77 Dental Anthropology 2019 │ Volume 32 │ Issue 02 The Medieval Transylvanian Oral Condition: A Case Study in Interpretation and Standardization Katie Zejdlik 1* , Jonathan D. Bethard 2 , Zsolt Nyárádi 3 , and Andre Gonciar 4 1 Anthropology and Sociology Department, Western Carolina University 2 Department of Anthropology, University of South Florida 3 Haáz Rezső Museum, Odorheiu Secuiesc, Romania 4 ArchaeoTek-Canada LLC., Ontario, Canada Health, as a descriptive term, is commonly used in the bioarchaeological literature to indicate evi- dence of pathological modification on the skeleton. However, the World Health Organization includes mental and social factors, in addition to bodily dis- ease states, as important to an assessment of health (WHO, 1999). Reitsema and McIlvaine (2014) have added that a majority of pathological modifications observable in skeletal and dental tissues could have been caused by a myriad of conditions. With- in the more focused parameters of oral health, the lack of patient histories, clinical records, and envi- ronmental living conditions has resulted in incon- sistent application of terminology, understanding of disease etiologies, and recording of observations in bioarchaeological contexts (Pilloud & Fancher 2019, this volume). What this means is that to un- derstand the ‘health’ of a population, one must consider physical, mental, and social factors with- out access to patient histories, clearly understood etiologies, or standardized definitions among re- searchers. Bioarchaeologists are suited to address this challenge through the application of a multi- faceted approach that pieces together cultural and biological information. Combined with the use of standardized language, communication between researchers can be improved and interpretations more accurately compared across sites. This paper examines pathological conditions of the oral cavity among medieval Transylvanian Székely communi- ties as a case study to apply the vocabulary and definitions discussed by Pilloud and Fancher (2019) and to demonstrate the challenges of com- parison between sites. Furthermore, it contributes to the paucity of information available on archaeo- logically derived skeletal collections from Eastern Europe. ABSTRACT Interpretation of dental ‘health’ in archaeologically derived skeletal assemblages is chal- lenging due to the lack of patient histories, clearly understood pathological processes, broad etiologies, and cultural perceptions of health. Furthermore, the language used in description of pathological condi- tions of the oral cavity condition is not consistent across researchers thereby resulting in challenging cross-site comparison. Standardization of terms and description is necessary as proposed by Pilloud and Fancher (2018). This paper demonstrates the challenges associated with cross-site comparisons through an attempt to place medieval Transylvanian Székely peoples’ oral condition within a larger medieval cultural and biological framework. To do this, first, a review of medieval perceptions of dental health and treatment is provided. Next, a total of 90 individuals recovered from two medieval Székely ceme- teries were analyzed for pathological conditions of the oral cavity. The results of the analysis were then compared to other medieval skeletal assemblages reporting on dental ‘health’. Results show that condi- tions of the medieval oral cavity cannot be generalized and comparisons are further complicated by a lack of standardization in description and reporting thus supporting this volume’s call for standardiza- tion. Results also show that conditions of the oral cavity are specific to time and place even between the two Transylvania sites discussed. *Correspondence to: Katie Zejdlik Western Carolina University Cullowhee, NC 28723 kzejdlik@wcu.edu Keywords: medieval; dental; health; Székely; Transylvania; archaeology 78 Dental Anthropology 2019 │ Volume 32 │ Issue 02 Condition of the oral cavity: Medieval cultural perspective Human skeletal remains hold important infor- mation about the social and biological context in which a specific person navigated. Interpretation of that individual’s lived experience begins with understanding the cultural context of the time. For the medieval individuals discussed here, an under- standing of medieval medical practices is useful. Healthcare in the middle ages was predomi- nately influenced by Hippocrates’s 5th century B.C. humoural theory. In his treatise, The Nature of Man, Hippocrates stated that the body was composed of humours, or body fluids, specifically, blood, yel- low and black bile, and