthetics and smells.

Concern around oral healthcare meant that discourses around mouths were central to medieval debates over the theoretical or folk origins of medicine. This is seen in the Arabic literature very clearly. The famed al-Rāzī (d 925) was concerned with separating himself from charlatan medical practice, as his titles make clear, such as ‘Epistle on the Reason Why the Ignorant Physicians, the Common People, and the Women in the Cities are More Successful than Men of Learning in Treating Certain Diseases and the Physician’s Excuse for This’, and his ‘Treatise on the Causes why Most People Turn Away from Excellent Physicians Towards the Worst Ones’ (Pormann 2005). Certainly, these long-winded titles may lend further credence to Álvarez-Millán’s (2004) argument, whereby the corpora produced by medieval Islamic physicians likely reflect self-aggrandising biographies rather than strict insight into medical practices. In fact, al-Rāzī’s famous example of critiquing charlatanism focuses on dental healthcare and extractions. In his Book of Medicine for al-Mansur (903), later translated into Latin in the 12th century as Liber ad Almansorem and widely influential in European medical practices, he describes a folk treatment whereby the ‘medic’ would secretly place a worm into someone’s mouth and then remove it so that the patient could see that it had been ‘removed’ from a cavity, thus curing the toothache (Savage-Smith 1996, 937–8).

While a number of medieval physicians criticise such charlatan cures, the etiological conception of worms causing carious lesions was long-held, with roots in Latin treatises. The concept of tooth-worms was not systematically questioned until the 18th century with Pierre Fauchard’s Le Chirurgien Dentiste (1728; Gerabek 1999). The etiology had been popularised by the Roman physician Scribonius Largus (d c 50 ad) in his De compositione medicamentorum, who stated that after fumigating the mouth with henbane (Hyoscyamus niger) and a rinsing of water, small worms may fall out in the process (Gerabek 1999, 2; Scribonius Largus, ch LIV, 61, 255–6). Tooth-worms were likely a wide-spread ailment in the medieval world, as the works of famous physicians such as Ibn Sīnā (d 1037) and Paracelsus (d 1541) make clear; 9th-/10th- century entries in manuscripts of medical texts from Frankia include ‘zanewurmr’ too⁴ (Riecke 2004, II, 532). Treatment varied from the direct extraction of worms to fumigations and rinses to chase out the worm from the cavity or abscess. Beyond henbane, prescriptions of tansy (Tanacetum vulgare) also appear to have been prevalent due to its ability to destroy worms (Spink and Lewis 1973; Gerabek 1999, 3; Anderson 2004; Benati 2020). Interestingly, worms could also be medicinally prescribed as a means of accelerating the removal of a tooth that was aching. Ibn Sīnā in his Canon of Medicine (al-Qānūn fī al-Ṭibb, 1025) explains that cabbage caterpillars could be placed on painful teeth so that they may eat the tooth away (King 2017, 201). Worms were the cause, and could possibly be the cure, too.

Divine intervention might also be sought to cure dental illness. A 14th-century manuscript in Italian and Latin includes a Brieve (Short notice) on toothaches and headaches, narrating a story of the Apostle Peter’s toothache, caused by an old worm ‘devouring his teeth.’ Jesus instructed the worms to make them go away. The blessing specifies that, ‘This short note can be worn in written form paying respect to Jesus Christ…And whoever wears this short note will be free from toothache. Do this for the servant of yours. Amen’ (Brieve al male de’ denti e a migrana, cioè duolo di testa; ill qual bireve si vuole portare in capo o addosso iscritto a reiverenzia di Jesus Cristo…) (Köhler 1868, 178–9; Benati 2020). Likewise, the English physician John of Gaddesden, whose Latin Rosa Medicinae (or Rosa Anglica) c 1314 was widely distributed in Europe, recommended blessings for toothache (Cholmeley 1912), ‘Also, write these words on the jaw of the patient: In the name of the Father, the Son and the Holy Ghost Amen. +Rex + Pax + Nax + in Christo Filio and the pain will cease at once as I have often seen’ (John of Gaddesden, fol 119, col B).

John of Gaddesden also noted that anyone praying to Saint Apollonia on February 9th (her feast day), would have their toothache cured (John of Gaddesden, fol 119, col B; Cholmeley 1912, 49). Saint Apollonia was a popular saint in the Middle Ages, associated often with cures for toothache (Coens 1952; Skrobonja et al 2009, 500; BHL, 639–42, including 651 supp). The earliest accounts of Apollonia’s martyrdom derive from Eusebius, whose 4th-century History of the Church includes a letter written in ad 249 to Emperor Decius by Bishop Dionysus of Alexandria describing Apollonia as an ‘old lady’ who was battered until her teeth were knocked out and then burned to death (Eusebius 1932, VI 41, 102, trans [English] 103; Callahan 1994, 119). The 13th-century Legenda Aurea identified Apollonia as, ‘an admirable virgin, well along in years’ who was captured by a mob of pagans, her teeth were knocked out and she was threatened with fire, which she valiantly leapt into, to escape (LA, ch 66, 445, trans [English], 268–9; Callahan 1994, 119–20). Another medieval story identifies her as the pious Christian daughter of a pagan king who removed her teeth (and tongue and eyes) in punishment for her refusal to sacrifice to pagan gods (BHL, 641; Coens 1952). A lead medallion of the 13th century depicts Apollonia with her pliers and a molar, and, on the reverse, a prayer, ‘Pray for us Apollonia, to the Lord that he take way all that is hurtful that we may not be accursed, troubled by disease of the teeth, but we may give thanks of health for head and body’ (Fig 1) (Poletti 1934, 113 and fig 41 therein). Given its shape, this was presumably intended to be worn.

Fig 1 Drawing of a lead medallion of Saint Apollonia. Image reproduced from Caronni (1812). (For transcription and translation of text, see Appendix 1).

