








































Bioarchaeology International

Copyright © 2021 University of Florida Press

DOI: 10.5744/bi.2021.1001
Volume 5, Numbers 1–2: 47–67

Classic Maya Dental Interventions: Evidence for 
Tooth Extractions at Piedras Negras, Guatemala
Joshua T. Schnella* and Andrew K. Scherera

aDepartment of Anthropology, Brown University, Providence, RI 02912, USA
*Correspondence to: Joshua T. Schnell, Department of Anthropology, Brown University, Box 1921, Providence,
RI 02912, USA

e-mail: joshua_schnell@brown.edu

ABSTRACT: Tooth extractions are among the most common dental procedures performed globally today; however, archae-
ological evidence for such procedures in the past is relatively scant and largely limited to the Classical world. We 
present a case of therapeutic dental extractions of pathological teeth at the ancient Maya site of Piedras Negras, 
Guatemala, during the Late Classic period (A.D. 600–800). The evidence comes from an assemblage of frac-
tured, pathological teeth (n = 127) recovered from the marketplace at Piedras Negras during excavations in 2016 
and 2017. We compare the Piedras Negras marketplace teeth to the broader Late Classic period mortuary popu-
lation at the site along three lines of analysis: (1) distribution of teeth by type (incisors, canines, premolars, and 
molars), (2) pathologies, including dental caries and calculus, and (3) dental wear. We also explore in detail the 
fracture patterns apparent in the marketplace assemblage. Our results indicate that the marketplace teeth dis-
play a significantly greater caries rate than the broader mortuary population and that posterior teeth (premo-
lars and molars) are overrepresented in the marketplace sample. These findings point toward therapeutic 
extractions intended to ameliorate pain associated with oral pathologies. This article presents one of the few 
case studies of ancient health care in the Americas and situates these practices within the market, an important, 
urban space across much of precolonial Mesoamerica.

Keywords: Maya; dentistry; tooth extraction; paleopathology

Las extracciones dentales se encuentran entre los procedimientos dentales más comunes realizados a nivel 
mundial en la actualidad. Sin embargo, la evidencia arqueológica para tales procedimientos es relativamente 
escasa en el pasado y se limita en gran medida al mundo Clásico. En este artículo, se presenta un caso de ex-
tracciones dentales terapéuticas de dientes patológicos en el antiguo sitio maya de Piedras Negras, Guatemala, 
durante el periodo Clásico Tardío (600-800 d.C.). La evidencia de este caso proviene de una colección de dientes 
patológicos y fracturados (n = 127) recolectados en el mercado de Piedras Negras durante las excavaciones real-
izadas en los años de 2016 y 2017. Estos dientes fueron comparados con otros dientes recolectados alrededor del 
sitio en contextos mortuorios del periodo Clásico Tardío a lo largo de tres líneas de análisis: (1) la distribución 
de los dientes por tipo (incisivos, caninos, premolares y molares), (2) las patologías, incluyendo caries dentales y 
cálculo y (3) el desgaste dental. Asimismo, se exploró en detalle los patrones de fractura aparentes en la colec-
ción del mercado. Los resultados de este análisis indican que los dientes del mercado muestran una tasa de 
caries significativamente mayor que los dientes recolectados en contextos mortuorios y que los dientes posteri-
ores (premolares y molares) se encuentran sobrerrepresentados en la muestra proveniente del mercado. Estos 
hallazgos demuestran el uso de extracciones terapéuticas designadas a aliviar el dolor asociado a las patologías 
bucales. Este artículo presenta uno de los pocos estudios de caso de atención médica en el pasado en las Améri-
cas y sitúa estas prácticas dentro del mercado, un importante espacio urbano que se encuentra a través de la 
Mesoamérica precolombina.

Received 27 July 2020  
Revised 16 December 2020  

Accepted 28 December 2020



Evidence for Tooth Extractions at Piedras Negras, Guatemala 48

Excavations in the Maya area (and elsewhere in the 
world) frequently produce isolated human teeth. 
Conventional wisdom is that these teeth come from 
disturbed burials and little further thought is given 
to their occurrence. In other instances, loose teeth 
have been found in Classic Maya ritual deposits and 
one interpretation holds that these were extracted 
from mourners as part of a royal mortuary rite 
(Scherer 2015a:154, 2015b). When we consider the loss 
of permanent teeth across human societies, both 
traumatic injury and extraction of carious and ab-
scessed teeth are common occurrences (Cahen et al. 
1985; Morita et al. 1994; Reich and Hiller 1993; Rich-
ards et al. 2005). And yet, archaeologically recovered 
isolated teeth are rarely understood within this 
framework, owing to the difficulty of reconstructing 
both the methods and contexts of ancient tooth 
extraction.

In this article, we provide evidence for tooth ex-
tractions at the Classic period (A.D. 350–900) Maya 
site of Piedras Negras, Guatemala (Fig. 1). Evidence 
for tooth extraction comes from a sample of 127 frac-
tured and pathological teeth recovered in approxi-
mately 74 m3 of excavated stratigraphy within the 
marketplace of Piedras Negras (see below), dating 
largely to the Late Classic period (A.D. 600–800).  
We compare the Piedras Negras marketplace tooth 
sample to that of the broader Piedras Negras 

mortuary sample along three lines of evidence: (1) 
distribution of tooth type, (2) pathology (caries and 
calculus), and (3) wear to determine whether the 
marketplace teeth, as a group, were markedly differ-
ent from the general mortuary population. If the 
marketplace sample represents the remains of  
extraction, we expect a different composition in 
terms of tooth type (incisor, canine, premolar, molar) 
than that derived from the mortuary population 
where teeth should be represented in close to the 
same proportions as they are in living individuals. 
This is because oral pathologies that require ex-
traction disproportionately affect the posterior teeth: 
premolars and molars (Demirci et al. 2010; Whitting-
ton 1999). Further, a greater incidence of pathology 
should be present in the marketplace sample if they 
were extracted for palliative reasons. Finally, less 
wear may be present in a sample of extracted teeth 
relative to the overall mortuary population, given 
that they were used for a shorter period of time than 
those teeth that followed their owners to the grave.  
In addition to these comparisons, we also consider 
the ante- and perimortem fracture patterns in the 
marketplace sample.

We hope our results inspire scholars working else-
where in the Maya area, especially those excavating 
public quotidian spaces such as marketplaces, to look 
for similar patterns in their assemblage of human re-
mains from non-mortuary contexts. Moreover, these 
data provide an important window into ancient 
health care practices in the Americas. Finally, the ap-
proaches taken here may prove useful for scholars in-
terested in the study of ancient dentistry elsewhere in 
the world.

Teeth in the Archaeological Record of the Maya 
Region

In the Maya area, aside from mortuary contexts, 
human teeth are found as part of isolated skulls in 
cases of decapitation (Barrett and Scherer 2005; 
Duncan 2011; Massey and Steele 1997; Whittington 
2003) or pectorals and other objects manufactured 
from skulls (Scherer 2015a:100–102; Wrobel et  al. 
2019). Teeth also are found isolated from skulls, 
most often as a single tooth encountered in con-
struction fill. There are examples, however, of in-
tentional deposits of teeth that warrant further 
consideration. In Belize as well as the central and 
eastern Petén of Guatemala, loose human teeth 
have been found within lip-to-lip cache vessels and 
have been variously interpreted as offerings, sacrifi-
cial victims, and companion burials (Chase and 
Chase 1998; Pitcavage and Braswell 2010;  

Figure 1. Regional map depicting location of Piedras Negras in relation 
to other archaeological sites mentioned in the text (map by J. Schnell).



Schnell and Scherer 49

Scherer 2015b). Often, these caches are located 
within or associated with tombs and burials, usu-
ally of elite or royal individuals as at El Zotz, Gua-
temala (Scherer 2015b, 2018), or Pusilha and Cahal 
Pech, Belize (Awe et al. 2009; Cheetham 2004; Pit-
cavage and Braswell 2010).

In these contexts, teeth usually occur in small 
numbers, generally no more than four or five, al-
though a few large deposits of teeth are known (Pen-
dergast et al. 1968; Saul and Hammond 1974). In the 
case of cache vessels, human teeth are occasionally 
accompanied by human phalanges (e.g., Ricketson 
and Ricketson 1937:55–56). Vessels have also been 
found containing phalanges alone. Collectively, these 
are often referred to as tooth caches and finger bowls 
(Chase 1994; Chase and Chase 1994, 1998, 2011; 
Cheetham 2004; Norton 2016; Song et  al. 1994). In 
other contexts, such deposits exist independent of 
any sort of vessel. In the cave of Actun Kabul, Belize, 
for example, several cultural scatters were found 
within the antechambers that contained isolated hu-
man skeletal elements. These were areas of inten-
tional deposition and comprised primarily of human 
teeth and bones of the hands and feet (Shelton et al. 
2015:24).

There are two prevailing explanations concerning 
the origins of the teeth, phalanges, and other bones in 
these cache deposits. Considering the small, portable 
nature of teeth and phalanges, it may be that these ele-
ments were collected from extant burials and kept on 
hand, and later deposited as part of ritual practice, per-
haps at stations in established ritual circuits (Wrobel 
et al. 2013:132–133). The second concerns the removabil-
ity of these elements from living persons. The teeth in 
these deposits are most often incisors, the teeth that are 
most easily avulsed from living persons and whose ab-
sence will have the least impact on masticatory func-
tion (Scherer 2015a:154). Similarly, the bones present 
are most often the distal and intermediate phalanges of 
the hand, both easier and more dramatic to remove 
than the comparable bones of the foot.

Archaeologists have recovered a few deposits con-
sisting solely of teeth. At Lubaantun, Belize, for ex-
ample, 59 loose teeth were found against the wall of a 
small structure at the far north end of the site core, 
dating to the Late Classic (ca. A.D. 700–800). They 
appear to have been buried as a single deposit (Saul 
and Hammond 1974:124). The Lubaantun deposit is 
unique in that it seems to be the intentional deposi-
tion of the complete dentitions of two individuals. 
The authors argue, based on the completeness of the 
dentitions and the preservation of the teeth, that they 
were recovered from a burial long after decomposi-
tion had occurred (Saul and Hammond 
1974:124–126).

The largest deposit of loose teeth was excavated at 
the site of Yakalche, located just 16 miles northeast of 
Altun Ha, Belize. During the 1967 season of the Royal 
Ontario Museum’s project at Altun Ha (Pendergast 
1979), preliminary excavations at Yakalche yielded a 
total of 379 human teeth scattered in a single layer 
dated to the Postclassic period along the western face 
of a platform in the central area of the site (Pender-
gast et al. 1968). Unlike the Lubaantun cache, the Ya-
kalche teeth come from a minimum of 43 individuals. 
Additionally, the majority (60.9%) of these teeth 
come from individuals aged 6 to 9 based on dental 
development (Pendergast et al. 1968:641). Unlike the 
restricted radius of the Lubaantun cache, the Ya-
kalche teeth were encountered scattered along the 
face of a platform, often one at a time or in small 
groups of no more than five, within fill that overlaid 
the plaza floor (Pendergast et al. 1968:637–638). While 
the Yakalche deposit remains poorly understood, it 
highlights the range of contexts, quantities, and ages 
of the individuals represented in individuals repre-
sented in deposits of loose teeth in the Maya region.

Piedras Negras, Guatemala

The major Maya polity capital of Piedras Negras is 
located on the eastern shore of the Usumacinta River 
in the western region of what is now Guatemala’s 
Parque Nacional Sierra del Lacandón. Piedras Negras 
was the seat of a royal dynasty that governed the 
community and greater kingdom throughout the 
Classic period (Proskouriakoff 1960). Its occupational 
history began ca. 250 B.C. in the Late to Terminal 
Preclassic period (Houston et  al. 2000) and ended 
around A.D. 930 in the Terminal Classic period by 
which point most of the region was largely depopu-
lated (Golden et al. 2008:252; Golden et al. 2016).

The site has been the focus of a number of archaeo-
logical projects since it was reported to the interna-
tional community by Teobert Maler who visited the 
site in 1894 (Maler 1901). Subsequent visits by Syl-
vanus Morley in the early twentieth century eventu-
ally led to an expedition sponsored by the University 
of Pennsylvania from 1931 to 1939, directed by Linton 
Satterthwaite (Weeks et  al. 2005:1–2). From 1997 to 
2000, and again in 2004, the site was revisited by the 
Proyecto Arqueológico Piedras Negras (PAPN), di-
rected by Stephen Houston and Héctor Escobedo 
(Escobedo and Houston 1997, 1998, 1999, 2001, 2005) 
and, from 2016 to 2017, the Proyecto Paisaje Piedras 
Negras–Yaxchilan (PPPNY) conducted excavations 
at the site under the direction of Andrew Scherer, 
Charles Golden, Griselda Pérez Robles, and Mónica 
Urquizú (Pérez Robles et al. 2016; Urquizú et al. 2017). 



Evidence for Tooth Extractions at Piedras Negras, Guatemala 50

This paper deals directly with materials recovered 
during those two most recent field seasons of the 
PPPNY and with comparative data from the PAPN. 
Specifically, it focuses on excavations conducted 
within a series of three patio groups located in the S 
quadrant of the site, hereafter referred to as the 
Southeast Marketplace (Fig. 2).

Based on a density of materials recovered during 
early test excavations in the northernmost of these 
three patios (Escobedo 1997; Jackson and Hruby 2001; 
Urquizú 1998), Zachary Hruby, Richard Terry, and 
Mark Child of the PAPN proposed that this area may 
have functioned as Piedras Negras’s market. When 
the PPPNY returned to the site, they sought to con-
firm this hypothesis and excavated a total of 29 units 
across these three patio groups, focusing largely on 
the open plaza spaces (Fig. 3). For detailed informa-
tion on these excavations, see the original research 
reports (Pérez Robles et al 2016; Urquizú et al. 2017). 
These excavations yielded a larger than normal quan-
tity of ceramic sherds, worked and unworked shell, 
lithic debitage and artifacts, unworked and worked 
skeletal material from both humans and animals, 
bone debitage, human teeth, and small quantities of 
greenstone, quartz, pyrite, and other stones (Roche 

Recinos and Matsumoto 2016; Roche Recinos et  al. 
2017).