phlegm. These humours corresponded with different conditions and sea- sons: blood, hot and wet, predominates in spring; yellow bile, hot and dry, in summer; black bile, cold and dry, in autumn; and phlegm, cold and wet, in winter (Jouanna, 2012). It was thought that every person had a different make-up of humours; even organ systems within people had different humoural constructions and poor health resulted when the humours were out of balance. The noted Greek physician, Galen, later supported and ex- panded Hippocrates’ work, which gave it the sus- tainable success that carried it into the Enlighten- ment (Jouanna, 2012; King, 2013). Multiple other interpretations branched off Hippocrates’ original idea but the vocabulary and general understanding of the humours remained prevalent in medieval understandings of health and medicine (Jouanna, 2012; King, 2013). The broadly applied humoral theory extended into dentistry (Anderson, 2004; Bifulco et al., 2016). The Medical School of Salerno, Italy was one of the most influential medical resources of the medieval period. In addition to general medicine, they paid attention to dentistry and domestic oral hygiene. Trotula De Ruggiero, a person of somewhat mythic status associated with the Salerno school, is credit- ed with writing the first treatise on oral hygiene (Bifulco et al., 2016). She advocated deep dental cleaning and brushing, mouthwash, chewing of herbs for daily cleaning and pleasant breath, as well as remedies for gingivitis, halitosis, and tooth whitening. Many of the ingredients she suggested are still used today in cosmetic and hygiene prod- ucts (Bifulco et al., 2016). Though these practices are largely unobservable in skeletal remains, they indicate that medieval people were interested in oral care in addition to more visible and serious modifications. Conditions of the oral cavity observable in the archaeological record include general tooth decay, dental caries, periapical lesions, and tooth loss. Toothache, which could have several etiologies, the most treated problem in medieval dental medicine, was managed with everything from fumigations to oaths (Anderson, 2004; Bifulco et al. 2016). J. Platearius, a doctor in the Salerno school, wrote that dental pain was specifically a result of imbal- anced warm and cold humours from the brain or stomach (cited in Bilfulco et al., 2016). Additional- ly, some of the doctors at Salerno believed tooth decay was caused by odontalgic worms that caused pain with their movements, an idea that dates to Sumerian texts from 5,000 B.C. Gilbertus Anglicus (c.AD 1240) also agreed that tooth worms caused dental pain and required balancing the hu- mours (cited in Anderson, 2004). Dental caries and fistulae were treated with herbal concoctions placed as a paste within the cavity of the tooth (Anderson, 2004) or by cauterizing the rotten den- tal pulp and sealing it with wax, which essentially destroyed the pulp chamber nerve supply (Bifulco et al., 2016). Dental care was limited to non-invasive treat- ment (Anderson, 2004). Dental extraction was rare- ly cited in the Salerno documents because it was not a practice of physicians but rather “charlatans who practiced their profession in the streets and in open-air markets, and replacing the tooth with a tiny piece of wood or an iron bolt” (Bifulco et al., 2016:2). The ‘charlatans’ were barber surgeons and willing to do surgery, unlike doctors. They often learned their skill through performing surgery on the war wounded or as an apprentice; though, many had no formal education, and most were illiterate. Eventually surgery became a formalized profession and barbers were not allowed to pro- vide surgical intervention except in cases of tooth extraction and blood-letting (Pelling, 1998). Access to barber surgeons was regulated by the Catholic Church and not accessible to females (Lopez et al., 2012). Those who could not access or afford a bar- ber surgeon depended on prayer or pilgrimage as a means for a cure (Anderson, 2004). Medieval peo- ples understood that small infections of any type could become fatal if not attended to and took all available treatment precautions (Pelling, 1998). In terms of actual oral heath, it is unknown what medieval peoples perceived as unhealthy. Literature related to oral ‘health’ during the medie- val period is often derived from skeletal assem- blages and the interpretations of modern research- ers. That is the problem with the casual use of the word ‘health’. It is temporally and socially compli- 79 Dental Anthropology 2019 │ Volume 32 │ Issue 02 cated to define. At best, researchers must anecdo- tally