Relics of Apollonia, especially her teeth, have been held in great esteem for their curative properties. The 17th-century chronicler Thomas Fuller noted how King Edward VI’s decree that all of the Saint’s teeth should be brought to a public officer for the purpose of curative efforts, resulted in a literal tonne of teeth. Astonished, he remarked, ‘Were her stomack proportionable to her teeth, a County would scarce afford her a meals meat’ (Fuller 1665, 331). Some of her purported teeth are housed in the Sé de Porto in Northern Portugal, and the Cathedral of Mary’s Assumption in Rab, Croatia. Indeed, an upper right first premolar (PM¹, 5) held to be that of Saint Apollonia has even been studied for its dental morphology and pathology (Skrobonja et al 2009).

Processions venerating Saint Apollonia’s relics still take place today in parts of Europe. A parade of Saint Apollonia’s relics (alongside those of Saint Ursula) takes place in September in the Belgian city of Tournai.⁵ In the Flemish Ardennes region of Belgium, Saint Apollonia’s feast day is celebrated with the special baked good geutelingen, typically made of flour, eggs, milk, salt, yeast, and cinnamon which, according to tradition, provided year-long immunity to toothaches.⁶ In a medical and pathogenic framework, bioarchaeologists may struggle to see a pastry consisting of carbohydrates as a form of oral healthcare. Yet such processions and treats remind that toothaches, cavities, and all manner of oral pathological lesions are not simply biological pathologies with etiological pathways, but also generate social acts—a means of coming together, to bake, to celebrate, to pray and to prevent.

Images of Saint Apollonia provide information about medieval oral health and hygiene, such as the dozens of late-medieval Books of Hours which mark her feast with depictions of her martyrdom. Callahan has shown that later medieval depictions of Apollonia’s martyrdom evolved from an aged virgin having her teeth removed by blunt impact to a younger, aristocratic figure experiencing a slow removal of her teeth one by one through the use of extraction irons (Callahan 1994). In depictions, she is often shown with exaggeratedly large forceps gripping a tooth, frequently a molar, as well as a book or the palm of the martyr (Boléo 1960, 1963). In fact, by seriating numerous depictions of Saint Apollonia, José de Paiva Boléo (1963) traces changes in dental extraction technology through her depictions over time: early models of forceps were blacksmith irons, characterised by curved rods which permitted more force to be applied in a prying motion, resembling the design of a hammer prying a nail from a board. This may have been due to the limited knowledge of sub-gingival root structures, which were thought to be straight rather than curved, in addition to the fact that many extractions for lay people were likely done by local blacksmiths or even barbers, given the tools and strength needed (Boléo 1963; Jones 2014, 22). Similarly, pincers were relatively simple C-clamps, that gripped the lingual (tongue-facing) and buccal (cheek-facing) sides of a tooth, only making contact with the crown. Handles became increasingly straighter over time with the improved knowledge of root structures as curved, and clasps became narrower and more ‘bird-beak’ in shape in order to establish a grip further down the tooth’s surface, though these refinements did not occur systematically until the 17th century (Boléo 1963). As such, early models were probably bulky and poorly designed, perhaps resulting in more crown fractures than outright extractions (Boléo 1963). It is therefore not surprising that many medieval dentists were seen as charlatans and portrayed with contempt for their palliative efforts until at least the early 18th century (Jones 2014, 22–4). Colin Jones (2014) suggests that the etymological origins of dentist were born out of the French-Latin dentiste, which eventually replaced arracheurs de dents/toth-drawer (‘tooth drawer’) that had been used for centuries before. For artistic renditions of dentists and their accompanying scepticism, readers are encouraged to closely examine Lucas Van Leyden’s The Dentist (1523) and Hieronymus Bosch’s Haywain Tryptich (1512–16).

A BIOCULTURAL APPROACH TO MEDIEVAL MOUTHS—THE CASE OF LATE-MEDIEVAL VILLAMAGNA

Jones (2014, 18) convincingly coined ‘the Olde Regime of Teeth’ to characterise how tooth loss affected 17th- and 18th-century French peasants and kings alike, in some cases reducing speech to ‘an affair of grunts and whistles’ and even making it difficult for portrait-painters in the case of social elites. However, outside of careful and contextual scholarship such as his, medieval oral cavities and accompanying dentition have often been caricatured in grotesque portrayals or descriptions (Burridge 2020, 28). Stereotypes and tropes about medieval mouths as rotten, foul-smelling voids continue to permeate both scholarship and popular culture. Some of these analyses rely on art-historical sources, or retrospective diagnoses (for a discussion, see Muramoto 2014, 9) that focus on famous historical figures, with comparatively little conducted on the actual dental remains of the common medieval individual.

Despite historical, artistic, and literary evidence from throughout the Middle Ages, as discussed above, which demonstrates the epistemological importance of mouths and the remedies for them, the question of what medieval mouths were like from a material perspective has proved paradoxically simple yet equally elusive. In short: what did average mouths look like in the Middle Ages? How were they shaped and maintained. Were there changes with regard to age, biological sex, gender, or social status. These basic questions are critical to understanding both the biological and social dimensions of medieval mouths. This paper argues that oral cavities and the care that went to maintaining them are best understood in a biocultural framework rather than a pathological one alone, and that greater insights can come from everyday evidence of practice rather than high-status, exceptionally resourced mouths, or medical treatises.

Bioarchaeological investigations of medieval oral cavities can illuminate the material dimensions of mouths in everyday people. Both the social and material dimensions of oral health and hygiene can be revealed using a historical bioarchaeological framework (Hosek et al 2020; Colleter et al 2023). Focusing on 19th-century America, Lauren Hosek and colleagues have made a strong case for how the bioarchaeologically and historically situated mouth emerges as a nexus of class, medical care, and identity by employing bioarchaeological methodologies in concert with the analysis of archival sources. Rozenn Colleter et al (2023) closely examine a 17th-century female aristocrat and contextualise their diagnoses of periodontal disease in light of aesthetic, therapeutic and social treatments. Anita Radini et al (2019) recently discovered how lapis lazuli inclusions within calculus (mineralised tartar/plaque) remains from a 12th-/13th-century female skeleton point to the individual’s participation in either manuscript production or lapidary medicine. The material dimensions of medieval oral cavities can thus supplement or even challenge assumptions around people who are otherwise obscured in the available evidence, and collectively reveal population-wide patterns.