As a result of these excavations, these three patio 
groups have been confirmed as a marketplace, now 
referred to as the Southeast Marketplace, with the 
supposition that the area covered by Operation 15I 
represents the focal point of marketing activities  
(Fig. 3; Golden 2017; Golden et al. 2020; Pérez Robles 
et  al. 2017; Roche Recinos 2016; Roche Recinos and 
Matsumoto 2016; Roche Recinos et al. 2017; Scherer 
et al. 2017; Schnell 2017). The identification of Piedras 
Negras’s marketplace builds off of prior observations 
that Classic period Maya markets are bounded by 
long-range structures (similar to S-17 and S-18) and 
may have a pyramidal structure similar to the small 
S-11 pyramid, as at Buenavista del Cayo, Calakmul, 
and Chunchucmil (Cap 2015a; Carrasco Vargas et al. 
2009; Dahlin et al. 2007; Doyle 2012; Roche Recinos 
2016:42–45; Tokovinine and Beliaev 2013).  
Pre-Columbian Mesoamerican markets are known 
to have been both places of production and healing 
(Cap 2015b; Hirth 2009, 2013, 2016; Nichols 2013; 
Shaw 2012). These three patio groups, which pro-
duced large quantities of lithic and bone debitage in-
dicative of production, are also bounded by three 

Figure 2. Map of the marketplace (inset) and its location within the 
Piedras Negras site core (digital map by Z. Nelson, N. Curritt, and  
T. Murtha with additions by J. Schnell based on original map by F. Parris  
and T. Proskouriakoff).

Figure 3. Excavations within the marketplace during the 2016–2017 
field seasons (digital map by Z. Nelson, N. Curritt, and T. Murtha with 
additions by J. Schnell based on original map by F. Parris and T. 
Proskouriakoff).



Schnell and Scherer 51

sweatbaths, used across Mesoamerica for birthing 
and a range of curing activities.

The distinctive stratigraphy of the patio floors of 
the marketplace further distinguishes it from both 
residential contexts and the civic-ceremonial center 
of Piedras Negras. Most of the marketplace’s stratig-
raphy is comprised of a sequence of thin floors laid 
over the course of the Classic period that then give 
way to a sequence of platforms in the final episodes of 
construction and occupation (Golden 2017:57).  
Missing from the stratigraphic layers of the market-
place excavations is evidence for stucco-finished 
floors typical of the acropolis of Piedras Negras and 
the adjacent ceremonial zone. In contrast, the patio 
floors of the marketplace vary between packed sedi-
ment and sand, suggestive of the regular resurfacing 
of a heavily trafficked space. The density and distri-
bution of artifacts are interpreted as a mix of debris 
swept into the floors during relatively frequent resur-
facings as well as objects that fell or were dropped 
during quotidian activities and subsequently tram-
pled into the floor surface.

Chronology of the marketplace excavations has 
been derived from a series of radiocarbon dates pro-
vided by the University of Arizona AMS laboratory, 
combined with analysis of associated ceramic mate-
rials, under the direction of Mónica Urquizú and 
Ana Lucia Arroyave (Urquizú and Menéndez 2016; 
Arroyave et al. 2017). Both analyses indicate that this 
area of the site saw initial use and construction 
during the Early Classic period with most of the lay-
ers dating to either the Yaxche (A.D. 620–750) or 
Chacalhaaz phase (A.D. 750–850) of the Late Classic 
period (Holley 1983; Muñoz 2004).

No burials have been found within the market-
place despite their ubiquity in other areas of Piedras 
Negras where a total of 127 burials have been exca-
vated to date (Coe 1959; Houston et al. 2003; Schnell 
and Scherer 2017; Schnell et al. 2017). The lack of buri-
als not only highlights the unlikelihood that this area 
served a domestic function but also indicates that the 
teeth were not eroded or exhumed from nearby mor-
tuary deposits, as has been suggested for miscella-
neous human remains found at other sites, such as 
Tikal, Guatemala (Weiss-Krejci 2011). Classic period 
mortuary practices at Piedras Negras generally con-
sisted of the placement of extended supine bodies in 
primary interments below household or plaza floors. 
Residences elsewhere in the site are so crowded with 
subfloor burials that some were dug through earlier 
ones (Scherer 2015a:102). Isolated elements of human 
bone were found in the marketplace excavations, in-
cluding a partial cranial vault, an os coxa, a distal hu-
merus, numerous long bone fragments, and a smaller 
number of cranial fragments (Jackson and Hruby 

2001:29; Schnell et al. 2017). Many of these elements 
bear cutmarks related to the manufacture of bone 
tools and other objects. From the PPPNY excava-
tions, bone that could be securely identified as hu-
man (including teeth) represents a small portion  
(n = 290; 6.1%) of a much larger assemblage of bone 
recovered from the marketplace (n = 4,741). Addi-
tionally, 1,429 (30.14%) elements could be securely 
identified as animal, leaving a sizable number as po-
tentially human or animal (n = 3,022; 63.74%). Of the 
unidentified elements, 19.6% (n = 593) were worked, 
which hindered taxa identification. The worked bone 
included both production debris and finished prod-
ucts consistent with sites of bone working found else-
where in the Maya area, such as the Group L4-3 
workshop at Dos Pilas, identified by Kitty Emery 
(2008, 2009, 2010). Notably, no children’s bones were 
found in the Southeast Marketplace assemblage  
despite subadults representing roughly one-third of 
the remains recovered in the mortuary sample at the 
site (Scherer 2015a:41).

The Dental Assemblage

Among the human remains and other objects recov-
ered from the marketplace of Piedras Negras were 
127 isolated teeth, many of which were fractured and 
pathological (Fig. 4). In no instance were the teeth 
found clustered together nor were they found within 
a ceramic vessel. There is little evidence to suggest 
they were part of a ritual deposit and, in fact, no ex-
ample of a tooth cache or finger bowl as described 
earlier in this paper has ever been found at Piedras 
Negras. Rather, these teeth (and teeth fragments)  
appear to have been treated similar to the other mate-
rials recovered in the marketplace excavations and 
likely represent debris that was either lost acciden-
tally or intentionally discarded. Of the 127 total 

Figure 4. Selected teeth and tooth fragments demonstrating the patho-
logical, fragmentary nature of the marketplace assemblage (photo by J. 
Schnell).



Evidence for Tooth Extractions at Piedras Negras, Guatemala 52

dental elements, 9.5% (n = 12) were deciduous and 
28% (n = 35) were very small enamel or root frag-
ments that could not be further identified and were 
excluded from this study. Only two teeth, both mo-
lars, were definitively associated with Early Classic 
(A.D. 350–600) strata and were also excluded due to 
the small sample size from this period. The rest of the 
identified teeth (n = 78) were recovered from Late 
Classic strata and comprise the marketplace sample 
for this study (Table 1).

It was not possible to identify discrete individuals 
in the marketplace assemblage, and thus we could 
only estimate a Minimum Number of Individuals 
(MNI) based on the most frequently encountered 
tooth, in this case the right third maxillary premolar 
(MNI = 6). However, if we assume that the dental re-
mains do not represent complete dentitions and that 
each individual may be represented by only one or a 
few teeth, the actual number of individuals repre-
sented by the dental assemblage is likely much higher. 
Outside of the marketplace, isolated teeth are rare in 
the Piedras Negras archaeological record. In the 
combined 7 years of work by the PAPN and PPPNY, 
only 15 human teeth have been found scattered across 
73 operations (not including burials or the market-
place). This is in stark contrast to the 127 human teeth 
produced in the marketplace alone.

Observing the unlikelihood that such a large num-
ber of teeth in a part of the site void of burials was a 
product of postdepositional taphonomic processes, 
we hypothesized that the teeth entered the archaeo-
logical record following extractions for palliative care 
based on the fragmentary and pathological nature of 
the sample. To test this hypothesis, we completed a 
series of basic statistical comparisons between the 
marketplace sample and an aggregated mortuary 
population. This mortuary population is comprised 
of all individuals excavated from the burials at Pie-
dras Negras, previously studied by Scherer (Houston 
et  al. 2003; Scherer et  al. 1999, 2001; Scherer et  al. 
2007). Since we excluded the two Early Classic mar-
ketplace teeth from the study due to low sample size, 
all comparisons are made to only the Late Classic pe-
riod mortuary sample. We also limited the mortuary 

population to permanent teeth, as the subsample of 
deciduous teeth (n = 12) from the marketplace was 
too small for statistical comparisons. Because dis-
crete individuals could not be identified in the mar-
ketplace assemblage, we treated the Late Classic 
mortuary population as an aggregate collection of 
teeth, to facilitate comparison. The Piedras Negras 
mortuary sample, then, consists of 853 permanent 
teeth dating to the Late Classic period. The Late Clas-
sic marketplace sample, on the other hand, consists 
of 78 permanent teeth and tooth fragments.

Methods

Each human tooth from the Southeast Marketplace 
was inventoried and scored for dental caries, dental 
wear, enamel hypoplasia, dental modification, dam-
age, and any other notable features (Buikstra and 
Ubelaker 1994; Romero 1951; Scott 1979; Smith 1984). 
Dental modifications were scored but are not consid-
ered in this paper. These are the same methods em-
ployed by Scherer in his analysis of the teeth from the 
127 burials that comprise the Piedras Negras mortu-
ary population, with some minor differences as noted 
below. The marketplace teeth were compared to those 
of the broader Piedras Negras mortuary population 
along three lines of analysis: (1) the distribution of 
teeth by type in each sample, (2) pathologies, includ-
ing caries and calculus, and (3) dental wear. Each 
tooth from the marketplace was scored twice, once 
by Schnell and a second time by Scherer. Discrepan-
cies between the two scores favored Scherer’s inter-
pretation in order to maintain compatibility with his 
earlier analyses. Additionally, the marketplace teeth 
were examined carefully for damage and fractures.

Raw counts of tooth types (incisors, canines, pre-
molars, molars) were tabulated for both the market-
place and the Piedras Negras mortuary samples and 
used to calculate relative proportions for molars, pre-
molars, canines, and incisors. If the teeth entered the 
archaeological record randomly, whether taken from 
graves elsewhere in the site or perhaps from skulls 
that were worked, carried, or retained at the market-
place, the relative proportion of tooth type (incisor, 
canine, premolar, molar) should be similar to the 
proportions of the Piedras Negras burial assemblage. 
Of course, not all burials will produce teeth in the 
ratio expected for a typical adult owing to antemor-
tem tooth loss and incomplete recovery by archaeolo-
gists. Nevertheless, we expect the deviation should be 
small unless a particular practice targeted the re-
moval of certain teeth across the entire population of 
Piedras Negras. Moreover, proportions in both 
should mirror that of a typical adult mouth. Third 

Table  1. Distribution of teeth in the Piedras Negras marketplace Late 
Classic sample by ceramic phase

Ceramic Phase Dates (CE) n

Yaxche 620–750 20

Yaxche-Chacalhaaz 620–850 23

Chacalhaaz 750–850 35

Total 78



Schnell and Scherer 53

molar agenesis is rare among the Maya and so a com-
plete dentition consists of 32 teeth, with eight incisors 
(25%), four canines (12.5%), eight premolars (25%), 
and 12 molars (37.5%). If the marketplace dental as-
semblage was produced from patterned behavior that 
targeted certain teeth, then we should expect devia-
tions in those anticipated frequencies. For example, 
as noted earlier, Maya tooth caches are significantly 
comprised of incisors. In regard to pathologies like 
dental caries and abscesses, the posterior teeth are 
disproportionately affected, a pattern with significant 
temporal depth and global scale that still holds true 
today (Cucina et  al. 2011; Demirci et  al. 2010; Lan-
franco and Eggers 2012; Moore and Corbett 1973; 
Whittington 1999). Thus, we should expect their 
overrepresentation in a sample of extracted teeth 
where the practice was intended to ameliorate pain 
associated with oral pathology.

Within the marketplace sample, caries were only 
recorded when they could be observed as discrete le-
sions on whole teeth or large fragments of tooth 
crowns. Frequencies of carious versus non-carious 
teeth were compared between the marketplace and 
the mortuary sample. Dental calculus was scored for 
both location and severity (Buikstra and Ubelaker 
1994). Because of the limits of sample size within the 
marketplace, dental calculus was compared between 
the marketplace and the mortuary sample by calcu-
lating a general combined average calculus score for 
all teeth from each sample. Dental wear was recorded 
on all teeth and tooth fragments that had more than 
half of their occlusal or incisal surfaces present fol-
lowing Smith (1984). Molar wear was also scored fol-
lowing Scott’s (1979) quadrant scoring method. The 
Smith method utilizes an eight-point scale and dif-
ferentiates scoring guidelines according to tooth 
type. The Scott method records each quadrant of a 
molar on a 10-point scale, giving each tooth a score 
ranging between four and 40. Wear was compared 
across the two samples by tooth type (incisors, ca-
nines, premolars, molars). With regard to dental 
wear, the Scott (1979) method was not utilized in 
Scherer’s study of the mortuary sample. Thus, all 
comparisons of dental wear focus on scores derived 
using Smith’s (1984) method. All descriptive and uni-
variate statistics were conducted using R statistical 
software.

