Dental Anthropology 2019 │ Volume 32 │ Issue 02

Outlining a Definition of Oral Health within the Study of Human
Skeletal Remains

Marin A. Pilloud
1*

and James P. Fancher
2

1
Department of Anthropology, University of Nevada, Reno

2
Department of Anthropology, Texas State University, San Marcos

Recently the concept of “health” has been criticized
in bioarchaeology (e.g., Reitsema & McIlvaine,
2014). Defining health in past populations, or even
among the recently deceased, can be difficult if not
impossible as this concept incorporates somewhat
unknowable factors about lifestyle and well-being.
In response, the term “stress” was incorporated
into research, which shifted the focus to conditions
of disease or growth disruption. Yet, the etiology
and interpretation of these markers of stress may
not fully capture the experienced life of people in
the past. For example, a study based on data from
the Mexico Family Life Survey found that individ-
uals with anemia were of various socioeconomic
statuses and generally did not report being in poor
health (Piperata et al., 2014). As skeletal signs of
anemia are generally used in bioarchaeology as
indicators of stress, this study of living individuals
has highlighted the actual role of anemia in the
lives of people currently experiencing it. Based on
recent critiques, the incorporation of stress was
cited as merely being a replacement for “poor
health”, while still failing to address the issues in-
herent in interpreting the levels of health and stress
in past populations.

These critiques about quantifying general
health and stress in bioarchaeology can be extend-
ed to the concept of oral health. A term that has
been used in various contexts within the bioarchae-
ological literature to describe numerous conditions
of the teeth and their surrounding bony structures.
Despite its common use, there is currently no con-

sensus on what should constitute oral health with-
in the bioarchaeological record, and multiple indi-
cators of stress, growth disruption, infection, oral
pathology, and non-specific disease may be includ-
ed. A more comprehensive discussion of oral
health within the bioarchaeological record is war-
ranted given inconsistencies in discussion of oral
conditions and advances in the clinical literature.

In 2014, the American Dental Association
(ADA) House of Delegates adopted the following
definition of oral health as “a functional, structural,
aesthetic, physiologic and psychosocial state of
well-being… essential to an individual’s general
health and quality of life” (http://www.ada.org/
en/about-the-ada/ada-positions-policies-and-
statements/ada-policy-definition-of-oral-health).
In 2016, the World Dental Federation (FDI, once
called the Fédération Dentaire Internationale)
adopted a new definition of oral health that echoes
the sentiment of the ADA in that oral health is
much more than the mere absence of disease. The
FDI defines oral health as “the ability to speak,
smile, smell, taste, touch, chew, swallow, and con-
vey a range of emotions through facial expressions
with confidence and without pain, discomfort, and

ABSTRACT The term oral health is regularly used in bioarchaeological research to discuss a myriad of
pathological conditions of the oral cavity. However, there is very little consensus on what conditions
should be included in such a study, and some of the conditions are at odds with those in the clinical lit-
erature. In this manuscript, we outline the clinical definition of oral health and develop a strategy in
which bioarchaeology can address this type of research. We argue that the terms dental disease and/or
pathological conditions of the oral cavity should be used in lieu of oral health. Various conditions that
can be included in such research are outlined. Finally, definitions, clinical etiologies, and recording
schema for these conditions are discussed as relevant to bioarchaeological studies.

*Correspondence to:
Marin A. Pilloud
Department of Anthropology
University of Nevada, Reno
Reno, NV 89557
mpilloud@unr.edu

Keywords: periodontal disease, dental caries, hypercementosis, periapical lesions, calculus, antemortem
tooth loss, linear enamel hypoplasia

Dental Anthropology 2019 │ Volume 32 │ Issue 02

disease of the craniofacial complex” (Glick et al.,
2016:916). This work further emphasizes the inter-
action of disease status, physiological function, and
psycho-social function along with determining and
moderating factors that influence overall oral
health (Glick et al., 2016).