pull information from various types of know- ing (images, educational documents, song, and folklore) to try to understand an ancient perspec- tive. In the case of the medieval oral condition, dental medicine and hygiene made important ad- vancements during the medieval period and from that, we argue, that we can infer that the numerous treatments for dental pain and dental hygiene re- sulted from medieval concern for oral care. Condition of the oral cavity: Medieval bioarchae- ological perspective Information derived from research on skeletal as- semblages provides a data-driven perspective to complement the less direct information available from cultural sources like the examples discussed above. The bioarchaeological literature often re- ports on types and frequencies of dental modifica- tions with reference to the social factors that might have impacted the results. These findings are then used to make an assessment about the dental, or overall, ‘health’ of the population represented by the skeletal assemblage. For instance, Lopez and colleagues (2012) reviewed the diverse factors that contribute to various conditions of the oral cavity covering explanations from clinical processes, gen- dered access to dental care, consumption of cario- genic foodstuffs, and culture-specific food prepara- tion techniques. They demonstrated through a comprehensive literature review that generaliza- tions about etiologies cannot be made and that the interpretations must be heavily context dependent. Lopez et al. (2012) investigated sex-differences in oral health from two medieval sites in Spain and concluded that there were no sex-based differences in dental health. These findings mirror similar con- texts in France (Esclassan et al., 2009) and Croatia (Šlaus et al., 2011). However Lopez et al. (2012) note that when compared to the modern age indi- viduals (late 18th century), sex-based differences were evident. Belecastro and colleagues (2007) investigated diet changes and health decline in response to large social and economic changes after the fall of the Roman Empire. The dentition of two temporal- ly contiguous sites (Roman Imperial to Early Medi- eval) in central Italy were investigated to make inferences about dietary practices across time. They concluded that overall protein consumption reduced after the decline of the Roman Empire and that the medieval diet consisting of higher carbo- hydrate intake led to an increase in dental wear, periapical lesions, and calculus. The lack of in- creased dental caries was thought to be due to the increased level of wear resulting from a harder and more fibrous diet, which required longer and stronger mastication. As the complicated morphol- ogy of the tooth wore away, there would be less opportunity for carious lesions to form; an inter- pretation supported by dental data from other me- dieval sites (Caglar et al. 2007; Chazel et al. 2005; Esclassan et al. 2009). Belecastro and colleagues (2007) also coupled dental data with pathological skeletal markers and evidence of infectious disease to conclude that while diet did not appear to change in significant ways, health conditions pre- sent during the Roman Imperial era continued and then worsened. The inverse relationship of high dental wear and low dental carious lesions was not found at other medieval sites investigating changes in den- tal data between medieval sites and other time pe- riods (e.g, Šlaus et al., 2011; Srejić, 2001), which demonstrates the variability in the medieval oral condition. Another example is demonstrated through frequency of carious lesions. Low levels of carious lesions and dental wear were reported for a medieval coastal site in Croatia (Novak et al., 2012). Rapid urbanization of the site during the Late Medieval period led to an increase in infec- tious disease indicators and overall reduction of health (Novak et al., 2012). Conversely, high levels of carious lesions and dental wear were present in two medieval, cemeteries from Serbia (Srejić, 2001). The cause of the high frequency was interpreted to be a result of food processing and poor oral hy- giene. Overall, there does not appear to be a general status of oral condition across the medieval period and conditions are highly specific to geographic, temporal, and social contexts. Interpretations of ‘health’ range from multiple lines of evidence as discussed above to more limited interpretations about diet and comparison to other medieval sites (e.g, Caglar et al., 2007; Chazel et al., 2005; Srejić, 2001). Each author managed challenges associated with limited historical data, limited comparative