Meta-analyses that aggregate data on numerous medieval dental assemblages throughout Europe can also help to situate oral health in historical context. In analysing a large aggregation of medieval British dental remains, Charlotte Roberts and Margaret Cox (2003) found that the frequency of teeth affected by caries increased minimally from the early (410–1050 ad) to the late (1050–1550 ad) medieval period, but the prevalence of individuals with carious lesions increased dramatically (from 5% to greater than 50%) throughout the Middle Ages. Notably, both caries prevalence (proportion of individuals affected) and frequency (proportion of teeth affected) declined from the preceding Roman period (43–410 ad) and became similar to one anotherby the early medieval period (410–1050 ad), before diverging in the late-medieval period (1050–1550 ad). Similarly, analyses on dental remains from medieval Croatia showed little increase in frequencies between early and late-medieval periods (Vodanović et al 2005). Analyses on 12th- to 14th- century dental remains in France showed elevated carious frequencies in male teeth (21.9%) compared to female teeth (14.0%), but no statistically significant differences (Esclassan et al 2009). A diachronic meta-analysis conducted by Luis Pezo Lanfranco and Sabine Eggers (2012, 8–9) identified variability in caries prevalence and frequency throughout medieval Europe. Drastic increases in caries prevalence and frequencies can be seen in the West when globalised sugar processing and trade arrived in the early modern period. Similarly, in another large meta-analysis of European dental remains (n = 4,998 individuals), Antonia Müller and Kais Hussein (2017) found that the turn of the 18th century accompanied an increase in mean caries and ante-mortem tooth loss frequencies, probably coinciding with nutritional changes with regard to sugar, and possibly extractions. A large study conducted as part of the Global History of Health project, analysed n = 9,930 individuals from various European archaeological sites from the 3rd century ad to the 19th century for a variety of oral health indicators (Witwer-Backofen and Engel 2019). The authors found no statistically significant differences in dental caries frequencies nor ante-mortem tooth loss between medieval sub-chronologies (eg early medieval, late medieval). However, when grouped as ‘Pre-medieval/medieval’ and compared to early modern- and Industrial-period dental assemblages, the latter periods showed dramatic increases in both dental caries and ante-mortem tooth loss (Witwer-Backofen and Engel 2019, 110–17, 128–9). Altogether, the authors highlight the importance of numerous factors in explaining the observed patterning, ranging from climatic changes, to the impact of the colonial sugar trade, altitude and oral healthcare (Witwer-Backofen and Engel 2019, 129–31). Finally, a recent meta-analysis by Carolina Bertilsson et al (2022) found a statistically significant increase in average caries experience over time (9000 bc–1850 ad; P < 0.001) with the later-medieval period and early modern period showing dramatic increases in caries as a result of increasing fermentable carbohydrates and sucrose.

Notably, most meta-analyses that have examined medieval oral health in European populations have done so in a diachronic manner, often aggregating medieval dental remains and pathological lesions into a larger sample to compare with other time periods. In order to better elucidate variation in caries and ante-mortem tooth loss within the medieval period, this paper present a new synthesis of medieval caries and ante-mortem tooth loss (AMTL) focusing on adult (permanent) dentition from 48 reports and publications (see Appendix 3). The total sample is characterised by at least 5,210 individuals, representing a minimum of 88,866 teeth and 84,770 sockets. While this analysis is by no means exhaustive or representative of the entire medieval period, these data help to visualise variability within and throughout the medieval period. It is however acknowledged, like other meta-analyses on dental analyses from archaeological sites, that comparing carious frequencies between sites is not always straightforward, due to differences in both recording and reporting procedures. For example, some studies report frequencies by the proportion of individuals affected, while others report the proportion of teeth affected by specified lesions. The under-representation of dental septa here is a result of under-reporting, not necessarily poor preservation. Additionally, the criteria for caries diagnosis can also vary depending on factors such as: visual or radiographic analysis, whether permanent or deciduous are included in final calculations, the demographic make-up of the sample (age-at-death distribution, biological sex), issues of age-estimation methodologies, variability in diagnostic criteria, inter-/intra-observer error, among other things. Therefore, this analysis is restricted to only permanent dentition from medieval (ad 500 to approximately 1500) site reports. While this significantly restricts the overall sample to anglophone reports, it is believed that it should help give a snapshot of larger trends and variation within and throughout the medieval period.

This synthesis shows that carious lesions and ante-mortem tooth loss varied considerably by site and throughout the medieval period, both in terms of teeth and individuals affected (Figs 2 and 3).

Fig 2 Proportion of teeth/sockets affected by caries and ante-mortem tooth loss (AMTL) by site. See Appendix 3 for a detailed list of sites.

Fig 3 Proportion of teeth/sockets and individuals affected by caries and ante-mortem tooth loss in the medieval sites analysed (grey dots). Box and whisker plot overlays mean, interquartile range, and minimum/maximum values. Black squares depict Villamagna. See Appendix 3 for a detailed list of sites.

While caries prevalence varies throughout the medieval period, dental abrasion and attrition are often severe, probably as a result of coarse-textured foodstuffs and inclusions from milling stones (Lopez et al 2012, 527; Pezo and Eggers 2012, 11). In sum, while meta-analyses help to contextualise medieval dental health in broader chronological and continental terms, clearly there is significant variation in dental and oral health throughout the medieval period as a result of localised diets, subsistence patterns, and food preparation techniques, and it is therefore best understood in a regional manner. In the case of medieval mouths, etiologies, disease patterning, and disease experiences were probably mediated at the community level, meaning they were shaped by local contexts of food provisioning and allocation among different social groups, as well as attitudes towards the mouth.

VILLAMAGNA: A CASE STUDY IN MEDIEVAL MOUTHS

In order to illustrate the benefit of a biocultural and multi-scalar analysis of medieval mouths, and to develop the contextual information provided by the medieval texts discussed above, we present here a case study of individuals from the late-medieval site of Villamagna. Situated some 75 km south-east of Rome in the Sacco valley of Lazio (Fig 4), Villamagna was founded as an imperial estate during the Roman Empire, hosting the young emperor Marcus Aurelius (Fentress and Maiuro 2011). By the 10th century, part of the estate was a monastery, with a village for those who worked the monastery’s lands; this lasted until the end of the 13th century. In the 14th and 15th centuries, the area around the church was fortified (a castrum) (Fentress et al 2016; Goodson 2016). Excavations revealed a sizeable cemetery (n = 404 individuals) contemporary with the monastery and subsequently with the castrum. Despite being adjacent to the monastery, the cemetery has a varying demography of adults, children, males and females, suggesting that it served the rural community who had labour ties to the larger estate, not just the monks of the monastery (Candilio and Cox 2016; Fenwick 2016). Archival documents in the cathedral of Anagni attest to the extent of the monastery’s agricultural lands in the neighbouring valley of the Sacco River, the range of crops grown and the working conditions of the peasants on the land (Goodson 2016, 410–19).