From a research perspective, and in a clinical
setting, it is critical to understand treatment out-
comes and levels of oral health, as poor oral health
can have further health and social implications. In
recent clinical literature poor oral health has been
linked to Type 2 diabetes (Leite et al., 2013), obesity
(Östberg et al., 2012), and eating disorders
(Johansson et al., 2012). Further, oral health has
been related to school performance (Abanto et al.,
2011; Jackson et al., 2011), quality of life, self-
esteem (Bennadi & Reddy, 2013; Gerritsen et al.,
2010), and depression (Okoro et al., 2012). The
concept of Oral Health-Related Quality of Life
(OHRQoL) has grown over the last decade and is
being recognized as a critical part of dental re-
search and clinical dental practices (Sischo &
Broder, 2011). The OHRQoL is typically studied
through questionnaires and serves as a means to
quantify outcomes to better evaluate treatment in a
clinical setting (Bennadi & Reddy, 2013).

The definitions proposed by the ADA and FDI
as well as the study of OHRQoL, raise questions
about how bioarchaeologists currently use the term
oral health, as it is not possible to understand the
“psychosocial well-being” of past populations
based only on the archaeological record. Further,
the clinical research on oral health shows a discon-
nect with how the term is being used in bioarchae-
ological research. This paper proposes to address
inconsistencies and misconceptions in studies of
oral health on skeletal remains. We begin with a
review of the current trends in the use of the term
and end with a proposed outline of how the term
can be used in research on skeletal remains.

Current Use of Oral/Dental Health
While the clinical definition of oral health includes
conditions of the oral cavity that are detrimental to
one’s general quality of life, within bioarchaeologi-
cal research this definition can vary widely. This
variation is illustrated in a survey of articles pub-
lished in the American Journal of Physical Anthropolo-
gy, International Journal of Osteoarchaeology, and the
International Journal of Paleopathology between 1977
and 2018. Those articles that use the term “dental
health” or “oral health” in the title or abstract
(n=44) were searched to identify trends in the use
of this term. Two of the articles that were recov-

ered in the search were later found to not be relat-
ed to oral health and were removed from further
discussion.

In these articles, oral health was quantified
through various skeletal indicators to include: peri-
odontal disease, dental caries/carious lesions, line-
ar enamel hypoplasia, crown variation, morpholo-
gy, dental/occlusal wear, calculus, enamel hypo-
plasia, periapical defect/lesion/granuloma/
abscess, antemortem tooth loss, cleft palate, alveo-
lar defects/lesions, chipping, dental tilting, hy-
percementosis, dens in dens, agenesis, and ante-
mortem tooth loss. A word cloud was created to
highlight the frequency of each type of skeletal in-
dicator (Figure 1). By far the most commonly in-
vestigated conditions were dental caries, ante-
mortem tooth loss, and abscesses.

Within this body of literature there is little con-
sensus on what factors should be studied as part of
oral health and may also employ varying defini-
tions of these pathological conditions. However,
these research foci are generally in line with the
World Health Organization (WHO) definitions of
dental disease, which include “dental cavities, peri-
odontal (gum) disease, oral cancer, oral infectious
diseases, trauma from injuries, and hereditary le-
sions” (http://www.who.int/mediacentre/
factsheets/fs318/en/). While these dental diseases
may be relatively straightforward to diagnose in a
clinical setting with a well-known patient history
and clinical records, similar diagnoses in archaeo-
logical populations may be impossible to assess.
We therefore dedicate the following section to out-
lining factors that can be used in defining diseases
of the oral cavity in a bioarchaeological setting.

Proposed Use
We propose that based on recent critiques of the

Figure 1. Word cloud highlighting use of terms in
research on “oral/dental health”.

Dental Anthropology 2019 │ Volume 32 │ Issue 02

use of the term health, conditions of the oral cavity
be termed dental disease or pathological condi-
tions of the oral cavity. These terms shift the focus
from the unknowable aspects of health (i.e., psy-
chosocial well-being) to conditions that can be
identified in the maxilla, mandible, and teeth with
known etiologies. Below we outline which condi-
tions can be used as part of this definition, condi-
tions which are less applicable, and those that
should not be included in studies of this nature.