sites, and a general lack of standardized recording and reporting methods. These were some of the hurdles faced when placing the Transylvania case study sites into various comparative categories. Biocultural Context For the last seven years, our work has focused on documenting the lives of medieval and early mod- ern Transylvanian Hungarians (Bethard et al., 2019; Molnár, 2001). The study area encompasses a 80 Dental Anthropology 2019 │ Volume 32 │ Issue 02 region of Eastern Transylvanian located inside the Carpathian Basin. It is currently home to over 600,000 people and called the Székelyföld by the ethnic Hungarian inhabitants who have lived there for nearly 1,000 years. In this study, two historically Hungarian Tran- sylvanian cemeteries located 18.5km apart in Har- ghita County, Romania were analyzed (Figure 1). The Papdomb archaeological site in Văleni (Hungarian: Patakfalva), Romania designates the ruins of a medieval church and its associated burial grounds. The second archaeological site is a medie- val cemetery located on the grounds of the Catho- lic Church in Bradeşti (Hungarian: Fenyéd), Roma- nia. Though inhabitants of both villages are identi- fied as Romanian citizens today, the whole of Tran- sylvania was not incorporated into the current po- litical boundary of Romania until the conclusion of World War I. For the last millennium, the inhabit- ants of both Văleni and Bradeşti have identified as Hungarian, more specifically, as Székely. For clari- ty of discussion, the sites will be referred to via their official archaeological site designators; Papdomb and Fenyéd. Excavation of the Patakfalva cemetery site be- gan in 2014 as a salvage project per the request of the villagers. A collaboration between the inhabit- ants of Patakfalva, the Haáz Rezső Múzeum in nearby Odorheiu Secuiesc, and ArchaeoTek- Canada, LLC was created to excavate and analyze the remains. The Papdomb site was used repeated- ly for several hundred years as indicated by histor- ic records, temporally specific artifacts like coins, and evidence of burials truncated by later burials (Figure 2). In general, people were interred in a supine, extended position with their heads to the west, feet to the east. Body arrangement, soil stains left by decomposition, and remnants of coffin wood suggest that most individuals were buried in a coffin or a shroud. Overall preservation of skele- tal remains, including infants, was good. The Fenyéd cemetery was used repeatedly for several hundred years, primarily during the 11th and 12th centuries. Salvage excavations were con- ducted in 2013 due to erosion that exposed the me- dieval cemetery and a total of 54 burials were re- moved (Figure 3) (Nyárádi, 2013). Historical information about the medieval pe- riod in Transylvania can be hard to find. Much of the research about the area is not published in Eng- lish and does not show up in a standard literature search. Additionally, the history of the area is high- ly contentious in terms of which peoples invaded, owned, and occupied the landscape, as such sources can be heavily biased toward a singular perspective with conflicting information between sides (Lendvai, 2004). Archaeological evidence has been used as a more reliable indicator of the area’s history (Ţiplic 2006). However, even this method is complicated due to outside influences directing the interpretation of sites as a part of a pre-1990 Roma- nian research agenda (Cosma & Gudea, 2002 cited in Ţiplic, 2006). Archaeological and historical evidence demon- strates that starting in the 9th century the Carpathi- an Basin was an area of extensive biological and Figure 1. Tri-part map successively focusing on the location of the two cemeteries. Map modified from Mol- nár et al. (2015). 81 Dental Anthropology 2019 │ Volume 32 │ Issue 02 Figure 2. Burial plan map of Papdomb site with 2014 and 2015 trenches outlined. Figure 3. Burial plan map of Fenyéd site burials. 