Fig 4 Map of central Italy and the site location of Villamagna. Drawing by Caroline Goodson.

Skeletal analysis at Villamagna (Trombley et al 2019) has revealed high rates of oral pathological lesions compared to other medieval sites (Figs 2 and 3). Notably, 73.3% of individuals (55/75) and 16.6% of the dentition analysed (300/1804) showed signs of ante-mortem tooth loss. Cavities affected 80% (60/75) of individuals and 20% of observable dentition (307/1534), and after correcting for ante-mortem tooth loss (following Lukacs 1995; see also Duyar and Erdal 2003), frequencies were estimated to have affected 30–35% of the dentition. Examples of the observed oral pathological lesions can be seen in Fig 5.

Fig 5 Mandible and accompanying dentition of HRU 4307. This exhibits signs of oral pathological lesions typical of what was observed in the Villamagna skeletal sample, including: a) likely gum disease due to alveolar recession accompanied by active remodelling and architectural changes; b) carious lesions (cavities); c) antemortem tooth loss; d) enamel chipping; and e) advanced tooth wear. Photograph by Trent Trombley.

A large proportion (44.3%) of these cavities were situated interproximally, in the spaces between adjacent teeth. Calculus accretions were observed in 63.7% of teeth when pooled by sexes (830/1459). Periapical lesions, which probably form as a result of severe cavities that penetrate the pulp-chamber and go on to infect the maxillary and mandibular structures that house the teeth, were relatively few (2.3–3.3%) but when observed were often severe in size, and typically located buccally (cheek-side) or labially (lip-side). The term ‘periapical lesion’ is used here in place of abscess, as abscessing is a particular manifestation of periapical voids accompanied by pyogenic infection (pus-producing). Periapical lesions were identified based on the criteria proposed by George Dias and Nancy Tayles (1997). Finally, individuals from Villamagna showed high rates of gum disease, with accompanying recession of the surrounding bone, often in excess of 2 mm, totalling 90.4% of affected individuals (66/73). N W Kerr (1988, 1991) posits that gingivitis (category 2) can be distinguished from periodontitis (categories 3–5) from the micro-architecture of the interdental septa, while Alan Ogden (2008, 289) presents a more sceptical and critical assessment in being able to discern gingivitis in skeletal remains. Periodontitis is only reported here as scores of three or higher. When separated by sex, 83.3% (30/36) of females and 97.3% of males (36/37) exhibited signs of benign (gingivitis) or extreme (periodontitis) gum disease. Altogether, these results indicate the teeth at the back of the mouth were most prone to accumulation of debris, infection and tooth loss (Fig 6).

Fig 6 Heat map of ante-mortem tooth loss (AMTL) and prevalence (ie presence) at Villamagna. Darker blue refers to higher probability of tooth being present, and lighter blue/red refers to a tooth more likely to have been lost ante-mortem. AMTL rates based on 47 females and 48 males (2,302 total loci) from the late-medieval period. Drawing by Trent Trombley.

When this information is paired with observed patterns of extreme dental wear, where enamel had been completely worn away or even chipped off to expose underlying dentine and pulp chambers, it is suggested that the mastication of starchy cultigens or coarse-textured foodstuffs were likely factors in infection and tooth loss. Gritty dietary inclusions from marl implemented in fertiliser may have also played a role, but these are typically removed in food production (Mathew 1993; Jones 2004). More likely, gritty inclusions were the result of coarse millstones leaving grit in flours. The effects of this patterned tooth loss often meant that individuals lost five or more teeth by 30 years of age, and mouths preserved anterior dentition but little to no posterior dentition whatsoever (Fig 5). Interestingly, females did appear to show an increasing loss of mandibular medial incisors compared to their maxillary or adjacent counterparts, which could possibly be explained by the employment of mandibular incisors as a ‘third hand’ to aid in craft production. The prevalence of interproximal carious lesions (cavities between adjacent teeth) and calculus accretions are likely inter-related, and suggest a general lack of inter-dental cleaning, such as tooth-picking or flossing. Indeed, the majority of individuals at Villamagna experienced high rates of gum disease.

OSTEOBIOGRAPHICAL APPROACH TO ORAL CAVITIES AT VILLAMAGNA

While community-level analyses help to illustrate general trends in medieval oral cavities, they may fail to capture more local and individual experiences. In order both to contextualise the sample-level dental analyses, and to obtain a more textured understanding of medieval mouths and to avoid the ‘tyranny of the average,’ (Hosek and Robb 2019, 15) an osteobiographical approach is employed, focusing on two individuals from the site of Villamagna, HRU 4142 and HRU 2828. Originating with the works of Frank and Julie Saul (Saul 1972; Saul and Saul 1989), osteobiography was developed as a means of detailing life histories of individual skeletal remains, and how such individuals may compare (and contrast) with larger sample-level bioarchaeological analyses. Since its inception, osteobiography has blossomed as a bioarchaeological framework, ranging from meticulously descriptive accounts (Lovell and Dublenko 1999; Lessa and Guidon 2002), to more humanistic and interpretive narratives (Hawkey 1998; Hosek and Robb 2019; Boutin 2012a, 2012b).⁷ Recently, John Robb et al (2019) effectively demonstrated the efficacy of employing osteobiographical approaches in medieval contexts. Comparing the textual biography with osteobiographies of contemporaries buried in the same medieval cemetery, they show how osteobiographical information can often paint a more textured, experiential picture of everyday medieval people than texts. In doing so, they also demonstrate how osteobiographies are not ‘ancillary’ or supplementary information to historical documents, but provide a framework for nuanced historical inquiry, especially in rural settings where texts may be less frequent. Finally, they make a case to ‘dethrone’ textual evidence as the gold standard for biographical reconstruction of everyday people of the past, as historical texts often, 1) focus on a narrower ‘wavelength’ of information compared to the skeletal record, 2) fail to capture and reflect lived experiences, and 3) exclude the vast majority of everyday people (Robb et al 2019, 29).