Conditions to include as dental disease/
pathological conditions of the oral cavity:
Dental caries is a disease process characterized by
dental hard tissue destruction of tooth enamel and
dentin due to the bacterial fermentation of con-
sumed carbohydrates. There can be many contrib-
utors to dental caries, to include diet, tooth mor-
phology, calculus, age, sex, microbiology, and peri-
odontal disease (Fakhruddin et al., 2018; Feather-
stone, 2008; Larsen, 2015; Young et al., 2015). A
recent study of the human oral microbiome found
that the progression of dental caries was related to
a multiple bacterial species, not just Streptococcus
mutans, as was previously thought. Further, indi-
viduals without carious lesions exhibited the pres-
ence of various other bacteria (e.g., genera of Ag-
gregatibacter and Rothia) that were found to impede
the development of cariogenic bacteria (Belda-
Ferre et al., 2012).

In the clinical literature, much work has focused
on the prevention of dental caries and increasing
outcomes for patients. A Center for Disease Con-
trol and Prevention study on the presence of dental
caries in the United States from 2005-2008 found
that 75% of individuals had at least one dental res-
toration, and that 20% had untreated dental caries.
Untreated dental caries differed significantly
across socioeconomic status; although, younger
individuals showed more equity in terms of dental
restoration presence (Dye et al., 2012). These pat-
terns are in line with recent studies in Canada and
the United States that found a decline in socioeco-
nomic inequalities in terms of oral health (Bernabé
& Marcenes, 2011; Elani et al., 2012).

Within bioarchaeological research, patterns in
dental caries prevalence speak to disease loads and
changing diets. The presence of carious lesions is
also age dependent and will manifest differently in
different teeth. There are various models for scor-
ing dental caries in bioarchaeological research. In a
clinical setting, rates of carious lesions are recorded
using the DMFT method. In which the total num-
ber of diseased (D), missing due to disease (M),

and filled teeth (F), is divided by the total number
of teeth (T). This system would clearly have lim-
ited utility in bioarchaeology due to the lack of
filled teeth, teeth missing post-mortem, and the
inability to determine the cause of antemortem
tooth loss (Waldron, 2009).

For skeletal remains, the Moulage system could
be employed, which is a series of 85 plaster models
that illustrate varying degrees of carious decay in
different locations (Hillson, 2001). However, these
plaques were not made widely available outside of
Scandinavia, and only a few photographs are avail-
able in published manuscripts (Lindström, 1940;
Rönnholm et al., 1951), which makes their broad
use impractical. Hillson (2001) proposed an alter-
nate method for recording dental caries in which
efforts are made to separate data in terms of tooth
type, age cohort, sex, and lesion type and location.
Such an approach can account for differential
preservation of tooth types and age groups – both
of which have an overall effect on dental caries
prevalence calculations. While the method pro-
posed by Hillson (2001) is by far the most nuanced
and accounts for a range of biological variation,
the most commonly employed method of dental
caries recordation is that outlined in Buikstra and
Ubelaker (1994). This method relies on a visual in-
spection of the dentition with recording of dental
caries by tooth type and surfaces affected.

Periodontal disease is actually a cluster of inflam-
matory diseases that affect the periodontium
(Langlais et al., 2017; Lindhe & Lang, 2015). Clini-
cally it is especially noted by the inflammatory sta-
tus of gingiva and other soft tissues. The diseases
are generally chronic and slow progressing in na-
ture; although, more aggressive and acute forms
do exist. The primary cause is a complex communi-
ty of microbes that form a biofilm on tooth surfaces
and interact with the host response systems to cre-
ate an inflammatory response. There are many
contributing factors that include local tooth anato-
my, virulence of the biofilm, and systemic condi-
tions that modify the host response. There are also
various biological, social, and behavioral risk fac-
tors, which include: socioeconomic status, tobacco
use, hormones, stress, excessive alcohol consump-
tion, diabetes, obesity, osteoporosis, root abnor-
malities, enamel pearls, impacted third molars, and
trauma, among many others (Jin et al., 2011). The
WHO estimates that between 5 and 20% of adults
globally have severe periodontitis (Jin et al., 2011).
Periodontal disease remains a major cause of tooth
loss in both developed and developing countries