82 Dental Anthropology 2019 │ Volume 32 │ Issue 02 cultural movement from various groups including Slavs, Croatians, Bulgarians, Avars, Franks, Bijelo- Brdo and the first Hungarians (Lendvai, 2004; Ţiplic, 2006). Over the subsequent centuries, popu- lations increased and decreased as a result of polit- ical and religious influences, especially from the Tatar invasion of the early 13th century. The medie- val population size for Transylvania as a region has been estimated around 250,000 people with 100 -200 people in an average-sized village. Mountain- ous villages, such as the ones in our case study, may have been smaller with difficult to estimate population sizes (Ţiplic, 2006). The effects of large-scale social changes on small villages in Transylvania are unknown. This infor- mation could be gleaned from cemetery data (Ţiplic, 2006), but there has been limited published skeletal research on sites from the Carpathian Ba- sin. Although the Bijelo-Brdo culture predates the two sites discussed herein, Bijelo-Brdo cultural ele- ments are present in Transylvania and associated with early Hungarian sites (10th-11th century). Vo- danovic and colleagues (2005) report on frequency and location of tooth loss and dental carious le- sions from the Bijelo-Brdo archaeological site near Osijek, Croatia. They found that carious dental le- sions and antemortem tooth loss increased with age. Antemortem tooth loss was 11.9% among old- er individuals and 6.7% for all individuals exam- ined. They also found that 46.9% of individuals had at least one carious lesion with 1.8% of young- er individuals having at least one carious lesion and 14% of older individuals having at least one carious lesion. Causes for the pattern of dental modification observed were vaguely attributed to diet and lifespan but no direct evidence for ante- mortem tooth loss or carious dental lesions was provided. In reference to food, Peschel and col- leagues (2017) examined the diet of 12th to 19th cen- tury Transylvanians excavated from the Bögöz Re- formed Church in Mugeni (Hungarian: Bögöz), Romania. They found that people were consuming animals fed from native grasses (pigs, sheep, and cows) as well as broomcorn or foxtail millet. They also reported that individuals from the earlier cen- turies ate less meat and fish. It is unclear to what degree the Transylvanian villagers participated in available dental or other medical treatments during the medieval period. Westernization in the Székelyföld was visible as early as the 12th century as seen through the pres- ence of a distinct style of hairpin found in associa- tion with burials at multiple cemeteries. This find- ing suggests that mountainous communities might not have been as isolated as assumed (Nyárádi & Gáll, 2015; Ţiplic, 2006). In terms of dental care and status, members of the noble family from the area were interred at the Papdomb site and do not show any direct evidence of dental treatment. Nor do their teeth appear to have less pathological dental modification than others in the Papdomb cemetery as evidenced by the presence of periapical lesions, carious lesions, and antemortem tooth loss includ- ing one edentulous individual. To further investigate how the oral condition of the two Transylvanian cemetery assemblages com- pared to other medieval sites, we chose to place the two sites within the broader context of the medie- val period in Europe. In doing so, we came across the research challenges described in this paper. Methods and Materials One of the goals of this paper is to report on patho- logical conditions of the oral cavity among medie- val Transylvanian Székely communities as a case study to apply the vocabulary and definitions dis- cussed by Pilloud and Fancher (2019) and to demonstrate the challenges of comparison between sites. Skeletal assemblages from two cemeteries locat- ed 18.5km apart in Harghita County, Romania were analyzed. All the burials excavated between 2014 and 2015 have been analyzed and comprise the sample of this study. These graves are from trenches within the walls of the church; within the churchyard, and outside the yard wall (see Figure 2) providing a sample of individuals across the site. A total of 218 burials were removed during the two seasons of excavation (Nyárádi, 2014; Zejdlik, 2015). All dental elements were sorted and identified by dental arcade, tooth type, and side. Buikstra and Ubleker (1994) and the Arizona State Museum systems were utilized to document dental carious lesions, periodontal recession, antemortem tooth loss, and periapical lesions. Antemortem tooth loss and periapical lesions were not always scorable due to poor preservation of maxillary and mandib- ular bone. To acquire data from comparable medieval sites and to test the utility of a standardized language and definitions as called for by Pilloud and Fanch- er (2019), a literature review was conducted to syn- thesize data related to conditions of the oral cavity from medieval sites across Europe. Müeller and Hussein’s 2017 meta-analysis of dental conditions was used as a model as it provided an extensive overview of the literature reporting on ‘dental health’ from sites between 3,000 BC and the 20th century. We modified their table by extracting only 83 Dental Anthropology 2019 │ Volume 32 │ Issue 02 adults