Osteobiography is not meant to be a tokenist representation of an entire community (or epoch for that matter), nor simply provide rich descriptive details. Rather, osteobiography, like microhistory for historians, employs textured detail as a methodological means and scale for shedding light on larger societal, populational, and historical aspects. An osteobiographical approach to medieval mouths offers an opportunity to gauge the lived experience, appearance, and palliative care of dental pathological lesions in everyday medieval people. Doing so also helps to reframe dental tissues and situate lesions in the context of people, rather than abstracted into aggregations of dental assemblages. The likely importance of facial recognition—and by extension the mouth—in medieval society cannot be overlooked, as the small-scale population of much of agrarian medieval Europe likely fostered interpersonal relationships and familiarity (Green 2010, 150). Given the wider context of exegetical and medical understandings about mouths, this paper seeks to consider how such ideas related to individual experiences.

The individuals 4142 and 2828 are focused on for the following reasons:

• Both individuals were relatively contemporaneous, dating to the late-medieval (c ad 1350–1500) phase of the cemetery.

• Both 4142 and 2828 were buried in the churchyard and were thus probably rural workers who had labour ties to the estate, the centre of which was the church and the fortifications around it. While little contemporary writing centres their experiences or lives, they and people like them were central to the economy and were audiences for the theology of the day.

• Both 4142 and 2828 were relatively well-preserved in regard to their observable tooth sockets (n = 28 and 32, respectively).

• HRU 4142 was determined to be a female at least 50+ years of age, where HRU 2828 was determined to be a male of 30–49 years of age. Focusing on individuals from different sex and age groups might help to illustrate the variation that was observed across both sex and age. Biological sex and age are often observed as predictors for patterning in dental pathological lesions, both in clinical (eg, Martinez-Mier and Zandona 2013 for sex differences in caries; Russell et al 2013 for sex differences in AMTL) and bioarchaeological studies (eg, Watson et al 2010; Lukacs 2017: Trombley et al 2019). As such, it is often crucial to consider individuals of differing age and sex when analysing larger community patterns in dental pathological lesions.

• These individuals are representative of the wider population, in that they have oral pathological lesions typical of the late-medieval dental remains at Villamagna (Trombley et al 2019). Both exhibited AMTL, carious lesions, calculus, and periapical lesions within or slightly above sex- and age-specific cohort frequencies for the larger sample. HRU 4142 fell well within range of observed sample frequencies for older females in AMTL (20.7% in 4142 vs 19.03% in sample), carious lesions (31.8% in 4142 vs 21.34% uncorrected and 33.48% corrected in sample), calculus (68.2% in 4142 vs 64.12% in sample), though exceeded general prevalence in periapical lesions (10.3% in 4142 vs 3.98% in sample). Conversely, while HRU 2828 did exceed older male prevalence in AMTL (62.5% in 2828 vs 24.01% in sample), carious lesions (54.5% in 2828 vs 25.74% uncorrected and 40.65% corrected in sample), and periapical lesions (12.5% in 2828 vs 2.23% sample), the patterning of these pathological lesions illustrate some of the challenges when aggregating dental tissues by type/loci (frequencies) rather than by individuals (prevalence). Males in general exhibited higher rates of corrected carious lesions and AMTL at the sample level, suggesting that while HRU 2828 may exhibit larger than expected prevalence oral pathological lesions, when compared with 4142 they are actually more indicative of larger general trends observed at the site.

• While representative of dental health at the site, both HRU 4142 and 2828 are atypical in displaying differing marks within the teeth that were formed as a result of non-dietary activities (non-alimentary activity induced dental modifications; AIDMs), that left physical traces within their respective dental remains. As such, they provide an opportunity to examine how mouths might have been entangled with activities other than just disease.

HRU 4142

HRU 4142 was buried in a simple earthen grave with a N(head)/S(feet) orientation and in supine position. HRU 4142 showed classic female pelvic morphological traits, including an obtuse greater sciatic notch, the presence of sub-pubic concavity and restriction, an obtuse sub-pubic angle and the presence of a ventral arc (Phenice 1969; Buikstra and Ubelaker 1994; Walker 2005; Trombley et al 2018, 4). The pubic symphysis and auricular surfaces showed signs of advanced degeneration and pitting, strongly suggesting at least 50 years of age (Lovejoy et al 1985; Brooks and Suchey 1990; Buikstra and Ubelaker 1994).

HRU 4142 displayed relatively minor rates of ante-mortem tooth loss (AMTL; 20.7%), losing six of their teeth before death. Seven of the observable 22 teeth (31.8%) showed signs of cavitation, and some 15 teeth (68.2%) had calculus accretions. In fact, calculus on the mandibular left lateral incisor (LI₂; 26/42),⁸ was excessive, forming a ‘tent’-like structure or calculus ‘bridge’ that extends some 5 mm towards the midline (mesially). Given the overall shape and projection paired with excessive alveolar margin resorption, it is likely that this calculus accretion actually rested atop the gumline of the resorbed medial mandibular incisor(s). HRU 4142 also showed signs of three sites of likely abscesses, the most major being a large contiguous area of necrotic resorption (localised cell death resulting in loss of bone tissue) of the right third (RM³; 1/18) and second (RM²; 2/17) maxillary molars. Given the positioning at the apices, the voids themselves being greater than 3 mm, rounded margin accompanied by apparent remodelling, it is likely that these were chronic abscesses rather than periapical granulomas (though see Dias and Tayles 1997 and Ogden 2008, 297 for further discussion). Most of the alveolar margin had receded significantly (>2 mm), with 11 of the 14 (78.6%) observable bony barriers between neighbouring tooth sockets (interdental septa) showcasing signs of aggressive gum disease (periodontitis) evidenced by steep inter-dental architecture and honeycombed appearance (Kerr 1988, 1991). Additionally, the left mandibular condyloid process showed signs of joint alteration, osteophytosis, and accompanying porosity, suggesting minimal osteoarthritis at the jaw, or temporo-mandibular joint (TMJ; Rando and Waldron 2012). Finally, the right mandibular molars showed extreme dental wear, in a shearing-like pattern toward the cheek-side (buccal) of the mouth.