In the case of damaged teeth from the market-
place, fractures were qualitatively described to distin-
guish between antemortem, perimortem, and 
postmortem trauma on the basis of location and 
quality of the defect. Unfortunately, anthropological 
research on tooth fractures (as opposed to bone frac-
tures) is quite limited in terms of distinguishing be-
tween antemortem trauma, perimortem fractures, 

and postmortem damage. Here, we use perimortem 
to refer to the death of the tooth, whether caused by 
the death of the person or from its extraction from a 
living person. By postmortem we mean damage to 
the tooth long after death, whether caused by tapho-
nomic processes in the archaeological record, excava-
tion, or damage in subsequent handling by 
researchers (Hughes and White 2009; Viciano et al. 
2012). Antemortem fractures are readily distin-
guished from perimortem fractures or postmortem 
damage in that the margins of fractures will become 
rounded and blunted due to continued occlusion 
(Milner and Larsen 1991; Scott and Winn 2011). Peri-
mortem tooth fractures are difficult to distinguish 
from postmortem damage because both are charac-
terized by sharp, angular margins. However, right 
angles are common in postmortem damage as are 
fractures that traverse the dentinoenamel junction 
(DEJ) (Fig. 5A). In vivo, the DEJ acts as a stabilizing 
biomechanical structure and plays an important role 
in arresting crack propagation before it reaches the 
dentin. Without this important structure, postmor-
tem cracks require much less force to bridge enamel 
and dentin (Dong and Ruse 2003). When postmor-
tem damage does involve separation of enamel from 
the dentin, as during excavation or handling of the 
teeth in the laboratory, a color contrast may result on 
the newly exposed surfaces (Fig. 5B; Milner and 
Larsen 1991; Scott and Winn 2011:724).

Results

The marketplace sample included 78 permanent teeth 
that could be identified by tooth type (Table 2). The 

Figure 5. Teeth demonstrating postmortem damage from the Brown 
University Osteology Teaching Laboratory collection: (a) fracture of 
buccal crown of a mandibular premolar showing a right-angle fracture 
that bisects the enamel and dentin and exposes the pulp chamber; (b) 
enamel fragmentation from the buccal aspect of a mandibular molar 
exposing the underlying dentin (arrow; photos by J. Schnell).



Evidence for Tooth Extractions at Piedras Negras, Guatemala 54

posterior teeth (77%; premolars and molars) notably 
outnumber the anterior teeth (23%; incisors, canines, 
and two supernumerary teeth), deviating from what 
we would expect if the distribution followed that of a 
typical Maya adult (37.5% anterior; 62.5% posterior). 
In contrast, the Piedras Negras mortuary sample 
more closely matches the expected ratio: 42.1% ante-
rior, 57.9% posterior. The distinctions are even more 
stark when individual tooth classes are considered. 
Only 10% of the marketplace teeth were identified as 
incisors, versus 25.6% in the mortuary sample, the 
latter closely mirroring the expected 25% of incisors 
in a typical complete adult dentition. Premolars are 
the most overrepresented tooth in the marketplace 
sample, comprising 37% of the sample, as compared 
to their 27.8% representation in the mortuary popula-
tion. Again, that latter figure more closely mirrors 
the 25% we would expect based on premolar distribu-
tion in a complete dentition. Molar teeth are also 
more represented in the marketplace sample (40%) 
than in the mortuary sample (30.1%). The fact that 
the relative frequency of molars in the mortuary pop-
ulation is below what is expected for a normal denti-
tion points to posterior tooth loss in the Piedras 
Negras population, some of which may have been 
due to extractions. It is noteworthy that premolars 
are not underrepresented in the mortuary sample as 
molars are, but it is difficult to point to a specific eti-
ology that may explain this pattern. Tooth loss can 

result from a number of different causes, of which  
extraction is just one. It may simply be that, all fac-
tors considered, molars were more susceptible to 
tooth loss than premolars in the Piedras Negras pop-
ulation. Overall, though, the distribution of tooth 
type within the marketplace not only highlights that 
it is an atypical sample but accords with expectations 
that premolars and molars should be overrepresented 
in a sample of tooth extractions aimed at alleviating 
oral pathologies that disproportionately affect the 
posterior teeth.

The second line of analysis used to evaluate evi-
dence for dental extraction is the pattern of patholo-
gies present in the marketplace sample relative to 
Piedras Negras’s mortuary sample. Since we elimi-
nated small tooth fragments from the pathological 
analysis, we were able to score only 53% of the mar-
ketplace sample (n = 41) for caries. The calculated 
caries rate for the marketplace was 59% (n = 24).  
In contrast, of the 832 teeth (97.5% of total) in the 
Late Classic period Piedras Negras mortuary popula-
tion sample that were scored for caries, 17.2%  
(n = 143) demonstrated caries. The marketplace den-
tal sample demonstrated a caries rate more than 
three times that of the Piedras Negras burial sample 
(Table  3), a difference that is statistically significant 
based on chi-square analysis χ2 = 40.6, df = 1,  
P < .001). Nevertheless, the number of carious teeth is 
likely underestimated within the marketplace since 
small tooth fragments were not counted despite the 
fact that some of the fragments from the marketplace 
are clearly carious (Fig. 6). Dental calculus was com-
pared between the total marketplace sample and that 
of a combined sample of teeth from the mortuary 
population. The combined average calculus score for 
the marketplace (μ = 0.9) was slightly lower than that 
of the broader mortuary population  
(μ = 1.09), but a t-test indicates that this is not a statis-
tically significant difference (t = 1.4, df = 31.58,  
P = 0.18).

Table  2.  Distribution of teeth by type in the Late Classic period marketplace and the Late Classic period Piedras Negras mortuary population as 
compared to the distribution of teeth within a “typical” Late Classic period Maya adult individual

Tooth
Marketplace
n (%)

Piedras Negras Mortuary Population
n (%)

Distribution of Teeth in a “typical” adult
n (%)

Incisor 8 (10) 218 (25.6) 8 (25)

Canine 8 (10) 141 (16.5) 4 (12.5)

Premolar 29 (37) 237 (27.8) 8 (25)

Molar 31 (40) 257 (30.1) 12 (37.5)

Supernumerary 2 (3) 0 (0) 0 (0)

Total 78 (100) 853 (100) 32 (100)

Table  3.  Overall Late Classic period caries rates of the marketplace  
assemblage versus the adult mortuary population of Piedras Negras

Market-
place
n (%)

Piedras Negras Mortuary 
Population
n (%)

Total teeth 41 (100) 832 (100)

Total carious teeth 24 (59) 143 (17.2)

Total non-carious teeth 17 (41) 689 (82.8)



Schnell and Scherer 55

Comparison of the incidence of dental wear  
focused on the posterior teeth due to the low number 
of incisors and canines in the marketplace sample 
that could be scored for wear (n = 1 and n = 4,  
respectively). Of the 29 identified premolars and pre-
molar fragments, 35% (n = 10) could be scored for 
wear and of the 31 molars, 39% (n = 12) could be 
scored. In the Late Classic Piedras Negras mortuary 
population, 95.8% (n = 227) of the 237 premolars had 

been scored for wear, as had 97.3%  
(n = 250) of the 257 available molars (Table  4).  
The mean premolar wear score for the Southeast 
Marketplace sample (μ = 2.0) is roughly equivalent to 
that of the mortuary sample (μ = 2.044) and a two-
sided t-test shows the difference is not statistically 
significant (t = 0.1, df = 9.43, P = 0.93). On the other 
hand, the mean wear score of the molars in the 
Southeast Marketplace sample was lower (μ = 1.58) 
than that of the mortuary sample (μ = 2.50). A two-
sided test on the molar values did indicate a statisti-
cally significant difference (t = 4.4, df = 14.63,  
P < .001). The molar wear analyses do support our hy-
pothesis that the marketplace teeth would  
exhibit less wear than those in the mortuary sample. 
However, dental wear is multifaceted and although a 
younger age-at-death profile is a plausible explana-
tion for the discrepancy in mean molar wear between 
the two samples, we cannot rule out other explana-
tory factors such as occupational differences and di-
etary differences. We suggest, though, in light of our 
other findings, that being extractions, these teeth 
were in use (and thus subject to attrition) for a shorter 
period of time than those teeth that followed their 
owners into the grave.

Of the 78 teeth in the marketplace sample, 77%  
(n = 60) are fractured (e.g., missing part of a crown 
or root) or are themselves fragments of a root or 
crown. Only one of the fractured teeth is consistent 
with a traumatic blow to the mouth of a living per-
son. However, this tooth is afflicted by extensive 
caries, which presumably facilitated its fracturing. 
Overall, the fracture patterns observed in the teeth 
from the marketplace at Piedras Negras are consis-
tent with either (1) damage from extraction or (2) 
fragmentation of dental crowns already partially 
destroyed by dental caries. In one example, a right 
maxillary molar (PN-15I-1-4) exhibits a perimor-
tem fracture and appears to have fractured due to a 
twisting motion (Fig. 7A). The same tooth also 
shows apical root resorption that is consistent with 
root behavior at the site of a pulpal infection (Fig. 
7A; Fuss et  al. 2003:176). Observations of modern 
exodontia indicate that rotation is one of the most 
common forces applied (Ahel et al. 2015:984). This 
combined presence of root resorption and fracture 
by axial rotation is consistent with extraction in re-
sponse to oral pathology. In quite a few other cases, 
enamel chipping and even crown fractures were 
observed on or near the cementoenamel junction 
(CEJ), particularly on the labial or buccal aspects of 
teeth (Fig. 7B). None of this chipping is consistent 
with antemortem damage where subsequent use of 
the tooth would polish the fractured edges. While 
postmortem damage may also cause separation of 
the enamel, the focus on the CEJ and the small 

Figure 6. Small dental fragments from the marketplace sample exhibit-
ing carious destruction: (a) unknown crown fragment with destruction 
of the dentin within the pulp chamber (PN-15H-1-3), (b) maxillary pre-
molar fragment with destruction of the dentin within the pulp chamber 
(PN-15I-11-8), and (c) left mandibular canine with caries on the distal 
aspect of the enamel (PN-15I-1-9; photos by A. Scherer).



Evidence for Tooth Extractions at Piedras Negras, Guatemala 56

surface area affected is more suggestive of damage 
caused during extraction (compare the slight chip-
ping in Fig. 7B with exfoliation of the enamel of the 
buccal surface of the tooth in Fig. 5B).

Table  4.  Late Classic period premolars and molars distributed by Smith dental wear score for the marketplace and Piedras Negras adult mortuary 
population with percentages by column

Marketplace Piedras Negras Mortuary Population

Smith Score
Premolars
n (%)

Molars
n (%)

Premolars
n (%)

Molars
n (%)

1 4 (40) 6 (50) 60 (26) 41 (16)

2 4 (40) 5 (42) 112 (49) 109 (44)

3 0 1 (8) 40 (18) 62 (25)

4 2 (20) 0 15 (7) 19 (8)

5 0 0 0 13 (5)

6 0 0 0 3 (1)

7 0 0 0 3 (1)

8 0 0 0 0

Total 10 (100) 12 (100) 227 (100) 250 (100)

Figure 7. Fractured teeth from the marketplace sample: (a) right 
maxillary molar exhibiting external apical root resorption and 
fractured roots (PN-15I-1-4); (b) left mandibular canine with labial 
enamel chipping at the cementoenamel junction (PN-15I-1-21; pho-
tos by A. Scherer).

Figure 8. Prepared jade tooth inlay (PN-15I-1-4; photo by A. Roche 
Recinos).

Figure 9 Micro-quartz fragments including a prismatic fragment that 
may have served as a drill bit (white circle) from Piedras Negras’s mar-
ketplace (PN-15I-1-4; photo by A. Roche Recinos).



Schnell and Scherer 57

Discussion

The combination of an atypical distribution of teeth 
and pathology in the marketplace sample relative to 
the mortuary sample, coupled with the evidence for 
fracturing within the marketplace sample, supports 
our hypothesis that this anomalous assemblage of 
isolated teeth might be explained by therapeutic 
tooth extractions. While one could argue that the el-
evated frequency of caries in the marketplace sample 
indicates these teeth were drawn from a more car-
ies-prone population than that of their contemporar-
ies in the greater mortuary sample, the more 
parsimonious explanation is that the higher preva-
lence of dental caries reflects the extraction of patho-
logical teeth from living individuals. It is also 
probable that teeth were extracted as a result of ab-
scesses and other infections of both teeth and the as-
sociated alveolar region, including nonspecific 
disorders, such as nonodontogenic tooth pain (Matts-
check et  al. 2016) or persistent dentoalveolar pain 
(Nixdorf and Moana-Filho 2011). Without the aid of 
radiography, the source of oral pain is often difficult 
to isolate and tooth extraction—even when not 
needed—provides one of the few options available to 
alleviate suffering.

Interpretation of the calculus data is less straight-
forward, in part because the presence of calculus re-
flects a broader range of factors, including diet, 
hygiene, and other individual differences (Hanihara 
et al. 1994; Kinaston et al. 2019; Lieverse 1999; White 
1997). Calculus, like all dental pathologies, is also age 
related—the longer a person lives, the more time is 
available for calculus to build up. The slightly lower 
levels of calculus in the marketplace sample may re-
flect loss of calculus postmortem, with the teeth not 
protected in a sealed mortuary context. Calculus may 
also have been lost when teeth were extracted. Fi-
nally, the lower incidence of calculus may be due to 
the fact that as dental extractions, the teeth have a 
potentially younger age-at-death profile than the 
mortuary sample, assuming that at least some of the 
individuals who had their teeth extracted at the mar-
ketplace then went on to continue to live and eventu-
ally die at Piedras Negras. Ultimately, it is impossible 
to explain why the incidence of calculus is lower in 
the marketplace sample, though a number of poten-
tial explanations accord with the hypothesis that 
these teeth represent the remains of tooth 
extractions.

Ancient Maya dentistry

Earlier work on Maya dentistry has focused almost 
exclusively on cosmetic dental modifications at the 

expense of other dental interventions. Much of the 
earliest work involved classification efforts and the 
creation of typologies describing the breadth of mod-
ifications present in Mesoamerica (Rubín de la Bor-
bolla 1940; Dembo and Imbelloni 1938; Engerrand 
1917; Hamy 1882; Romero 1951, 1970; Stewart 1941). 
Since the mid-twentieth century, focus has shifted to-
ward understanding the social significance of these 
modifications and the technical aspects of their 
preparation (Fastlicht 1951, 1976; Fastlicht and 
Romero 1951; Gwinnet and Gorelick 1979; Havill 
et al. 1997; Ramírez-Salomón 2016; Ramírez-Salomón 
et  al. 2003; Tiesler 2001; Tiesler et  al. 1999; Tiesler 
et  al. 2002; Tiesler et  al. 2017). Even archaeological 
studies that position dentistry as an occupation have 
historically focused exclusively on cosmetic modifi-
cation procedures (Becker 1973:400–401; Romero 
1958). Only very recently have scholars begun to pay 
attention to oral care practices (Cucina and Tiesler 
2011; Tiesler et al. 2017), despite acknowledgment of 
these practices in the literature for quite some time. 
In 1971, Samuel Fastlicht wrote that Maya dentistry 
“had two aspects; one referred to the diseases of the 
mouth and their treatments, the other to dental mu-
tilations involving filing and incrustations” (Fastlicht 
1971:36; authors’ translation from Spanish original).