Dental Anthropology 2019 │ Volume 32 │ Issue 02

(Pihlström et al., 2005).
Disease limited to the gingiva often does not

cause attachment loss and is usually reversible.
Disease that affects the deeper structures of the
periodontium lead to irreversible loss of connective
tissue attachment and bone loss. Clinically, diagno-
sis is made based on a combination of measurable
factors including pocket depth, clinical attachment
loss, anatomical variations, tooth mobility, quanti-
ty and position of dental calculus, radiographic
changes, and quantity of inflammation. The only
factors that may reliably survive to the postmortem
or bioarchaeological cases are quantity and posi-
tion of dental calculus, attachment loss, and radio-
graphic changes. A combination of these data is
needed to assess the periodontal status of osseous
specimens. Much evidence is currently available
that links active periodontitis with numerous acute
and chronic systemic diseases, including cardio-
vascular diseases, diabetes, pulmonary diseases, a
cerebrovascular diseases (Albandar et al., 2018;
Jepsen et al., 2018; Gerry J. Linden & Herzberg,
2013; Gerard J. Linden et al., 2013)

There are multiple methods to score periodon-
tal disease. In an epidemiological setting periodon-
tal disease may be recorded using the Community
Periodontal Index of Treatment Needs (CPITN),
which requires a special probe to document the
status of disease and treatment needs (Ainamo et
al., 1982). (Comment: In fact, this system is some-
what flawed and not often used currently, but
there is a long history in the literature). As there is
no soft tissue in the bioarchaeological record, Karn
et al. (1984) described a series of deformities of the
alveolar process that include crater, moat, ramp,
and plane to describe the disease process. Nearly a
decade later, Kerr (1991) proposed an alternate
scoring system in which the top of the interdental
wall was described as flat/curved, porous, or with
breakdown of the contour. Most recently, Waldron
(2009) suggested the presence of periodontal dis-
ease should be recorded in individuals with 3 mm
or greater distance between the cemento-enamel
junction (CEJ) and the alveolar crest (AC) and rec-
ommended that the distance be documented with a
periodontal probe. This is the method that most
closely approximates the clinical gold standard for
measuring the clinical attachment loss associated
with periodontal disease, which is the diagnostic
basis for defining periodontitis in humans (Eke et
al., 2012; Holtfreter et al., 2015; Papapanou et al.,
2018). However, when measuring skeletal remains
it is also necessary to consider that the connective
tissue component of the periodontal attachment
apparatus is missing, and a 1mm subtraction from

the measured distance from the CEJ to the AC is
necessary to allow for this missing portion of the
biological width of tissue attachment (Gargiulo et
al., 1961). The epidemiological threshold to define
early periodontitis for human studies is 3mm of
attachment loss (Eke et al., 2018), which would be
measured as 4mm of distance from the CEJ to the
AC. The clinical threshold that is often used is
2mm of attachment loss (Papapanou et al., 2018)
(3mm measured from the CEJ to the AC), which
encourages clinicians to diagnose and treat perio-
dontitis at the earliest stages in order to prevent
continued irreversible attachment loss.

Periapical lesions are related to pulpitis when an
infection penetrates the pulp cavity. The term peri-
apical lesion is a general term to describe a disturb-
ance of the skeletal tissue around the apex of the
tooth that may be related to a granuloma, cyst, or
an abscess (Figure 2). The general term of
‘periapical lesion’ is preferred as the specific etiolo-
gy is not possible to diagnose or differentiate with-
out a soft tissue biopsy or a definitive patient histo-
ry (Langlais et al., 2017). Even in a clinical setting
these distinctions can be difficult to make
(Stockdale & Chandler, 1988), again underscoring
the need to keep terminology general in bioarchae-
ological research. These lesions are merely record-
ed by location and as present or absent.