from medieval sites and by removing data on postmortem tooth loss, periodontal disease, and linear enamel hypoplasia. The choice to focus on adults was made to simplify the table; adults were more frequently examined than non-adults. Adults were considered individuals aged 16 years and older. Post-mortem tooth loss was removed from our analysis because it did not provide useful in- formation regarding the condition of the oral cavi- ty. Periodontal disease was removed because only two of the 21 references reviewed reported on it. The resulting table (Table 1) consists of 21 refer- ences reporting on conditions of the oral cavity from medieval peoples across Europe. The 21 refer- ences include the two case study cemeteries dis- cussed below. It should be noted that some refer- ences report on multiple sites. When possible, the site demographics were broken into male and fe- male. Each dental condition was reported per total available teeth. Without a set glossary of terms and definitions, one cannot be confident what is being compared. Pilloud and Fancher (2019) have provided recom- mendations on etiology, skeletal representation, and caution when examining various dental dis- eases or conditions. In most of the literature cited in Table 1, the authors did not describe etiologies. Instead, emphasis was placed on the physical evi- dence being observed and the criteria used to as- sess it. However, in a few cases, such as DeWitte and Bekvalac (2010) and Lopez et al. (2012) a clear and descriptive presentation of conditions and po- tential etiologies of the oral cavity are presented. A summary of Pilloud and Fancher’s (2019) recom- mendations specifically related to the conditions identified in this paper and reduced to application in observation is provided below: Antemortem tooth loss: Assessment of this condition should be used cautiously be- cause it has many causes. Investigators should preference a large gap in the den- tal arcade with evidence of reactive bone. They should also be aware of potential dental agenesis and impaction. If uncer- tain, antemortem tooth loss should not be recorded. Carious dental lesions: It is important to differentiate between carious lesions as the physical, dental hard tissue destruc- tion of tooth enamel and, dental caries as the disease process of bacterial fermenta- tion of consumed carbohydrates. The two terms should be used separately. Periapical lesions: This is a general term to describe a disturbance of the skeletal tis- sue around the apex of the tooth that may be related to a granuloma, cyst, or an abscess. The general term of ‘periapical lesion’ is preferred as the spe- cific etiology can be difficult to diagnose without a soft tissue biopsy or a defini- tive patient history. Results A review of the 21 references in Table 1 revealed a range of definitions and etiologies associated with the conditions described. Diagnostic criteria for antemortem tooth loss was reported in a range of ways. In some cases, the criteria to define ante- mortem tooth loss was not defined (e.g., Lingström & Borrman, 1999; Slaus et al., 1997; Srejić, 2001). In the most simplistic descriptions, it was differentiat- ed from postmortem tooth loss in which there was evidence of an alveolar socket (e.g., Caglar et al., 2007; Esclassan et al., 2009; Vodanović, 2005). Oth- ers described antemortem tooth loss as evidenced by alveolar resorption or remodeling (e.g., Chazel et al., 2005; Lopez et al., 2012; Meinl et al., 2010; Novak, 2015; Slaus et al., 2010; Stránská, 2015). Studies did not consider agenesis or impaction as a potential explanation for a lack of tooth presence. Carious dental lesion criteria were also de- scribed in numerous ways. Most authors used the term caries and did not distinguish between the process and the physical manifestation. The major- ity of the studies identified carious lesions as ‘caries’ and diagnosed them based on an enamel defect, specifically a pit that could be probed, and made the point to note that discoloration or a sticky lesion was not considered a carious dental lesion (e.g., Belcastro et al., 2007; Meinl et al., 2010; Novak, 2015; Stránská, 2015). Some authors also used radiographic imaging in addition to macro- scopic observation to identify carious lesions (e.g., Chazel et al., 2005). Most papers did not record periapical lesions. Those that did referred to them as abscesses. Diag- nostic criteria in the papers described the presence of a perforating fistula as necessary for a diagnosis (e.g., Belcastro et al., 2007; Šlaus et al., 2010). Only Novak (2015) included the description of a sinus present in