At Piedras Negras, there is circumstantial evidence 
to indicate that both therapeutic interventions, such 
as tooth extractions, and cosmetic modifications, 
such as inlaying, were conducted in the marketplace. 
At least one finished, prepared jade dental inlay was 
encountered during excavations in a stratigraphic de-
posit within which a number of teeth were also found 
(Fig. 8). While it is impossible to know whether inlays 
were kept on hand or commissioned as bespoke pro-
ductions, it is probable that the actual drilling of the 
enamel openings into which the inlays were set did 
take place in the marketplace. Fastlicht was the first 
to draw a connection between jewelry making and 
lapidary drilling and drilling dental inlay cavities. He 
suggested that holes were drilled into the enamel 
with a tube of hard stone, such as quartz, aided by 
abrasives, such as sand (Fastlicht and Romero 
1951:70–71). Similar methods are proposed for the 
drilling and polishing of jade by Maya lapidarists 
(Kidder et al. 1946; Kovacevich 2007, 2011). A number 
of prismatic quartz pieces and chert drill bits (Fig. 9) 
were found during the marketplace excavations that 
could have been used to drill both teeth and precious 
stones (Roche Recinos, personal communication, 
2020).

While ethnohistoric sources shed light on precolo-
nial therapeutic dental interventions, the subject has 
not been a central focus for scholars interested in in-
digenous medicine in Mesoamerica (Andrews Heath 



Evidence for Tooth Extractions at Piedras Negras, Guatemala 58

de Zapata 1979; Bricker and Miram 2002; Gates 2000; 
Gubler and Bolles 2000; Hernández 1959; Roys 1965, 
1976; Sahagún 2012). Much of what we know comes 
from early colonial-era documents, such as Sahagún’s 
Florentine Codex, an expansive chronicle of Mexica 
life at the time of the conquest. In addition to provid-
ing instructions for cleaning and extracting teeth, 
the Florentine Codex also presents 27 images of pa-
tients and doctors, one of which shows an individual 
suffering from toothache alongside a glyph repre-
senting teeth affixed with the sign for water (Fig. 10). 
The central Mexican Badianus Manuscript, as well as 
several Maya texts such as the Chilam Balam books 
and the Libro del Judío, describe a number of reme-
dies for cleaning the teeth, dealing with dental pain, 
and even extracting teeth. Additionally, Alonso de 
Molina’s (1571) Nahuatl dictionary defines a number 
of terms related to dental specialists, oral diseases, 
and dental anatomy that suggests a robust, complex 
dental tradition in Mesoamerica.

Our identification of isolated teeth with fractured 
roots aligns well with a hypothesis posed by Fastlicht 
who, speaking of Mesoamerican sites, observed that 
“[it is] with great curiosity we hope to find fractured 
roots, since one would imagine primitive dentists 
would have left roots in the alveolus during unpleas-
ant extractions, as is encountered in modern ones” 
(Fastlicht 1947:12; authors’ translation from Spanish 
original). The fracturing of roots remains a problem 
in contemporary clinical extractions. For example, a 
recent report suggests that anywhere from 15% to 
37% of edentulous dental patients have at least one 
retained root fragment (Nayyar et  al. 2015:Table  1). 
This was clearly a problem for Maya extractions as 
well as evident in a recently reported case of an 

embedded root fragment in a mandible at Xcambó, 
Yucatán (Cucina and Tiesler 2011). Similar instances 
may be overlooked in other Maya skeletal samples 
since radiography is often necessary to identify re-
tained rood tips. While the maxillae and mandibles 
of the Piedras Negras mortuary sample have not been 
subject to radiography, 81 cases of antemortem tooth 
loss were observed out of a total sample of 301 observ-
able alveolar canals, providing at least circumstantial 
evidence for tooth extraction at the site. Even more 
dramatic are two edentulous mandibles, one of which 
belongs to the occupant of an Early Classic period 
royal tomb (Fig. 11).

Contemporary clinical data indicate that any-
where from 9% to 20% of simple extractions result in 
fracture to the tooth (Baniwal et al. 2007; MacGregor 
1969; Venkateshwar et al. 2011), making it the “most 
common intraoperative complication during tooth 
extraction” (Ahel et al. 2015:984). The risk of compli-
cation is due to a variety of factors, including the skill 
and expertise of the practitioner, the technique and 
instrument used, and the integrity of both the tooth 
and surrounding alveolar bone. Clinical studies show 
that during in vivo tooth interventions (e.g., caries 
drilling or extraction) teeth are more likely to frac-
ture if the structural integrity of the enamel or dentin 
has already been weakened by caries or some other 
pathology and fracture lines may run along those 
points of weakness (Kishen 2015). In contrast, teeth 
that are fractured in vivo as a result of violent injury 
(e.g., a heavy blow to the mouth) tend to result in root 
fractures, or fracturing along horizontal planes, usu-
ally at the alveolar margin, typically involving com-
plete separation of the crown from the roots (Fig. 12; 
Andreasen et al. 2018:377; Lukacs 2007:150). Only one 
such case was observed in the marketplace sample, 

Figure 10. Folio 160 from Book 10 of the Florentine Codex, depicting an 
individual suffering from a toothache; the symbol at left is a Nahuatl 
glyph that includes a water sign and may somehow relate to toothache 
(drawing by J. Schnell after the original, Sahagún 2012).

Figure 11. Superior view of an edentulous mandible from Piedras Ne-
gras Burial 110, an old adult probable male, from an Early Classic royal 
tomb (photo by A. Scherer).



Schnell and Scherer 59

with fractures to individual root radicals more com-
mon, as described in the results.

While studies concerning antemortem and peri-
mortem dental fractures and trauma in archaeologi-
cal populations are scant (Alvrus 1997; Gibbon and 
Grimoud 2014; Lukacs 2007; Lukacs and Hemphill 
1990; Merbs 1968; Viciano et al. 2012), clinical litera-
ture in modern populations suggests that dental frac-
tures primarily affect the anterior dentition (Bastone 
et al. 2000; Brunner et al. 2009). Severe fractures such 
as crown-root fractures that involve the enamel, den-
tin, and cementum are quite rare (Andreasen et  al. 

2018:355). In the posterior teeth, these fractures are 
typically caused by indirect trauma (usually the re-
sult of the lower jaw coming into forceful contact 
with the upper through a fall or collision; Andreasen 
et  al. 2018:274). Further, these fractures are almost  
always “uncomplicated,” that is, they do not involve 
the pulp (Andreasen et al. 2018:355). In the market-
place sample, however, complicated crown-root frac-
tures of the posterior teeth are quite common, many 
of which display fracture planes indicative of the 
forces typically involved in exodontia. A left mandib-
ular third molar from PN-15G-25-2 exhibits this pat-
tern, with half of the root complex fractured from the 
tooth, as well as a significant portion of the coronal 
dentin and surrounding enamel, exposing the pulp 
chamber (Fig. 13A). This particular tooth also exhib-
its a large cervical caries on the aspect of the tooth 
opposite the fracture. Although traumatic fractures 
of the posterior teeth are exceptionally rare (Bastone 
et  al. 2000:6), fractures affecting these teeth, espe-
cially the molars, are common during extraction 
(MacGregor 1969:Table III). Here, the presence of a 
large caries as well as the tooth’s position in the den-
tal arcade relative to the fracture planes both point 
toward a therapeutic extraction. Some of the enamel 
chipping around the CEJ observed in the market-
place sample (Fig. 7B) may be explained by extraction 
methods. For example, if a gripping instrument or 
percussive force was used, damage to the enamel and/
or fractures to the tooth at the gum line would be ex-
pected. In other cases, such as a buccal cusp fragment 
of a maxillary premolar from PN-15I-12-4, similar 
fracture patterns to those described in the molar 
above are directly associated with carious dentin 
(Fig. 13B). Moreover, many of the dental fragments 
recovered within the marketplace exhibit carious 
dentin (Fig. 6) and are thus consistent with the pat-
tern of expected fragmentation during exodontia of 
crowns weakened by caries. Importantly, there were 
no obvious refits in the assemblage, indicating that 
crown fragmentation was not due to postmortem ta-
phonomic damage once the teeth had entered the 
stratigraphy.

Health care in the marketplace

These findings suggest that the marketplace at Pie-
dras Negras was not only a destination for economic 
exchange but was also an important center for heal-
ing along the Usumacinta River. Skilled tooth ex-
tractors in antiquity were likely sought out by 
individuals with oral pathologies who were suffering 
immense pain. It was, however, not a procedure with-
out risk and the process itself could also be a source 
of pain. As an analogy from contemporary times, 

Figure 12. Left mandible from Plaza 1, Oztoyahualco, Teotihuacán, 
showing horizontal perimortem fracturing of the canine and molars 
consistent with a traumatic blow (photo by A. Scherer). The lateral as-
pect of the ascending ramus shows extensive cutmarks (not visible in 
the photo) consistent with defleshing and extraction from a fleshed 
body.

Figure 13. Complicated dental fractures in the marketplace sample: (a) 
left third mandibular molar with fractured root and enamel (PN-
15G-25-2); (b) maxillary premolar buccal cusp (PN-15I-12-4; photos by 
A. Scherer).



Evidence for Tooth Extractions at Piedras Negras, Guatemala 60

one K’iche’ woman from Guatemala with no fewer 
than 22 tooth extractions observed: “It hurts and 
sometimes it bleeds a lot. Sometimes the dentista 
does not have much experience and leaves the root. 
That really hurts!” (Lee 2007:186).

We do not know precisely how the ancient Maya 
extracted teeth. In some cases, it may have been done 
with simple manipulation by hand. In other in-
stances, it may have involved cutting the surround-
ing gingival tissue or the use of tools made of bone, 
wood, or stone to leverage the tooth within and ulti-
mately out of the alveolus. Tweezers like those found 
at Tikal (Moholy-Nagy and Coe 2008:Fig. 209) were 
perhaps used, though no such implements have been 
found at Piedras Negras. Ethnographic and ethno-
historic evidence suggests that plants may also have 
been used to aid in tooth extraction (Atran et  al. 
2004; Balick and Arvigo 2015; Breedlove and Laugh-
lin 2000; Hunter and Arbona 1995; Mendieta and del 
Amo 1981; Roys 1976). Ongoing paleoethnobotanical 
analyses in the marketplace have confirmed the pres-
ence of a variety of plants with known medicinal 
uses, including some associated with the manage-
ment of dental pain (Watson et al. 2019).

The identification of dental extractions at Piedras 
Negras presents one of the few case studies of ancient 
health care in the Americas and emphasizes the close 
relationship between medicine and markets across 
much of Mesoamerica (Kashanipour 2012:132; Sa-
hagún 2012). The market has long played a central 
role in indigenous medical systems in the region, 
particularly due to its tendency to draw visitors from 
relatively large catchment areas into a single, often 
urban setting. Early colonial writers noted the pres-
ence of apothecaries and physicians in these markets 
as well (Cortés 1962:87–88; Sahagún 1961:30, 53). The 
provision of medical services as an economic ex-
change is also prevalent in the Maya region. In the 
eighteenth century Popol Vuh, a quasi–mythical-his-
torical account of creation and the history of the 
K’iche’ nation, the pair of primordial grandparents 
describe how they provide for their family by offering 
a variety of medical services, such as curing the eyes, 
setting broken bones, and removing worms from 
teeth (Christenson 2003:99). This last service is a 
metaphor for tooth extractions, as belief in the “tooth 
worm” as a cause of toothache and dental disease is 
widespread in the Maya region (Augusto Ávila 
1977:26–27; Breedlove and Laughlin 2000:234, 243; 
Casagrande 2002:77; Lee 2007:187; Roys 1965:55–57).

In recent times in Mesoamerica, itinerant healers, 
including dental specialists, travel to regional mar-
kets in order to offer their services on major market 
days. Gordon Schendel (1968:51) reports on an indig-
enous dental practitioner who visited Querétaro, a 

city in central Mexico, on market days. He would set 
up an old kitchen chair in a street behind the market 
and pull teeth using ancestral medicine. In the Gua-
temalan town of Nahualá, patients line up outside of 
dental offices on market days, many “clutching their 
cheek, sometimes with a towel draped over the shoul-
der to catch the blood when they get their turn” (Lee 
2007:186). At Antigua Santa Catarina Ixtahuacán, 
another town in Guatemala, an itinerant dentista 
comes to town on market days, rents out a small 
adobe room, and charges just 10 quetzales (~ US$1.30) 
for dental extractions (Lee 2007:188).

Archaeologically, sweatbaths provide the most sa-
lient evidence for loci of ancient Maya healing due to 
their association with midwifery, ritual, and healing 
as commonly noted by colonial writers (Coto 1983:61; 
Durán 1971) and ethnographers (Berlin and Berlin 
1966; Cosminsky 1972; Katz 1993; Maffi 1994; 
Moedano 1977; Virkki 1962; Wagley 1949; Wauchope 
1938). Ethnohistoric evidence also associates sweat-
baths with marketplaces. For example, in the mid-six-
teenth century, Francisco López de Gómara noted 
the presence of a public bath in the marketplace at 
Ocotelulco (1966:120). The traditional Maya sweat-
bath is a vapor bath in which steam is produced 
through water applied to a bed of heated rocks in a 
central chamber (Groark 2005:786). Ancient monu-
mental sweatbaths have a distinct architectural sig-
nature, including a firebox in the central chamber. 
Eight sweatbaths have been identified at Piedras Ne-
gras: seven monumental baths and one associated 
with a rural house group, the largest number in the 
Maya area (Child 2006; Houston 1996). Three of Pie-
dras Negras’s eight sweatbaths are found at the 
Southeast Marketplace (Fig. 3): S-2 and S-4 are lo-
cated along the western edge of the market and S-19 
is located on the opposite end of the market, adjacent 
to the two principal range structures (S-17 and S-18). 
These three sweatbaths are in the most accessible part 
of the site and were the ones presumably available to 
the general populace as well as visitors to the site, 
many of whom would have arrived from the south, 
either by the pathway that enters the site or via canoe 
at Piedras Negras’s nearby beach.