Previous analyses (Trombley et al 2018) employing both macroscopic and microscopic techniques have revealed that HRU 4142 showed signs of activity induced dental modifications (AIDMs) as evidenced by both enamel chipping and enamel notching (Bonfiglioli et al 2004). For example, the maxillary right central incisor (RI¹; 8/11) showed V-shaped wear that runs labio-lingually (from lip-side to tongue-side). Notably, almost the entirety of the tooth’s surface enamel had been effaced, labially (on the lip-side) through enamel chipping as evidenced by the rugged labial surface, and lingually (on the tongue-facing side) through wear as evidenced by the smooth, polished underlying dentine. This contrasts with the adjacent maxillary left central incisor (LI¹; 9/21), which showcases V-shaped mesio-distal wear (from the midline of the mouth towards the rear of the mouth) with the apex situated near the midline of the incisal surface, accompanied by both an enamel notch and chip. Given, 1) the positioning of the chip along the incisal surface, 2) the relatively small area of enamel displaced, and 3) co-occurrence of an enamel notch, it is likely the product of non-alimentary material being placed or held repeatedly within the mouth. This is posited as the product of using the teeth in craft production, perhaps fibre processing or sewing, by placing an exogenous material such as hemp fibres or sewing needles within the mouth. Notably, the width of the enamel notch actually falls within the distribution of needle diameter dimensions calculated from needles recovered at the site (Trombley et al 2018, 20–1). This, paired with other forms of material culture related to sewing found at the site of Villamagna (eg spindle whorls, spindle hooks), archival evidence for cannapinae (hemp groves; Goodson 2016, 284–6) and overall severity of enamel chipping/notching observed, suggests craft and textile production were likely practised at Villamagna, and that HRU 4142 may well have utilised their mouth as a ‘third hand’ to aid in various aspects of craft production (Cruwys et al 1992; Sperduti et al 2018).

In sum, what can be said about the mouth of HRU 4142 and how might it relate to the broader picture of oral health in medieval Europe considered above?

• Despite their age, 4142 retained a sizeable portion of their dentition, a subset of which showed minor carious lesions. At death, most teeth were able to occlude with their mandibular/maxillary counterparts, meaning they could eat a range of foods because they could chew well (see Van der Bilt 2011, and references therein for a comprehensive review). Clinical research on masticatory performance suggests that the number of teeth greatly influences chewing capabilities and bolus formation, with fewer than 20 teeth and/or fewer than eight functional tooth units (premolars and molars that can occlude) compromising ease of chewing and swallowing. This is often accompanied by alterations in food preference and undernutrition in later life (Hildebrandt et al 1995; Miura et al 1998; Sheiham et al 1999; Sheiham and Steele 2001; Sahyoun et al 2003; Walls and Steele 2004; Adiatman et al 2013; Zaitsu et al 2022).

• The contiguous abscess affecting the sockets of the right maxillary molars probably would have been painful, and possibly caused inflammation of the right cheek. As Ogden (2008, 295) states, it is nearly impossible to identify pain from skeletal manifestations of abscesses alone. However, given the severity, size, and proximity to the maxillary sinus, it’s likely that this would have caused some discomfort and possible pain (Hillson 2005, 307–14). In fact, odontogenic abscesses have been associated with swelling of the face (facial cellulitis), pain, difficulty swallowing (dysphagia) and breathing (dyspnea; Shama 2013, 274) and can even affect sensory mechanisms such as smell and taste (Bromley and Doty 2010, 228; Cowart 2011, 3–4; Malaty and Malaty 2013, 854, 857).

• Their gums were likely inflamed and sensitive, given the severity of periodontitis observed in the interdental septa throughout the oral cavity.

• Their left jaw joint might have occasionally caused soreness or discomfort due to the presence of arthritic changes (Suby and Giberto 2019).

• The prevalence of mineralised plaque above the gumline (supra-gingival calculus), particularly those situated lingually or the aforementioned calculus ‘bridge’ of the lower mandibular incisor would have probably been felt by the tongue and the latter would have been noticeable when smiling.

• ‘Bad breath’ (halitosis) has been linked to bacterial growth on the tongue (eg candidiasis), gum disease (periodontitis), dry mouth (xerostomia), and plaque buildup (Bromley and Doty 2010, 228). While it is near impossible to detect lingual fungal infections or reconstruct salivary profiles from skeletal remains, evidence of extreme calculus and periodontitis are signs that their breath was probably affected.

• Teeth in the upper jaw (maxilla) exhibited notches and chips, which might have affected oral appearance and eating, though were likely crucial in their supportive role for craft production.

• The culmination of all these lesions likely had effects on 4142’s dietary capabilities, nutrition, and daily life. While their teeth could occlude and conceivably chew, inflamed gums, abscesses, and mandibular joint disease likely affected what foods they preferred to eat. They may well have preferred soft-textured foodstuffs given these lesions and associated discomfort, and possibly limited dietary variability and nutritional intake (Fig 7).

Fig 7 HRU 4142: Juxtaposition of skeletal images and artistic reconstructions. a) Right aspect of face and oral cavity; b) Anterior aspect; c) Left aspect. Photographs by Trent Trombley and drawings by Alexandra Farnsworth.

HRU 2828

HRU 2828 was buried in a relatively simple earthen grave oriented in a W(head)/E(feet) direction and in supine position. Previous demographic assessments suggest the individual was a male, approximately 30–49 years of age (Trombley et al 2018, 4). HRU 2828 exhibited extreme ante-mortem tooth loss (62.5%), retaining only 11 teeth at death. The majority of remaining teeth (6/11, 54.5%) were carious, and their sockets exhibited extreme bone loss (alveolar recession) with some 60% of observable inter-dental septa displaying signs of periodontitis.