the alveolus at the apex of the tooth in addition to a perforating fistula as a diagnostic cri- terion. Several challenges were identified in the at- tempt to establish a bioarchaeological context use- ful for comparison to the Transylvanian Székely case studies, namely the lack of standardization, 84 Dental Anthropology 2019 │ Volume 32 │ Issue 02 Location/ Time period Individuals N (male/female/ indeterminate) Analyzed teeth N total teeth/ N alveolar pres- ence Antemortem tooth loss N (%) Carious dental lesions per tooth N (%male/ % female) Periapical lesions per tooth N (%male/ % female Reference Ireland (rural) 400 -1000 AD 167(85/82/-) 3233 ND (9.7%) 98(2.5%/3.6%) 85 2.3% Novak 2015 Italy (rural), 700 AD 88 (45/40/3) 1754/ND ND (14%) 263 (15%/ 15%) 4.5% Belcastro et al. 2007 Austria (urban), 700–800 AD 136 (64/72/-) 2215/3649 869 (24%) 331 (15%) ND Meinl et al. 2010 Czech Republic (rural) 800- 1100AD 241 (-/-/-) 1006/1011 0 6 (0.06%) ND Stránská et al. 2015 Czech Republic (urban) 800- 1100AD 487 (-/-/-) 1538/2699 0 18 (0.012%) ND Stránská et al. 2015 Croatia (rural) 700-1100 AD 151(59/38/-) 2707/ND 21.7% 318(11.1%/12.6%) 196 5.1% Šlaus et al. 2010 Croatia (urban) AD 1100- 1400 107(63/44/-) 643/1378 ND- data com- bined with ab- scesses 62 (11%/7.6%) ND- data com- bined with ante- mortem tooth loss Novak et al. 2012 Croatia (rural), 10 –11th century 81 (-/-/-) 923/ 1414 99/7% all 92/ 10% ND Vodanović et al. 2005 France (urban), 11 –15th 107 (-/-/-) 1183/3424 342 (10%) 107 (9%) ND Chazel et al. 2005 France (rural), 12 –14th 58 (29/29/-) 1395/1822 121 (7%) 250 (22%/ 14%) ND Esclassan et al. 2009 Scotland (rural), 1240–1440 561 (-/-/-) 9991/ND 7% all 709/ 7% ND Watt et al. 1997 Papdomb, Roma- nia (rural) 14th -15th 60 (34/21/5) 1074 /ND ND 12.4% 16 (1.4%) Current study Fenyéd-Bradesti, Romania (rural) 11 – 12th 32 (-/-/-) 569/ND ND 24.44% 1 (0.2%) Blevens and Adams 2017 England (urban), AD 1350-1538 190 (-/-/-) ND ND 484 (premolars and molars only) 27.3% ND DeWitte & Bekvalac 2010 Turkey (urban,) 13th 52(-/-/-) 261/ND 51 (6.9%) 8 (15.38%) ND Caglar et al. 2007 Spain (rural), 15th 240 (123/117/-) 1015/1254 239 (19%) 48 (5%/ 4%) ND Lopez et al. 2012 Scotland (urban), 13–16th 52 (-/-/-) 984/1246 60/ 4% all ages 54/ 5% ND Kerr et al. 1988 Serbia (rural), 14– 16th 369 (-/-/-) 1680/2874 299 (10%) 149 (9%) 24 (1.4%) Srejic 2001 Finland (urban, poor people), 15– 16th 294 (-/-/-) 4581/ 5803 Deciduous 600/600 622/11% all ages 731/16% ND Varrela 1991 Scotland (urban), medieval 74 (-/-/-) 1614/ 1958 Pre 255/ 279 156/8% all ages 134/8% 5/7% ND Kerr et al. 1990 Sweden (urban), 1621–1640 63 (-/-/-) 936/1997 Pre 13/48 55/3% all ages 106/11% ND Lingström and Borrman 1999 Croatia (rural), 14 –17th 68 (35/33/-) 765/ND ND 72 (9%) ND Šlaus et al. 1997 France (urban), 16 –17th 109 (-/-/-) 1267/3488 519 (15%) 236 (19%) ND Chazel et al. 2005 Table 1. Summary data on conditions of the oral cavity from medieval archaeological sites *ND= no data or not specified 85 Dental Anthropology 2019 │ Volume 32 │ Issue 02 which made overall construction of Table 1 compli- cated. There were various forms of missing data and different reporting styles especially in terms of demographics. Additionally, the lack of standardi- zation in description of conditions of the oral cavi- ty suggests that while there was a general under- standing of processes and analytical methods, there were certainly areas of concern regarding recorded data. The data from Table 1 was distilled into de- scriptive statistics per condition. The numbers pro- vided by each reference were broken down into the minimum percentage of the condition expressed, the maximum, and the mean. Not all references investigated all of the conditions reported in Table 1. The N column provides the number of refer- ences out of 21 that reported the condition. The results of the Transylvanian analysis were added to the bottom of the table to highlight how the Transylvanian cases fit into the general data on the medieval oral condition. Of the 21 references reviewed in Table 1, 18 reported on antemortem tooth loss. Antemortem tooth loss occurred at variables rates across medie- val sites with 0% reported for sites in the Czech Republic (Stránská et al., 2015) and 24% reported for a site in Austria (Meinl et al., 2010). The average number of total teeth lost antemortem across the sites recoded in Table 1 was 10.4%. Antemortem tooth loss was not recorded for the Papdomb or Fenyéd individuals for taphonomic and preserva- tion reasons Information regarding carious dental lesions from the two Transylvanian sites was examined against the descriptive statistics