Conclusions

In this article, we provide bioarchaeological evi-
dence for tooth extractions conducted at the Maya 
site of Piedras Negras, Guatemala, during the Late 
Classic period. We suggest that these extractions 
were conducted to alleviate pain and other ill con-
sequences associated with dental caries. This re-
search presents one of the few case studies of 



Schnell and Scherer 61

ancient health care in the Americas and provides a 
complement to prior scholarship on ancient Maya 
dentistry. Similar therapeutic dental extractions 
were presumably practiced across much of the 
Maya region and may explain some of the loose, 
isolated teeth found archaeologically. This study 
also supplements an emerging body of literature 
concerning indigenous therapeutic dentistry in the 
Americas (Goguitchaichvili et al. 2017; Ortiz et al. 
2016; Schwartz et al. 1995; Seidel et al. 2005; Turner 
2004) and ancient dental traditions elsewhere in 
the world (Becker 2014; Bennike 1985; Bernardini 
et  al. 2012; Coppa et  al. 2006; Forrai 2009; Oxilia 
et  al. 2015; Oxilia et  al. 2017). We hope that this 
study broadens the scope of scholarship on ancient 
Maya dentistry, beyond cosmetic modifications. It 
is clear that the indigenous peoples of Mesoamer-
ica, the Maya included, had a deep understanding 
of human anatomy and a complex medical tradi-
tion that surprised the Spanish upon their arrival 
and that most certainly existed long before then as 
well. Although we cannot draw a direct historical 
connection between the Piedras Negras market-
place assemblage and the dental treatments pre-
scribed in the colonial and ethnomedical literature, 
this evidence for dental extractions during the 
Classic period does provide significant temporal 
depth for therapeutic dentistry in the region more 
generally.

Acknowledgments

The authors would like to thank the entire Proyecto 
Paisaje Piedras Negras–Yaxchilan research team and 
all of its collaborators, as well as the Proyecto Arque-
ológico Piedras Negras, without whom this work 
would not have been possible. 2016 and 2017 excava-
tions in the marketplace were conducted by Charles 
Golden, Andrew Scherer, Shanti Morell-Hart, Ale-
jandra Roche Recinos, Mallory Matsumoto, and 
Joshua Schnell. We offer a special thanks to our col-
leagues for all of their efforts. Funding for the PPPNY 
was generously provided by the National Science 
Foundation (BCS-1505483/1505399) as well as the Al-
phawood Foundation. Funding for this particular re-
search, which was part of Schnell’s master’s thesis, 
was provided by the Brown University Graduate 
School, Department of Anthropology, and Center for 
Latin American and Caribbean Studies, as well as the 
Tinker Foundation. We also thank Stephen Houston 
and Charles Golden for comments and suggestions 
on a previous version of this paper. Finally, we would 
like to thank the four anonymous reviewers for their 
helpful comments on this work.

References Cited

Ahel, V., T. Ćabov, S. Špalj, B. Perić, D. Jelušić, and M. Dmitraši-
nović. 2015. Forces that fracture teeth during extraction with 
mandibular premolar and maxillary incisor forceps. British 
Journal of Oral and Maxillofacial Surgery 53(10): 982–987. 
DOI: 10.1016/j.bjoms.2015.08.007.

Alvrus, A. 1997. Trauma to the teeth and jaws: Three Nubian ex-
amples. Journal of Paleopathology 9:5–14.

Andreasen, Jens O., Frances M. Andreasen, and Lars Anders-
son, eds. 2018. Textbook and Color Atlas of Traumatic Injuries 
to the Teeth. 5th ed. Wiley-Blackwell, Hoboken, NJ.

Andrews Heath de Zapata, Dorothy. 1979. El Libro del Judío, o 
Medicina Doméstica. Dorothy Andrews Heath de Zapata, 
Mérida.

Arroyave, Ana Lucia, Ricardo Rodas, and Mónica Urquizú. 2017. 
Análisis de la cerámica y figurillas de Piedras Negras. In 
Proyecto Paisaje Piedras Negras–Yaxchilan, Informe de la Se-
gunda Temporada de Investigación, edited by Mónica Ur-
quizú, Andrew K. Scherer, and Charles W. Golden. Instituto 
de Antropología e Historia, Guatemala City, pp. 168–193.

Atran, Scott, Ximena Lois, and Edilberto Ucan Ek’. 2004. Plants 
of the Petén Itza’ Maya. Memoirs of the Museum of Anthro-
pology No. 38. University of Michigan, Ann Arbor.

Augusto Ávila, César. 1977. El Xul-E’: Creencias populares sobre 
la etiología de la caries y del dolor dental en grupos de indíge-
nas Kekchies. Guatemala Indígena 12(1–2):4–51.

Awe, Jaime, Nikolai Grube, and David Cheetham. 2009. Cahal 
Pech Stela 9: A Preclassic monument from the Belize Valley. 
Research Reports in Belizean Archaeology 6:179–189.

Balick, Michael J., and Rosita Arvigo. 2015. Messages from the 
Gods: A Guide to the Useful Plants of Belize. Oxford University 
Press, Oxford.

Baniwal, S., K. R. Paudel, U. Pyakurel, M. Bajracharya, and S. R. 
Niraula. 2007. Prevalence of complications of simple tooth ex-
tractions and its comparison between a tertiary center and 
peripheral centers: A study conducted over 8,455 tooth ex-
tractions. Journal of the Nepal Medical Association 46(165):20–
24. DOI: 10.31729/jnma.420.

Barrett, Jason W., and Andrew K. Scherer. 2005. Stones, bones, 
and crowded plazas: Evidence for Terminal Classic Maya war-
fare at Colha, Belize. Ancient Mesoamerica 16(1):101–118. DOI: 
10.1017/S0956536105050091.

Bastone, Elisa B., Terry J. Freer, and John R. McNamara. 2000. 
Epidemiology of dental trauma: A review of the literature. 
Australian Dental Journal 45(1):2–9. DOI: 10.1111/j.1834-
7819.2000.tb00234.x.

Becker, Marshall Joseph. 1973. Archaeological evidence for oc-
cupational specialization among the Classic Period Maya at 
Tikal, Guatemala. American Antiquity 38(4):396–406. DOI: 
10.2307/279144.

Becker, Marshall Joseph. 2014. Dentistry in ancient Rome: Di-
rect evidence for extractions based on the teeth from excava-
tions at the Temple of Castor and Pollux in the Roman Forum. 
International Journal of Anthropology 29(4):209–226.

Bennike, Pia. 1985. Paleopathology of Danish Skeletons: A Com-
parative Study of Demography, Disease and Injury. Akademisk 
Forlag, Copenhagen.

Berlin, Elois Ann, and Brent Berlin. 1966. Medical Ethnobiology 
of the Highland Maya of Chiapas, Mexico: The Gastrointesti-
nal Diseases. Princeton University Press, Princeton, NJ.

Bernardini, Federico, Claudio Tuniz, Alfredo Coppa, Lucia 
Mancini, Diego Dreossi, Diane Eichert, Gianluca Turco, Mat-
teo Biasotto, Filippo Terrasi, Nicola de Cesare, Quan Hua, 
and Vladimir Levchenko. 2012. Beeswax as dental filling on a 



Evidence for Tooth Extractions at Piedras Negras, Guatemala 62

Neolithic human tooth. PLoS ONE 7(9):e44904. DOI: 10.1371/
journal.pone.0044904.

Breedlove, Dennis E., and Robert M. Laughlin. 2000. Flowering 
of Man: A Tzotzil Botany of Zinacantán, Abridged Edition. 
Smithsonian Institution Press, Washington, D.C.

Bricker, Victoria R., and Helga-Maria Miram. 2002. An Encoun-
ter of Two Worlds: The Book of Chilam Balam of Kaua. Tulane 
University Middle American Research Institute, New 
Orleans.

Brunner, Flavio, Gabriel Krastl, and Andreas Filippi. 2009. Den-
tal trauma in adults in Switzerland. Dental Traumatology 
25(2):181–184. DOI: 10.1111/j.1600-9657.2008.00752.x.

Buikstra, Jane E., and Douglas H. Ubelaker. 1994. Standards for 
Data Collection from Human Skeletal Remains. Arkansas Ar-
cheological Survey Research Series No. 44, Fayetteville.

Cahen, P. M., R. M. Frank, and J. C. Turlot. 1985. A survey of the 
reasons for dental extractions in France. Journal of Dental Re-
search 64(8):1087–1093. DOI: 10.1177/00220345850640081401.

Cap, Bernadette. 2015a. Classic Maya Economies: Identification 
of a Marketplace at Buenavista del Cayo, Belize. Ph.D. disser-
tation, University of Wisconsin, Madison.

Cap, Bernadette. 2015b. How to know it when we see it: Market-
place identification at the Classic Maya site of Buenavista del 
Cayo, Belize. In The Ancient Maya Marketplace: The Archae-
ology of Transient Space, edited by Eleanor M. King. The Uni-
versity of Arizona Press, Tucson, pp. 111–137.

Carrasco Vargas, Ramón, Verónica A. Vázquez López, and Si-
mon Martin. 2009. Daily life of the ancient Maya recorded on 
murals at Calakmul, Mexico. Proceedings of the National 
Academy of Sciences 106(46):19245–19249. DOI: 10.1073/
pnas.0904374106.

Casagrande, David Gregory. 2002. Ecology, Cognition, and Cul-
tural Transmission of Tzeltal Maya Medicinal Plant Knowl-
edge. Ph.D. dissertation, University of Georgia, Athens.

Chase, Arlen F., and Diane Z. Chase. 1994. Maya veneration of 
the dead at Caracol, Belize. In Seventh Palenque Round Table, 
1989, edited by Merle Greene Robertson and Virginia M. 
Fields. Pre-Columbian Art Research Institute, San Francisco, 
pp. 55–62.

Chase, Diane Z. 1994. Human osteology, pathology, and demog-
raphy as represented in the burials of Caracol, Belize. In Stud-
ies in the Archaeology of Caracol, Belize, edited by Diane Z. 
Chase and Arlen F. Chase. Pre-Columbian Art Research In-
stitute Monograph 7, San Francisco, pp. 123–138.

Chase, Diane Z., and Arlen F. Chase. 1998. The architectural 
context of caches, burials, and other ritual activities for the 
Classic Period Maya (as reflected at Caracol, Belize). In Func-
tion and Meaning in Classic Maya Architecture, edited by Ste-
phen D. Houston. Dumbarton Oaks Research Library and 
Collection, Washington, D.C., pp. 239–332.

Chase, Diane Z., and Arlen F. Chase. 2011. Ghosts amid the ru-
ins: Analyzing Relationships between the Living and the 
Dead among the Ancient Maya at Caracol, Belize. In Living 
with the Dead: Mortuary Ritual in Mesoamerica, edited by 
James L. Fitzsimmons and Izumi Shimada. University of Ari-
zona Press, Tucson, pp. 78–101.

Cheetham, David. 2004. The role of “terminus groups” in low-
land Maya site planning: An example from Cahal Pech. In The 
Ancient Maya of the Belize Valley: Half a Century of Archaeo-
logical Research, edited by James F. Garber. University Press 
of Florida, Gainesville, pp. 125–148.

Child, Mark B. 2006. The Archaeology of Religious Movements: 
The Maya Sweatbath Cult of Piedras Negras. Ph.D. disserta-
tion, Yale University, New Haven, CT.

Christenson, Allen J. 2003. Popol Vuh: The Sacred Book of the 
Maya. University of Oklahoma Press, Norman.

Coe, William R. 1959. Piedras Negras Archaeology: Artifacts, 
Caches, and Burials. University Museum Monograph, 18. The 
University of Pennsylvania Museum of Archaeology and An-
thropology, Philadelphia.

Coppa, A., L. Bondioli, A. Cucina, D. W. Frayers, C. Jarrige, J.-F. 
Jarrige, G. Quivron, M. Rossi, M. Vidale, and R. Macchiarelli. 
2006. Early Neolithic tradition of dentistry: Flint tips were 
surprisingly effective for drilling tooth enamel in a prehis-
toric population. Nature 440:755–756. DOI: 10.1038/440775a.

Cortés, Hernando. 1962. Five Letters of Cortés to the Emperor: 
1519–1526. W. W. Norton, New York.

Cosminsky, Sheila. 1972. Decision Making and Medical Care in a 
Guatemalan Indian Community. Ph.D. dissertation, Brandeis 
University, Waltham, MA.

Coto, Thomás de. 1983. Thesaurus verborum. In Vocabulario de 
la Lengua Cakchiquel v[el] Guatemalteca, Nuevamente Hecho 
y Recopilado con Summo Estudio, Trabajo y Erudición, edited 
by R. Acuña. Universidad Nacional Autónoma de México, 
Mexico City.

Cucina, Andrea, Cristina Perera Cantillo, Thelma Sierra Sosa, 
and Vera Tiesler. 2011. Carious lesions and maize consump-
tion among the Prehispanic Maya: An analysis of a coastal 
community in northern Yucatan. American Journal of Physi-
cal Anthropology 145(4):560–567. DOI: 10.1002/ajpa.21534.

Cucina, Andrea, and Vera Tiesler. 2011. Salud oral y caries entre 
los mayas del período clásico. In Vida Cotidiana de los Antig-
uos Mayas del Norte de la Península de Yucatán, edited by Ra-
fael Cobos and Lilia Fernández Souza. Ediciones de la 
Universidad Autónoma de Yucatán, Mérida, pp. 23–44.