The absence of bone accompanied by spongey architecture (necrotic resorption) contiguously spanning most of the anterior maxillary alveolar structure probably indicates the presence of an abscess, or multiple abscesses (Dias and Tayles 1997; Ogden 2008). Given the evidence of severe osseous necrosis, it is possible that the maxillary anterior teeth experienced severe cavitation before the infection spread into the roots and accompanying nerve and blood vessels before draining into the facial structures. Such an area of necrotic bone suggests that the infection(s) became pyogenic and developed into a mass of inundated cells (granuloma) causing severe inflammation (Dias and Tayles 1997; Ogden 2008). The patterning of 2828s tooth loss is worth highlighting here, as they retained maxillary posterior teeth and mandibular anterior teeth, suggesting that virtually no teeth were in occlusion for some years prior to death. Mandibular anterior teeth showed steep, shearing wear situated along the lip-facing surface (vestibular/labial), suggesting they may have occluded with maxillary anterior teeth in a drastic ‘overbite’ fashion. This may have occurred to the extent that maxillary incisors experienced such extreme wear that pulp chambers became exposed and subsequently died, as evidenced by the large area of necrosis (cystic lesions) across the entire anterior maxilla. It is possible this wear was the result of non-dietary activities, using the front teeth as a ‘third hand’; however, it is difficult to say this with any degree of certainty. It could also be that the anterior maxillary teeth, and some mandibular anterior teeth, were lost as a result of severe trauma rather than activity induced wear perforating pulpal chambers, which can also lead to neighbouring necrosis in the maxilla (Ogden 2008, 294).

Notably, HRU 2828 retained one tooth, the maxillary left second premolar (LP²; 13/25), with signs of interproximal grooving, or grooves situated between neighbouring teeth. These semi-circular grooves were found on both the mesial and distal portions of the tooth, situated occlusal to the cemento-enamel junction (CEJ) and were oriented lengthwise from cheek to tongue (bucco-lingually). Both grooves coincided with furrowing, and the interdental septa between the tooth itself and the adjacent maxillary first molar showed signs of extreme gum disease (periodontitis) marked by steep topographical changes in alveolar architecture and remodelling (Kerr 1988, 1991). Additional analyses using scanning electron microscopy (SEM) found the grooves to contain microstriae oriented in a bucco-lingual direction parallel to the CEJ (Trombley et al 2018). Altogether, this suggests that HRU 2828 utilised an exogenous material similar to a tooth-pick as a palliative means of likely treating either the sub-cervical furrow, aggressive periodontitis, or a combination of both (Siffre 1911; Ubelaker et al 1969; Shulz 1977; Berryman et al 1979; Bermudez de Castro and Pérez 1986; Formicola 1988; Lukacs and Pastor 1988; Frayer 1991; Alt and Koçapan 1993; Bermudez de Castro et al 1997; Alt and Pichler 1998; Lorkiewicz 2011). Repeated picking at the surface over time might have left the grooves and microstriae in an orientation where the ‘tooth pick’ could pass between teeth from the cheek (buccal) side.

In sum, what can be said about the mouth of HRU 2828?

• Since virtually no teeth were in occlusion with their mandibular or maxillary counterparts, individual HRU 2828 would probably have had to chew either between mandibular anterior teeth and maxillary gums, or maxillary molars and mandibular gums. Not only would this have been difficult, but also probably would have limited their dietary possibilities to soft-textured foodstuffs or liquid in consistency (eg gruel) for some time prior to death.

• Absence of all anterior maxillary dentition might have also affected speech, as the loss of maxillary incisors can impact phonemic articulation such as dental fricatives (eg/t/or/d/), and labiodental fricatives (eg/f/or/v/) and anterior teeth are important as obstacles in sibilant fricatives (eg/s/or/z/; see Blasi et al 2019 for further discussion on bite configuration and fricatives). Furthermore, it is possible that observed oral pathologies in addition to tooth loss altered the bite configuration and further affected speech capabilities.

• The alveolar recession of the mandible probably affected their overall facial appearance, resulting in an overall decrease in facial height as well as a slightly sunken or collapsed appearance of the cheeks and increasing pronouncement of the chin (Bartlett et al 1992; Neave 1998; Albert et al 2007).

• The presence of severe necrosis associated with periapical inflammation points to some form of infection throughout the anterior maxilla. This likely would have been painful, and possibly resulted in swelling of the upper lips and facial region (facial cellulitis) as well as affecting smell, taste, and breath (Bromley and Doty 2010, 228; Cowart 2011, 3–4; Malaty and Malaty 2013, 854, 857; Shama 2013, 247).

• Severe cavitation, periapical inflammation, and periodontitis might also have resulted in sensitivity to extreme temperatures (eg hot and cold foodstuffs, liquids), meaning they probably avoided hot and cold foods and drinks.

• The gums were probably both sensitive and inflamed (gingivitis) as seen in the inter-septal architecture, and gum disease (periodontitis) was evident between the upper left second premolar (LP²; 13/25) and first molar (LM¹; 14/26).

• Interproximal furrowing of the left maxillary premolar (LP²; 13/25) accompanied by aggressive periodontitis and alveolar recession, probably resulted in persistent discomfort between the tooth and its neighbouring teeth/gums. Such discomfort may well have prompted HRU 2828 to use picks or other implements as a palliative means to relieve pain and discomfort from the affected area(s). The formation of these grooves on either side of the tooth suggest that such ‘tooth-picking’ probably occurred for some time.

• Overall, 2828’s mouth suggests severe periodontal disease, gum inflammation and possible bleeding, and abscessing. Lack of occlusion and functional dental units likely limited dietary potential for texture and temperature, and possibly led to undernutrition (Hildebrandt et al 1995; Miura et al 1998; Sheiham et al 1999; Sheiham and Steele 2001; Sahyoun et al 2003; Walls and Steele 2004; Van der Bilt 2011; Adiatman et al 2013; Zaitsu et al 2022) (Fig 8).

Fig 8 HRU 2828: Juxtaposition of skeletal images and artistic reconstructions. a) Right aspects of the face and oral cavity; b) Anterior; c) Left. Photographs by Trent Trombley and drawings by Alexandra Farnsworth.