provided in Table 2. All of the 21 references reviewed in Table 1 re- ported on carious lesion prevalence. Like ante- mortem tooth loss, dental carious lesions were re- ported at variables rates across medieval sites with 0.6% reported for sites in the Czech Republic (Stránská et al., 2015) and 27.3% reported for a St. Mary Graces cemetery site in England (DeWitte & Bekvalac, 2010). The average total teeth with cari- ous lesions across the sites recoded in Table 1 was 10.3%. Interestingly, the numbers for antemortem tooth loss and carious dental lesions across the sites are very similar. Also in both cases, the sites from the Czech Republic have the lowest numbers. When the two Transylvanian sites were compared to descriptive statistics in Table 2, the Papdomb site (12.4%) was just above the overall mean (10.3). However, the Fenyéd site (24.4%) was high. It was the second highest reported after the St. Mary Graces cemetery (27.3%). Both Transylvanian sites are higher than the Bijelo-Brdo culture site (7%) to which they are most culturally similar. Reporting of periapical lesions was limited. Of the 21 references in Table 1 only 6, including the two case studies, provided data. The lowest report- ed prevalence was the Fenyéd site case study (0.2%) and the highest (5.1%) reported was an ag- gregation of three, Early Medieval villages in Croa- tia (Šlaus et al. 2010). The Papdomb site had a fre- quency of 1.4%, which was the second lowest rate. Discussion The Fenyéd site had the second highest frequency of carious dental lesions among all 21 references reviewed and the lowest frequency of periapical lesions. The Papdomb site was slightly above aver- age for frequency of carious lesions and had the second lowest frequency of periapical lesions. The two cemeteries were 18km away from each other and were used at the same time. Both were in rural Transylvania in a hilly area of the Carpathian Ba- sin. They were, and remain, small villages with similar people, similar occupations, and similar access to resources. The two skeletal populations demonstrate very limited evidence of trauma or pathological indicators minus the expected occur- rences of osteoarthritis and other common degen- erative modifications in older individuals. All things considered, it had been assumed that the two sites would have had similar conditions of the oral cavity. It is possible that sample size, 32 adults from Fenyéd versus 60 adults from Papdomb, could have impacted the results. Regardless, the difference suggests that other factors were present and point in a direction of further investigation. Conclusions Health is a vague term that encompasses physical, emotional, mental, and social factors. To adequate- ly study health requires patient histories and a bet- ter understanding of etiological factors. It is diffi- cult to interpret in the bioarchaeological record. It is limited by the inherent attributes of archaeologi- cal skeletal assemblages. However, as bioarchaeol- ogists we are tasked with finding ways to over- come those challenges in investigation and inter- pretation to best represent the people we are speaking about. Situating interpretation within the social and cultural context of a specific time and place is im- portant even if it is indirect and acquired through less utilized means of knowing, such as images and folklore. This has become apparent in our re- search among the Székely of Transylvania whose 86 Dental Anthropology 2019 │ Volume 32 │ Issue 02 own origin story is unknown and has written itself out of lore and legend (Lemdvai, 2004). Next, ap- plying bioarchaeological data at various scales pro- vided different perspectives on the variability across time and place even though it all fell under the classification of ‘medieval.’ Specifically, this study demonstrated that the oral cavity was varia- ble across medieval Europe even in cases with sim- ilar contexts such as transitions from Late Antiqui- ty to the Early Medieval period, sites in Croatia and Romania with similar cultural periods, or two rural, Székely, Transylvanian villages. Finally, fur- ther complicating the situation was a lack of stand- ardization in descriptions and reporting, which underscores the call of Pilloud and Fancher (2019) to standardize terminology and further understand the etiology of processes that affect the oral cavity; hopefully, leading to improvements in data report- ing. We will never know what ancient individuals experienced or perceived in terms of their dental health but we can be more responsible in the way we discuss it. 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