Dahlin, Bruce H., Christopher T. Jensen, Richard E. Terry, Da-
vid R. Wright, and Timothy Beach. 2007. In search of an an-
cient Maya market. Latin American Antiquity 18(4):363–384. 
DOI: 10.2307/25478193.

Dembo, Adolfo, and José Imbelloni. 1938. Deformaciones Inten-
cionales del Cuerpo Humano de Carácter Étnico. Sec. A, Tomo 
3. Humanior Biblioteca del Americanista Moderno. José 
Anesi, Buenos Aires.

Demirci, Mustafa, Safa Tuncer, and Ahmet Ayhan Yuceokur. 
2010. Prevalence of caries on individual tooth surfaces and its 
distribution by age and gender in university clinic patients. 
European Journal of Dentistry 4(3):270–279.

Dong, X. D., and N. D. Ruse. 2003. Fatigue crack propagation 
path across the dentinoenamel junction complex in human 
teeth. Journal of Biomedical Materials Research 66A(1):103–
109. DOI: 10.1002/jbm.a.10541.

Doyle, James A. 2012. Regroup on “E-groups”: Monumentality 
and early centers in the Middle Preclassic Maya lowlands. 
Latin American Antiquity 23(4):355–379. DOI: 10.7183/ 
1045-6635.23.4.355.

Duncan, William N. 2011. Bioarchaeological analysis of sacrifi-
cial victims from a Postclassic Maya temple from Ixlu, El Pe-
ten, Guatemala. Latin American Antiquity 22(4):549–572. 
DOI: 10.7183/1045-6635.22.4.549.

Durán, Fray Diego. 1971. Book of the Gods and Rites and the An-
cient Calendar. Translated by Fernando Horcasitas and Doris 
Heyden. University of Oklahoma Press, Norman.

Emery, Kitty F. 2008. Techniques of ancient Maya bone working: 
Evidence from a Classic Maya deposit. Latin American Antiq-
uity 19(2):204–221. DOI: 10.1017/S104566350000780X.

Emery, Kitty F. 2009. Perspectives on ancient Maya bone craft-
ing from a Classic period bone-artifact manufacturing as-
semblage. Journal of Anthropological Archaeology 28(4): 
458–470. DOI: 10.1016/j.jaa.2009.07.003.



Schnell and Scherer 63

Emery, Kitty F. 2010. Dietary, Environmental, and Societal Impli-
cations of Ancient Maya Animal Use in the Petexbatun: A 
Zooarchaeological Perspective on the Collapse. Vanderbilt In-
stitute of Mesoamerican Archaeology Series Volume 5. Van-
derbilt University Press, Nashville.

Engerrand, G. 1917. Les mutilations dentaires chez les anciens 
Mayas. Revue Anthropologique 27:488–493.

Escobedo, Héctor L. 1997. PN 15: Excavaciones en las estructuras 
S-11, S-12 y S-10. In Proyecto Arqueológico Piedras Negras In-
forme Preliminar No. 1, Primera Temporada, 1997, edited by 
Héctor L. Escobedo and Stephen Houston. Instituto de An-
tropología e Historia, Guatemala City, pp. 121–132.

Escobedo, Héctor L., and Stephen D. Houston. 1997. Proyecto 
Arqueológico Piedras Negras Informe Preliminar No. 1, Prim-
era Temporada, 1997. Instituto de Antropología e Historia, 
Guatemala City.

Escobedo, Héctor L., and Stephen D. Houston. 1998. Proyecto 
Arqueológico Piedras Negras Informe Preliminar No. 2, Se-
gunda Temporada, 1998. Instituto de Antropología e Historia, 
Guatemala City.

Escobedo, Héctor L., and Stephen D. Houston. 1999. Proyecto 
Arqueológico Piedras Negras Informe Preliminar No. 3, Tercera 
Temporada, 1999. Instituto de Antropología e Historia, Gua-
temala City.

Escobedo, Héctor L., and Stephen D. Houston. 2001. Proyecto 
Arqueológico Piedras Negras Informe Preliminar No. 4, Cuarta 
Temporada, 2000. Instituto de Antropología e Historia, Gua-
temala City.

Escobedo, Héctor L., and Stephen D. Houston. 2005. Informe de 
las Intervenciones en la Estructura K-5 de Piedras Negras. In-
stituto de Antropología e Historia, Guatemala City.

Fastlicht, Samuel. 1947. Estudio dental y radiográfico de las mu-
tilaciones dentarias. Anales del Instituto Nacional de Antro-
pología e Historia 2:7–13.

Fastlicht, Samuel. 1951. Contribución al estudio del pegamento 
de las incrustaciones. In Homenaje al Doctor Alfonso Caso, 
edited by Alfonso Caso. Imprenta Nuevo Mundo, Mexico 
City, pp. 153–165.

Fastlicht, Samuel. 1971. La odontología en México Prehispánico. 
Ediciones Mexicanas, Mexico City.

Fastlicht, Samuel. 1976. Tooth Mutilations and Dentistry in 
Pre-Columbian Mexico. Quintessence Books, Berlin.

Fastlicht, Samuel, and Javier Romero. 1951. El Arte de las Mutila-
ciones Dentarias. Enciclopedia Mexicana de Arte, 14. Edi-
ciones Mexicanas, Mexico City.

Forrai, Judit. 2009. The beginning of dental caries and its treat-
ments. Revista de Clínica e Pesquisa Odontológica 
5(2):187–192.

Fuss, Zvi, Igor Tsesis, and Shaul Lin. 2003. Root resorption—di-
agnosis, classification and treatment choices based on stimu-
lation factors. Dental Traumatology 19(4):175–182. DOI: 
10.1034/j.1600-9657.2003.00192.x.

Gates, William. 2000. An Aztec Herbal: The Classical Codex of 
1552. Dover Publications, Mineola, NY.

Gibbon, Victoria, and Anne Marie Grimoud. 2014. Dental pa-
thology, trauma and attrition in a Zambian Iron Age sample: 
A macroscopic and radiographic investigation. International 
Journal of Osteoarchaeology 24(4):439–458. DOI: 10.1002/
oa.2228.

Goguitchaichvili, Avto, Juan Morales, Ramiro Aguayo Haro, 
Humberto Quiroz Castañon, and Jasinto Robles Camacho. 
2017. First evidence of complex dental practice about 1300 BP 
in Mesoamerica revealed by absolute geomagnetic intensity. 
Studia Geophysica et Geodaetica 61(2):310–317. DOI: 10.1007/
s11200-016-0851-3.

Golden, Charles W. 2017. Operación 15K: Excavaciones en la 
Estructura S-7. In Proyecto Paisaje Piedras Negras–Yaxchilan, 
Informe de la Segunda Temporada de Investigación, edited by 
Mónica Urquizú, Andrew K. Scherer, and Charles W. Golden. 
Instituto de Antropología e Historia, Guatemala City, pp. 
49–61.

Golden, Charles, Andrew K. Scherer, Melanie Kingsley, Stephen 
D. Houston, and Héctor Escobedo. 2016. The life and afterlife
of the Classic Period Piedras Negras kingdom. In Ritual, Vio-
lence, and the Fall of the Classic Maya Kings, edited by Gyles
Iannone, Brett A. Houk, and Sonja A. Schwake. University
Press of Florida, Gainesville, pp. 108–133.

Golden, Charles, Andrew K. Scherer, and René Muñoz. 2008. 
Piedras Negras and Yaxchilan: Divergent political trajectories 
in adjacent Maya polities. Latin American Antiquity 19(3):249–
274. DOI: 10.2307/25478230.

Golden, Charles, Andrew K. Scherer, Whittaker Schroder, Clive 
Vella, and Alejandra Roche Recinos. 2020. Decentralizing the 
economies of the Maya west. In The Real Business of Ancient 
Maya Economies: From Farmers’ Fields to Rulers’ Realms, ed-
ited by Marilyn A. Masson, David A. Freidel, and Arthur A. 
Demarest. University Press of Florida, Gainesville, pp. 
403–417.

Groark, Kevin P. 2005. Vital warmth and well-being: Steam-
bathing as household therapy among the Tzeltal and Tzotzil 
Maya of highland Chiapas, Mexico. Social Science & Medicine 
61(4):785–795. DOI: 10.1016/j.socscimed.2004.08.044.

Gubler, Ruth, and David Bolles. 2000. The Book of Chilam Balam 
of Na: Facsimile, Translation, and Edited Text. Labyrinthos, 
Lancaster.

Gwinnett, A. J., and L. Gorelick. 1979. Inlayed teeth of ancient 
Mayans: A tribological study using the SEM. Scanning Elec-
tron Microscopy 3(3):575–580.

Hamy, E. T. 1882. Les mutilations dentaires au Mexique et dans 
le Yucatan. Bulletins et Mémoires de la Société d’Anthropologie 
de Paris 5:879–882.

Hanihara, Tsunehiko, Hajime Ishida, Naoyuki Ohshima, 
Osamu Kondo, and Tetsuo Masuda. 1994. Dental calculus and 
other dental disease in a human skeleton of the Okhotsk cul-
ture unearthed at Hamanaka-2 site, Rebun-Island, Hokkaido, 
Japan. International Journal of Osteoarchaeology 4(4):343–351. 
DOI: 10.1002/oa.1390040408.

Havill, Lorena M., Diane M. Warren, Keith P. Jacobi, Karen D. 
Gettelman, Della Collins Cook, and K. Anne Pyburn. 1997. 
Late Postclassic tooth filing at Chau Hiix and Tipu, Belize. In 
Bones of the Maya: Studies of Ancient Skeletons, edited by Ste-
phen L. Whittington and David M. Reed. Smithsonian Insti-
tution Press, Washington, D.C., pp. 89–104.

Hernández, Francisco. 1959. Historia Natural de Nueva España, 
Volumen II. Universidad Nacional Autónoma de México, 
Mexico City.

Hirth, Kenneth G. 2009. Craft production in a central Mexican 
marketplace. Ancient Mesoamerica 20(1):89–102. DOI: 10.1017/
S0956536109990034.

Hirth, Kenneth G. 2013. The merchant’s world: Commercial di-
versity and the economics of interregional exchange in high-
land Mesoamerica. In Merchants, Markets, and Exchange in 
the Pre-Columbian World, edited by Kenneth G. Hirth and 
Joanne Pillsbury. Dumbarton Oaks Research Library and 
Collection, Washington, D.C., pp. 85–112.

Hirth, Kenneth G. 2016. The Aztec Economic World: Merchants 
and Markets in Ancient Mesoamerica. Cambridge University 
Press, Cambridge.

Holley, George R. 1983. Ceramic Change at Piedras Negras, Gua-
temala. Ph.D. dissertation, Southern Illinois University, 
Carbondale.



Evidence for Tooth Extractions at Piedras Negras, Guatemala 64

Houston, Stephen D. 1996. Symbolic sweatbaths of the Maya: 
Architectural meaning in the Cross Group at Palenque, Mex-
ico. Latin American Antiquity 7(2):132–151. DOI: 10.2307/ 
971614.

Houston, Stephen D., Héctor L. Escobedo, Mark Child, Charles 
Golden, and A. René Muñoz. 2000. El inicio de una ciudad 
Maya: Una perspectiva desde Piedras Negras, Guatemala. In 
Los Investigadores de la Cultura Maya, Vol. 8, Tomo I. Univer-
sidad Autónoma de Campeche, Campeche, pp. 9–27.

Houston, Stephen D., Héctor Escobedo, Andrew K. Scherer, 
Mark Child, and James Fitzsimmons. 2003. Classic Maya 
death at Piedras Negras. In Antropología de la Eternidad: La 
Muerte en la Cultura Maya, edited by Andrés Ciudad Ruíz, 
Mario H. Ruz, and María Josefa Iglesias Ponce de León. Socie-
dad Española de Estudios Mayas, Mexico City, pp. 113–143.

Hughes, Cris E., and Crystal A. White. 2009. Crack propagation 
in teeth: A comparison of perimortem and postmortem be-
havior of dental materials and cracks. Journal of Forensic Sci-
ences 54(2):263–266. DOI: 10.1111/j.1556-4029.2008.00976.x.

Hunter, John M., and Sonia I. Arbona. 1995. The tooth as a 
marker of developing world quality of life: A field study in 
Guatemala. Social Science & Medicine 41(9):1217–1240. DOI: 
10.1016/0277-9536(95)00011-U.

Jackson, Sarah E., and Zachary X. Hruby. 2001. PN 15: Excava-
ciones en la Estructura S-11 y plaza asociada. In Proyecto Ar-
queológico Piedras Negras Informe Preliminar No. 4, Cuarta 
Temporada, 2000, edited by Héctor L. Escobedo and Stephen 
D. Houston. Instituto de Antropología e Historia, Guatemala
City, pp. 27–36.

Kashanipour, Ryan Amir. 2012. A World of Cures: Magic and 
Medicine in Colonial Yucatán. Ph.D. dissertation, The Univer-
sity of Arizona, Tucson.

Katz, Esther. 1993. El temazcal: entre religión y medicina. In III 
Coloquio de Historia de la Religión en Mesoamérica y Áreas 
Afines, edited by Barbro Dahlgren Jordan. Instituto de Inves-
tigaciones Antropológicas, Universidad Nacional Autónoma 
de México, Mexico City, pp. 175–185.

Kidder, Alfred V., Justin Jennings, and Edwin M. Shook. 1946. 
Excavations at Kaminaljuyu, Guatemala. Carnegie Institu-
tion of Washington, Washington, D.C.

Kinaston, Rebecca, Anna Willis, Justyna J. Miszkiewicz, Mon-
ica Tromp, and Marc F. Oxenham. 2019. The dentition: Devel-
opment, disturbances, disease, diet, and chemistry. In 
Ortner’s Identification of Pathological Conditions in Human 
Skeletal Remains, edited by Jane E. Buikstra. 3rd ed. Aca-
demic Press, New York, pp. 749–798.