Like sample-level analyses conducted at Villamagna, the mouths of 4142 and 2828 did experience high rates of carious lesions, periapical inflammation and accompanying necrosis, and periodontitis. While the mouths of 4142 and 2828 certainly attest a range of pathologies, they need not be considered irregular. Rather, at least in the case of Villamagna, caries, calculus, periapical infection, and periodontitis and their symptomatic corollaries of toothache, halitosis, facial inflammation and sensitive gums were typical, if not normal. The monastic community at Villamagna, defunct by the time these two people lived, did not have a scriptorium and this post-monastic castrum probably had no access to the knowledge prescribed by the medical treatises, which in Italy tended to circulate in urban networks. The practice of medicine did not require manuscripts necessarily (eg, Trotula, see Green 2013, 1–17), but Villamagna did apparently lack a library which could have housed practical or theoretical treatises.

While it can reasonably be assumed that chronic oral pain affected most of this community, some members (such as 2828) sought to remediate it with palliative measures. However, given the degree to which the oral health of 2828 likely impeded food intake, speech, and health, would the community have perhaps considered their mouth to be corrupt? Would their mouth indeed have been seen as foul and diseased, or simply normal? Here it is suggested that the prevailing theological views on mouths as portals, combined with the frequency of remedies for oral health, can be applied to mouths such as these to indicate that while this mouth was typical in being a source of likely discomfort, it was probably simultaneously understood to be diseased and/or corrupt. Conversely, 4142's chipping, notching, and grooves in tandem with sewing materials found at the site suggests the medieval mouth’s importance in certain domestic economy. It can be imagined that these two individuals, and many others throughout the medieval period, conversed about toothache, and treatment specific to the molars, as Burridge (2020) found in her analysis of Carolingian documents. While it is not known for certain, the clear variation in oral cavities throughout the Middle Ages is likely explained not only by different techniques in food provisioning and starchy cultigens, but also by differing understandings of the oral cavity itself, and the epistemic, communal, and individual care that went into maintaining it.

CONCLUSION

This study demonstrates that the societal and cultural associations of biological variation, mouths included, are fluid and contextual. The anthropologist Margaret Mead once noted how the increased treatment of dental caries with oral healthcare resulted in shifting societal norms of what constituted a ‘normal’ mouth, and that those with caries who may have once been well within the statistical norm became subsequently ‘regarded as pathological deviations’ (Mead 1947, 63). C Loring Brace (1977) eloquently traced how clinicians have conceptualised oral aesthetics and proportions as normative with ‘deviations’, whereas anthropologists have instead viewed variation as normal. Brace (1977, 181) highlights how early orthodontic clinical conceptions such as W G A Bonwill’s ‘triangle’ or Graf Spee’s ‘the Curve of Spee’ that refer to mathematically and geometrically defined oral cavity dimensions may well have been ‘more akin to Pythagorean mysticism’, but inevitably set the stage for later clinicians to view oral cavities in a normative manner. Conversely, anthropologists have often viewed occlusion and oral cavities in a deep-time perspective, incorporating analyses of the hominin paleoanthropological record (eg, Blasi et al 2019), highlighting variation and temporal changes in place of normativity and deviations. This paper believes that both these anthropologists are worth reconsidering in light of medieval mouths and aesthetics, as the contemporary Western imagery of a perfectly aligned, symmetrical, white, dentate mouth as the baseline of how mouths ought to look and be in the past (or today for that matter) should be met with a heavy degree of anthropological scepticism.

Medieval mouths were undoubtedly entangled in daily life. Whether through quotidian acts such as eating, speaking, smiling, sewing, singing or kissing, or through more epistemological concerns such as Confession or corruption, mouths could be the centre of focus in academic, sensory, medical, cosmetic, and theological arenas alike. Mouths in the Middle Ages were more than just an aggregation of utilitarian tissues. The analysis above gives but a brief glimpse into the physical variation in medieval oral cavities, and the many ways in which people depicted and discussed the mouth in the Middle Ages. We should likely listen, lest we are left with ‘people-less teeth’ much like the ‘faceless blobs’ of the past Tringham (1991, 94) so eloquently described.

While neither archival, art historical, nor biological analyses will ever reveal the full picture of medieval mouths, here it is suggested that attention to their co-contributive potential is fruitful. Given the philosophical, spiritual, and medicinal importance attributed to the mouth during the Middle Ages, it seems only right to consider the mouth as a biosocial orifice. To this end, mouths and teeth should not only be considered for their biological information, but as embedded tissues, imbued with meanings and experiences for the people to whom they belonged.

Abbreviations
BHL	=	Bibliotheca hagiographica latina antiquae et mediae aetatis 1898–1901 (ed) 1986 Society of Bollandists, Brussels: Via dicta ‘des Ursulines’; Bibliotheca Hagiographica Latina Antiquae et Mediae Aetatis, Novum Supplementum 1986, ed Henri Fros, Brussels: Socieìteì Des Bollandistes.
LA	=	Jacobus de Voragine 1998, Legenda Aurea, ed Giovanni Paolo Maggioni, 2nd rev ed Florence: Sismel. Trans as The Golden Legend 1993, trans W G Ryan. Princeton and Oxford: Princeton University Press.

ACKNOWLEDGEMENTS

We thank Drs Elizabeth Fentress, Mauro Rubini, Alfredo Coppa and Francesca Candilio for their permission and aid in working with the human remains of Villamagna. We also thank Prof John Arnold, Prof Maureen Miller, Prof Katie Kinkopf, Peter Michelli, Mary Vitalli and Prof Laurie Wilkie for their feedback and aid in this project. We also extend our thanks to Prof Patrick Beauchesne, Gina Palefsky and Peter Dangsangtong for their support and dialogue in these topics.

Notes

4 See, for instance, val pal 1088 fol. 33r, which glosses Latin ‘migraniu’ with ‘Zanewrm’ [consultable online: <digi.vatlib.it/view/MSS_Pal.lat.1088>]

5 <denonne.maluchy.com/typroc/apollo.htm>

6 <geutelingen.com/>

7 See also Dettwyler (1991) for a discussion on paleopathology and compassion.

8 Teeth are reported here in the ‘Universal system’ (26) followed by the FDI system (42).