Kishen, Anil. 2015. Biomechanics of fractures in endodontically 
treated teeth. Endodontic Topics 33(1):3–13. DOI: 10.1111/
etp.12089.

Kovacevich, Brigitte. 2007. Ritual, crafting, and agency at the 
Classic Maya kingdom of Cancuen. In Mesoamerican Ritual 
Economy: Archaeological and Ethnological Perspectives, edited 
by E. Christian Wells and Karla L. Davis-Salazar. University 
Press of Colorado, Boulder, pp. 67–114.

Kovacevich, Brigitte. 2011. The organization of jade production 
at Cancuen, Guatemala. In The Technology of Maya Civiliza-
tion: Political Economy And Beyond in Lithic Studies, edited 
by Zachary X. Hruby, Geoffrey E. Braswell, and Oswaldo 
Chinchilla Mazariegos. Routledge, London, pp. 151–166.

Lanfranco, Luis Pezo, and Sabine Eggers. 2012. Caries through 
time: An anthropological overview. In Contemporary Ap-
proach to Dental Caries, edited by Ming-Yu Li. IntechOpen, 
Rijeka, HR, pp. 3–34.

Lee, Jared T. 2007. “If My Tooth Hurts, I Pull It Out”: Oral health 
in Antigua Santa Catarina Ixtahuacán. In Health Care in 

Maya Guatemala: Confronting Medical Pluralism in a Devel-
oping Country, edited by Walter Randolph Adams and John P. 
Hawkins. University of Oklahoma Press, Norman, pp. 
179–193.

Lieverse, Angela R. 1999. Diet and the aetiology of dental  
calculus. International Journal of Osteoarchaeology 9(4): 
219–232. DOI: 10.1002/(SICI)1099-1212(199907/08)9:4219::AID- 
OA4753.0.CO;2-V.

López de Gómara, Francisco. 1966. Cortés: The Life of the Con-
queror by his Secretary. University of California Press, 
Berkeley.

Lukacs, J. R. 2007. Dental trauma and antemortem tooth loss in 
prehistoric Canary Islanders: Prevalence and contributing 
factors. International Journal of Osteoarchaeology 17(2):157–
173. DOI: 10.1002/oa.864.

Lukacs, J. R., and B. E. Hemphill. 1990. Traumatic injuries of 
prehistoric teeth: New evidence from Baluchistan and Punjab 
provinces, Pakistan. Anthropologischer Anzeiger 48(4): 
351–363.

MacGregor, A. J. 1969. Factors affecting fracture of teeth during 
extraction. British Journal of Oral Surgery 7(1):55–62. DOI: 
10.1016/S0007-117X(69)80061-2.

Maffi, Luisa. 1994. A Linguistic Analysis of Tzeltal Maya Ethno-
symptomatology. Ph.D. dissertation, University of California, 
Berkeley.

Maler, Teobert. 1901. Researches in the Central Portion of the 
Usumatsintla Valley: Report of Explorations for the Museum, 
1898–1900. Memoirs of the Peabody Museum of American Ar-
chaeology and Ethnology Vol. 2, No. 1. Peabody Museum of 
Archaeology and Ethnology, Cambridge.

Massey, Virginia K., and D. Gentry Steele. 1997. A Maya skull pit 
from the Terminal Classic period, Colha, Belize. In Bones of 
the Maya: Studies of Ancient Skeletons, edited by Stephen L. 
Whittington and David M. Reed. Smithsonian Institution 
Press, Washington, D.C., pp. 62–77.

Mattscheck, Donna, Alan S. Law, and Donald R. Nixdorf. 2016. 
Diagnosis of the non-odontogenic toothache. In Cohen’s 
Pathways of the Pulp, edited by Kenneth M. Hargreaves and 
Louis H. Berman. 11th ed. Elsevier, St. Louis, pp. 684–705.

Mendieta, Rosa M., and Silvia del Amo R. 1981. Plantas Medici-
nales del Estado de Yucatán. Instituto Nacional de Investiga-
ciones Sobre Recursos Bióticos, Xalapa.

Merbs, Charles F. 1968. Anterior tooth loss in Arctic popula-
tions. Southwestern Journal of Anthropology 24(1):20–32.

Milner, George R., and Clark Spencer Larsen. 1991. Teeth as arti-
facts of human behavior: Intentional mutilation and acciden-
tal modification. In Advances in Dental Anthropology, edited 
by Mark A. Kelley and Clark Spencer Larsen. Wiley-Liss, New 
York, pp. 357–378.

Moedano, Gabriel. 1977. El temazcal y su deidad protectora en la 
tradición oral. Boletín del Departamento de Investigación de 
las Tradiciones Populares 4:5–32.

Moholy-Nagy, Hattula, and William R. Coe. 2008. The Artifacts 
of Tikal: Ornamental and Ceremonial Artifacts and Unworked 
Material. Tikal Report 27A. University Museum Monograph, 
127. University of Pennsylvania Museum of Archaeology and
Anthropology, Philadelphia.

Molina, Alonso de. 1571. Vocabulario en Lengua Castellana y 
Mexicana. Editorial Antonio Espinosa, Mexico City.

Moore, W. J., and Elisabeth Corbett. 1973. The distribution of 
dental caries in ancient British populations: II. Iron Age, Ro-
mano-British and mediaeval periods. Caries Research 7(2): 
139–153. DOI: 10.1159/000259838.

Morita, Manabu, Toshihide Kimura, Masaru Kanegae, Akira 
Ishikawa, and Tatsuo Watanabe. 1994. Reasons for extraction 



Schnell and Scherer 65

of permanent teeth in Japan. Community Dentistry and Oral 
Epidemiology 22(5PT1):303–306. DOI: 10.1111/j.1600-0528. 
1994.tb02056.x.

Muñoz, Arturo René. 2004. The Ceramic Sequence of Piedras Ne-
gras, Guatemala: Type and Varieties. FAMSI Report #2055. 
http://www.famsi.org/reports/02055/02055Munoz01.pdf.

Nayyar, J., M. Clarke, M. O’Sullivan, and L. F. A. Stassen. 2015. 
Fractured root tips during dental extractions and retained 
root fragments: A clinical dilemma? British Dental Journal 
218(5):285–290. DOI: 10.1038/sj.bdj.2015.147.

Nichols, Deborah L. 2013. Merchants and merchandise: The ar-
chaeology of Aztec commerce at Otumba, Mexico. In Mer-
chants, Markets, and Exchange in the Pre-Columbian World, 
edited by Kenneth G. Hirth and Joanne Pillsbury. Dumbar-
ton Oaks Research Library and Collection, Washington, D.C., 
pp. 49–84.

Nixdorf, Donald, and Estephan Moana-Filho. 2011. Persistent 
dento-alveolar pain disorder (PDAP): Working towards a bet-
ter understanding. Reviews in Pain 5(4):18–27. DOI: 
10.1177/204946371100500404.

Norton, Brandy N. 2016. A Categorization and Comparative 
Analysis of Maya Body Part Caches. Master’s thesis, Univer-
sity of Chicago, Chicago.

Ortiz, A., E. C. Torres Pino, and E. Orellana González. 2016. 
First evidence of pre-Hispanic dentistry in South America—
Insights from Cusco, Peru. HOMO-Journal of Comparative 
Human Biology 67(2):100–109. DOI: 10.1016/j.jchb.2015.09.006.

Oxilia, Gregorio, Flavia Fiorillo, Francesco Boschin, Elisabetta 
Boaretto, Salvatore A. Apicella, Chiara Matteucci, Daniele 
Panetta, Rossella Pistocchi, Franca Guerrini, Cristiana Mar-
gherita, Massimo Andretta, Rita Sorrentino, Giovanni Bos-
chian, Simona Arrighi, Irene Dori, Giuseppe Mancuso, 
Jacopo Crezzini, Alessandro Riga, Maria C. Serrangeli, An-
tonino Vazzana, Piero A. Salvadori, Mariangela Vandini, 
Carlo Tozzi, Adriana Moroni, Robin N. M. Feeney, John C. 
Willman, Jacopo Moggi-Cecchi, and Stefano Benazzi. 2017. 
The dawn of dentistry in the Late Upper Paleolithic: An early 
case of pathological intervention at Riparo Fredian. American 
Journal of Physical Anthropology 163(3):446–461. DOI: 10.1002/
ajpa.23216.

Oxilia, Gregorio, Marco Peresani, Matteo Romandini, Chiara 
Matteucci, Cynthianne Debono Spiteri, Amanda G. Henry, 
Dieter Schulz, Will Archer, Jacopo Crezzini, Francesco 
Boschin, Paolo Boscato, Klervia Jaouen, Tamara Dogandzic, 
Alberto Broglio, Jacopo Moggi-Cecchi, Luca Fiorenza, Jean-
Jacques Hublin, Ottmar Kullmer, and Stefano Benazzi. 2015. 
Earliest evidence of dental caries manipulation in the Late 
Upper Palaeolithic. Scientific Reports 5:1–10. DOI: 10.1038/
srep12150.

Pendergast, David M. 1979. Excavations at Altun Ha, Belize, 
1964–1970. 3 vols. Royal Ontario Museum, Toronto.

Pendergast, David M., Murray H. Bartley, and George J. Armel-
agos. 1968. A Maya tooth offering from Yakalche, British 
Honduras. Man 3(4):635–643. DOI: 10.2307/2798584.

Pérez Robles, Griselda, Andrew K. Scherer, and Charles Golden. 
2016. Proyecto Paisaje Piedras Negras–Yaxchilan: Informe de 
la Primera Temporada de Investigación. Instituto de Antro-
pología e Historia, Guatemala City.

Pérez Robles, Griselda, Andrew Scherer, Charles Golden, Shanti 
Morell-Hart, Juan Carlos Pérez, Omar Alcover, Alejandra 
Roche, Mallory Matsumoto, Joshua Schnell, Max Seidita, and 
Edwin Pérez Robles. 2017. Resultados de la segunda temporada 
de investigaciones del Proyecto Paisaje Piedras Negras–Yaxchi-
lan. Paper presented at the 31st Simposio de Investigaciones Ar-
queológicas en Guatemala, Guatemala City.

Pitcavage, Megan R., and Geoffrey E. Braswell. 2010. Diet, 
health, and death at Pusilhá, Belize. Research Reports in Beliz-
ean Archaeology 7:65–72.

Proskouriakoff, Tatiana. 1960. Historical implications of a pat-
tern of dates at Piedras Negras, Guatemala. American Antiq-
uity 25(4):454–475. DOI: 10.2307/276633.

Ramírez-Salomón, Marco. 2016. Composición Química, Propie-
dades Antisépticas y Selladoras del Cemento Utilizado en las 
Antiguas Incrustaciones Dentales Mayas y su Potencial Aplica-
bilidad en la Odontología Contemporánea. Ph.D. dissertation, 
Universidad Autónoma de Yucatán, Mérida.

Ramírez-Salomón, Marco, Vera Tiesler, Iván Oliva Arias, and 
Guillermo Mata Amado. 2003. Posibles técnicas empleadas en 
la decoración dental en la Mesoamérica Prehispánica. Un es-
tudio experimental de instrumentos y superficies. In Estudios 
de Antropología Biológica XI, edited by Carlos Serrano Sán-
chez, Sergio López Alonso, and Francisco Ortiz Pedraza. Uni-
versidad Nacional Autónoma de México, Mexico City, pp. 
983–998.

Reich, Elmar, and Karl-Anton Hiller. 1993. Reasons for tooth ex-
traction in the western states of Germany. Community Den-
tistry and Oral Epidemiology 21(6):379–383. DOI: 
10.1111/j.1600-0528.1993.tb01103.x.

Richards, W., J. Ameen, A. M. Coll, and G. Higgs. 2005. Reasons 
for tooth extraction in four general dental practices in South 
Wales. British Dental Journal 198(5):275–278. DOI: 10.1038/
sj.bdj.4812119.

Ricketson, Oliver G., and Edith B. Ricketson. 1937. Human re-
mains. In Uaxactun, Guatemala: Group E—1926–1931, edited 
by Oliver G. Ricketson and Edith B. Ricketson. Carnegie In-
stitution of Washington, Washington, D.C., pp. 139–149.

Roche Recinos, Alejandra. 2016. Maya Lithic Economies at Pie-
dras Negras, Guatemala: Production and Exchange in an Elite 
Architectural Complex. Master’s thesis, Brown University, 
Providence, RI.

Roche Recinos, Alejandra, Jesús Alejandro González Cόrdova, 
Shanti Morell-Hart, and Charles Golden. 2017. Operación 15I: 
Excavaciones en la plaza de la Estructura S-18. In Proyecto 
Paisaje Piedras Negras–Yaxchilan, Informe de la Segunda 
Temporada de Investigación, edited by Mónica Urquizú, An-
drew K. Scherer, and Charles Golden. Instituto de Antro-
pología e Historia, Guatemala City, pp. 8–32.

Roche Recinos, Alejandra, and Mallory Matsumoto. 2016. Op-
eración 15: Excavaciones en el Grupo S. In Proyecto Paisaje 
Piedras Negras–Yaxchilan, Informe de la Primera Temporada 
de Investigación, edited by Griselda Pérez Robles, Andrew K. 
Scherer, and Charles W. Golden. Instituto de Antropología e 
Historia, Guatemala City, pp. 7–34.

Romero, Javier. 1951. Las mutilaciones dentarias prehispánicas 
de América. In El Arte de las Mutilaciones Dentarias, edited 
by Samuel Fastlicht and Javier Romero. Ediciones Mexicanas, 
Mexico City, pp. 9–58.

Romero, Javier. 1958. Mutilaciones dentarias prehispánicas de 
México y América en general. Serie Investigaciones 3. Instituto 
Nacional de Antropología e Historia, Mexico City.

Romero, Javier. 1970. Dental mutilation, trephination, and cra-
nial deformation. In Handbook of Middle American Indians, 
Volume 9: Physical Anthropology, edited by T. Dale Stewart. 
University of Texas Press, Austin, pp. 50–67.

Roys, Ralph L., ed. 1965. Ritual of the Bacabs. University of Okla-
homa Press, Norman.

Roys, Ralph L. 1976. The Ethno-Botany of the Maya. Reprint ed. 
Institute for the Study of Human Issues, Philadelphia.

Rubín de la Borbolla, D. F. 1940. Types of tooth mutilation found 
in Mexico. American Journal of Physical Anthropology 
26(1):349–365. DOI: 10.1002/ajpa.1330260136.



Evidence for Tooth Extractions at Piedras Negras, Guatemala 66

Sahagún, Fray Bernardino de. 1961. Florentine Codex: General 
History of the Things of New Spain, Book 10: The People. Trans-
lated by Charles E. Dibble and Arthur J. O. Anderson. Univer-
sity of Utah Press, Salt Lake City.

Sahagún, Fray Bernardino de. 2012. Florentine Codex: General 
History of the Things of New Spain, Book 10: The People. 2nd 
ed. Translated by Charles E. Dibble and Arthur J. O. Ander-
son. University of Utah Press, Salt Lake City.

Saul, Frank P., and Norman Hammond. 1974. A Classic Maya 
tooth cache from Lubaantun, Belize. Man 9(1):123–127. DOI: 
10.2307/2800040.

Schendel, Gordon. 1968. Medicine in Mexico: From Aztec Herbs 
to Betatrons. University of Texas Press, Austin.

Scherer, Andrew K. 2015a. Mortuary Landscapes of the Classic 
Maya: Rituals of Body and Soul. University of Texas Press, 
Austin.

Scherer, Andrew K. 2015b. Osteology of the El Diablo Complex: 
Burial 9 and associated caches. In Temple of the Night Sun: A 
Royal Tomb at El Diablo, Guatemala, edited by Stephen Hous-
ton, Sarah Newman, Edwin Román, and Thomas Garrison. 
Precolumbia Mesoweb Press, San Francisco, pp. 180–209.

Scherer, Andrew K. 2018. Grave matters: Bioarchaeology and 
mortuary archaeology at El Zotz, Bejucal, and El Palmar. In 
An Inconstant Landscape: The Maya Kingdom of El Zotz, Gua-
temala, edited by Thomas G. Garrison and Stephen Houston. 
University Press of Colorado, Louisville, pp. 303–360.

Scherer, Andrew K., Griselda Pérez Robles, Charles W. Golden, 
Shanti Morell-Hart, Omar Alcover, Alejandra Roche Recinos, 
Mallory Matsumoto, Juan Carlos Pérez Calderón, Laura Lucía 
Gámez Díaz, Edwin Pérez Robles, and Rony Piedrasanta Cas-
tellanos. 2017. Resultados de la primera temporada de investi-
gaciones del Proyecto Paisaje Piedras Negras–Yaxchilan. In 
XXX Simposio de Investigaciones Arqueológicos en Guate-
mala, 2016, edited by B. Arroyo, L. Méndez Salinas, and G. 
Ajú Álvarez. Museo Nacional de Arqueología y Etnología, 
Guatemala, Guatemala City, pp. 287–295.

Scherer, Andrew K., Lori E. Wright, and Cassady J. Yoder. 2007. 
Bioarchaeological evidence for social and temporal differ-
ences in diet at Piedras Negras, Guatemala. Latin American 
Antiquity 18(1):85–104. DOI: 10.2307/25063087.

Scherer, Andrew K., Cassady J. Yoder, and Lori E. Wright. 1999. 
Los esqueletos de Piedras Negras: Reporte preliminar #3. In 
Proyecto Arqueológico Piedras Negras: Informe Preliminar No. 
3, Tercera Temporada, 1999, edited by Héctor L. Escobedo and 
Stephen Houston. Instituto de Antropología e Historia, Gua-
temala City, pp. 387–400.

Scherer, Andrew K., Cassady J. Yoder, and Lori E. Wright. 2001. 
Los esqueletos de Piedras Negras: Reporte preliminar #4. In 
Proyecto Arqueológico Piedras Negras: Informe Preliminar No. 
4, Cuarta Temporada, 2000, edited by Héctor L. Escobedo and 
Stephen Houston. Instituto de Antropología e Historia, Gua-
temala City, pp. 553–557.

Schnell, Joshua T. 2017. Medicine, Dental Practice, and the Pro-
duction of Bone Objects among the Classic Maya as seen from 
the S-Sector of Piedras Negras Guatemala. Master’s thesis, 
Brown University, Providence, RI.

Schnell, Joshua T., Sarah E. Newman, and Andrew K. Scherer. 
2017. Análisis óseos de Operación 15 de Piedras Negras. In 
Proyecto Paisaje Piedras Negras–Yaxchilan, Informe de la Se-
gunda Temporada de Investigación, edited by Mónica Ur-
quizú, Andrew K. Scherer, and Charles Golden. Instituto de 
Antropología e Historia, Guatemala City, pp. 200–228.

Schnell, Joshua T., and Andrew K. Scherer. 2017. Análisis de hue-
sos humanos de Operación 74 de Piedras Negras. In Proyecto 
Paisaje Piedras Negras–Yaxchilan, Informe de la Segunda 

Temporada de Investigación, edited by Mónica Urquizú, An-
drew K. Scherer, and Charles Golden. Instituto de Antro-
pología e Historia, Guatemala City, pp. 229–234.

Schwartz, Jeffrey H., Jaymie Brauer, and Penny Gordon-Larsen. 
1995. Brief communication: Tigaran (Point Hope, Alaska) 
tooth drilling. American Journal of Physical Anthropology 
97(1):77‒82. DOI: 10.1002/ajpa.1330970106.

Scott, E. C. 1979. Dental wear scoring technique. American Jour-
nal of Physical Anthropology 51(2): 213–217. DOI: 10.1002/
ajpa.1330510208.

Scott, G. Richard, and J. R. Winn. 2011. Dental chipping: Con-
trasting patterns of microtrauma in Inuit and European pop-
ulations. International Journal of Osteoarchaeology 
21(6):723–731. DOI: 10.1002/oa.1184.

Seidel, John C., Roger H. Colten, Edward A. Thibodeau, and 
John G. Aghajanian. 2005. Iatrogenic molar borings in 18th 
and early 19th century Native American dentitions. American 
Journal of Physical Anthropology 127(1):7–12. DOI: 10.1002/
ajpa.20177.

Shaw, Leslie C. 2012. The elusive Maya marketplace: An archaeo-
logical consideration of the evidence. Journal of Archaeologi-
cal Research 20(2):117–155. DOI: 10.1007/s10814-011-9055-0.

Shelton, Rebecca, Amy Michael, Maxwell Forton, and Joshua 
Burbank. 2015. Cultural Assemblages in the front and middle 
chambers of Actun Kabul. In The Central Belize Archaeologi-
cal Survey Project: A Report of the 2013 Field Season, edited by 
Gabriel D. Wrobel, Shawn G. Morton, and Christopher R. 
Andres. Belize Archaeological Research and Education Foun-
dation, East Lansing, MI, pp. 14–33.

Smith, B. Holly. 1984. Patterns of molar wear in hunter-gather-
ers and agriculturalists. American Journal of Physical Anthro-
pology 63(1):39–56. DOI: 10.1002/ajpa.1330630107.

Song, Rhan-ju, Bobbi Hohmann, Denise Mardiros, and David 
Glassman. 1994. All in the family circle: A second interim re-
port of the human skeletal remains from Tolok, Cahal Pech, 
Belize. In Belize Valley Archaeological Reconnaissance Project: 
Progress Report of the Sixth (1993) Field Season, edited by 
Jaime J. Awe. Institute of Archaeology, University of London, 
London, pp. 147–163.

Stewart, T. Dale. 1941. New examples of tooth mutilation from 
Middle America. American Journal of Physical Anthropology 
28(1):117–124. DOI: 10.1002/ajpa.1330280107.

Tiesler, Vera. 2001. Decoraciones Dentales entre los Antiguos Ma-
yas. Ediciones Euroamericanas, Mexico City.

Tiesler, Vera, Andrea Cucina, and Marco Ramírez-Salomón. 
2017. Permanent dental modifications among the ancient 
Maya: Procedures, health risks, and social identities. In A 
World View of Bioculturally Modified Teeth, edited by Scott 
Burnett and Joel Irish. University Press of Florida, Gaines-
ville, pp. 270–284.

Tiesler, Vera, Marco Ramírez-Salomón, and Iván Oliva Árias. 
1999. Técnicas de decoración dental en México: Un acer-
camiento experimental. Actualidades Arqueológicas: Pasado 
en Presente 2:18–24.

Tiesler, Vera, Marco Ramírez-Salomón, and Iván Oliva Árias. 
2002. Decoration techniques in ancient Mexico—a study of 
dental surfaces using radiography and S.E.M. Oral Health 
92(9):33–36.

Tokovinine, Alexandre, and Dmitri Beliaev. 2013. People of the 
road: Traders and travelers in ancient Maya words and im-
ages. In Merchants, Markets, and Exchange in the Pre-Colum-
bian World, edited by Kenneth G. Hirth and Joanne Pillsbury. 
Dumbarton Oaks Research Library and Collection, Washing-
ton, D.C., pp. 169–200.



Schnell and Scherer 67

Turner, Christy G., II. 2004. A second drilled tooth from prehis-
toric western North America. American Antiquity 69(2):356–
360. DOI: 10.2307/4128425.

Urquizú, Mónica. 1998. PN 15: Excavaciones en Estructura S-8, 
del Grupo S-11. In Proyecto Arqueológico Piedras Negras In-
forme Preliminar No. 2, Segunda Temporada, 1998, edited by 
Héctor L. Escobedo and Stephen D. Houston. Instituto de An-
tropología e Historia, Guatemala City, pp. 83–102.

Urquizú, Mónica, and Damaris Menéndez. 2016. Análisis 
cerámico temporada 2016 Proyecto Paisaje Piedras Negras–
Yaxchilan. In Proyecto Paisaje Piedras Negras–Yaxchilan, In-
forme de la Primera Temporada de Investigación, edited by 
Griselda Pérez Robles, Andrew K. Scherer, and Charles W. 
Golden. Instituto de Antropología e Historia, Guatemala 
City, pp. 216–242.

Urquizú, Mónica, Andrew K. Scherer, and Charles Golden, eds. 
2017. Proyecto Paisaje Piedras Negras–Yaxchilan: Informe de la 
Segunda Temporada de Investigación. Instituto de Antro-
pología e Historia, Guatemala City.

Venkateshwar, Gokul Parameswar, Mukul Nandkumar Padhye, 
Aman Rajiv Khosla, and Shruti Tejprakash Kakkar. 2011. 
Complications of exodontia: A retrospective study. Indian 
Journal of Dental Research 22(5):633–638. DOI: 10.4103/ 
0970-9290.93447.

Viciano, Joan, Sandra López-Lázaro, Deneb Teresa Cesana, 
Ruggero D’Anastasio, and Luigi Capasso. 2012. Multiple trau-
matic dental injuries: A case report in a young individual 
from the Samnitic Necropolis of Opi Val Fondillo (VI–V cen-
tury BC; Central Italy). Journal of Archaeological Science 
39(2):566–572. DOI: 10.1016/j.jas.2011.10.030.

Virkki, N. 1962. Comentarios sobre el baño de vapor entre los 
indígenas de Guatemala. Guatemala Indígena 2(2):71–85.

Wagley, Charles. 1949. The social and religious life of a Guate-
malan village. American Anthropologist 51(4, Part 2):1–150.

Watson, Sarah, Joshua T. Schnell, Shanti Morell-Hart, and An-
drew K. Scherer. 2019. Health Care in the Marketplace: Ex-
ploring Medicinal Plants and Practices at Piedras Negras. 

Paper presented at the 84th Annual Society for American Ar-
chaeology Meetings, Albuquerque, NM.

Wauchope, Robert. 1938. Modern Maya Houses: A Study of Their 
Archaeological Significance. Carnegie Institution of Washing-
ton publication, 502. Carnegie Institution of Washington, 
Washington, D.C.

Weeks, John M., Jane Hill, and Charles W. Golden, eds. 2005. 
Piedras Negras Archaeology, 1931–1939. University of  
Pennsylvania Museum of Archaeology and Anthropology, 
Philadelphia.

Weiss-Krejci, Estella. 2011. The formation of mortuary deposits: 
Implications for understanding mortuary behavior of past 
populations. In Social Bioarchaeology, edited by Sabrina C. 
Agarwal and Bonnie A. Glencross. Blackwell Publishing, 
Hoboken, NJ, pp. 68–106.

White, Donald J. 1997. Dental calculus: Recent insights into oc-
currence, formation, prevention, removal and oral health ef-
fects of supragingival and subgingival deposits. European 
Journal of Oral Sciences 105(5):508–522. DOI: 10.1111/j.1600-
0722.1997.tb00238.x.

Whittington, Stephen L. 1999. Caries and antemortem tooth loss 
at Copán: Implications for commoner diet. In Reconstructing 
Ancient Maya Diet, edited by Christine D. White. University 
of Utah Press, Salt Lake City, pp. 151–167.

Whittington, Stephen L. 2003. Analysis of human skeletal mate-
rial excavated by Guillemin. In Archaeology and Ethnohistory 
of Iximché, edited by C. Roger Nance, Stephen L. Whitting-
ton, and Barbara E. Borg. University Press of Florida, Gaines-
ville, pp. 241–304.

Wrobel, Gabriel, Christophe Helmke, Sherry Gibbs, George Mi-
cheletti, Norbert Stanchly, and Terry Powis. 2019. Two trophy 
skulls from Pacbitun, Belize. Latin American Antiquity 
30(1):218–223. DOI: 10.1017/laq.2019.1.

Wrobel, Gabriel D., Rebecca Shelton, Shawn Morton, Joshua 
Lynch, and Christopher Andres. 2013. The view of Maya cave 
ritual from the Overlook Rockshelter, Caves Branch River 
Valley, central Belize. Journal of Cave and Karst Studies 
75(2):126–135. DOI: 10.4311/2011AN0233.