Trauma to the oral cavity could be included under
dental disease as it is a disorder of function. Fur-
ther, it could affect the overall well-being of the
individual and is included in clinical definitions of
oral health. Traumata to the oral cavity could in-
clude acute trauma such as fractures to the mandi-

Figure 2. Example of a periapical lesion of the
right maxillary fourth premolar.

Dental Anthropology 2019 │ Volume 32 │ Issue 02

ble, maxilla, or teeth; or, more long-term trauma
such as damages due to bruxism, or issues with the
temporomandibular joint.

Cancers of the oral cavity affecting bone are rela-
tively rare in the bioarchaeological record, but
could be included in a general study of oral disease
according to the clinical definition of the WHO.
The most common contemporary type of cancer in
the oral cavity is squamous cell carcinoma, which
may or may not leave a signature on bone. The
incidence of oral cancer is also relatively low glob-
ally according to the Atlas of Oral Health
(Beaglehole et al., 2009). Oral cancers also tend to
have a greater prevalence in older humans, which
should be considered in archaeological samples.

Conditions to potentially include:
Abscess/granuloma/cyst are terms that should
generally be avoided individually as they require
soft tissue and/or clinical evidence for a definitive
diagnosis. As previously discussed, a more general
term such as “periapical lesion” or “a certain ana-
tomical lesion” is nearly always more accurate and
includes the undetermined status of the lesion. In
general, abscesses are acute lesions with purulent
discharge, granulomas are chronic lesions with or
without discharge, and cysts are epithelial-lined
benign neoplasms. These all may look the same
radiographically or as osseous lesions.

Calculus is a mineralized biofilm on the surface of
teeth. The accumulation and composition of calcu-
lus can be studied to understand the oral microbi-
ome, or may be measured in relation to other dis-
ease parameters (e.g., periodontal disease). How-
ever, the exact process of mineralization is not fully
understood (Warinner et al., 2015). Therefore, cal-
culus is thought to be more a product of disease
processes rather than the cause of disease, and may
be best included as part of pathological conditions
of the oral cavity as opposed to dental diseases or
can be included in a diagnosis of periodontal dis-
ease. In bioarchaeology, the presence of calculus is
typically recorded according to the scheme devel-
oped by Brothwell (1981) in which calculus pres-
ence is scored on a scale from 1 to 3 of increasing
severity.

Hypercementosis is the excessive build-up of ce-
mentum with unknown etiology (Corruccini et al.,
1987). Although, it has been suggested to be linked
to genes, Paget’s disease, rheumatoid arthritis, thy-
roid goiter, acromegaly, and rheumatic fever

(Mohan, 2014). As the etiology is unknown, it is
not appropriate to include it as part of studies fo-
cused on dental disease. However, it may be rec-
orded as a dental anomaly or in the differential
diagnosis of other, potentially related, conditions.

Antemortem tooth loss (AMTL) should be used
cautiously as there are many causes of this condi-
tion, some of which may not be related to disease
(e.g., dental ablation and trauma). Care must also
be taken in cases where dental agenesis may be a
factor (e.g., third molars, upper lateral incisors, or
lower third premolars). It is critical that radio-
graphs are taken in ambiguous cases to ensure im-
paction is not a factor. Although in the clinical lit-
erature, tooth loss is largely related to dental dis-
ease, predominantly periodontal disease and den-
tal caries (Gerritsen et al., 2010). Antemortem
tooth loss can more definitively be assigned in
studies of dental disease in cases where there is
large gap, reactive bone, a healed alveolar ridge
with a deficient volume of bone, or it is a tooth that
is not typically missing due to agenesis, trauma or
ablation (Figure 3). In cases of uncertainty, ante-
mortem tooth loss should not be recorded.

Conditions to limit or not include:
Enamel hypoplasia is a disruption in enamel secre-
tion during dental development (Goodman &
Rose, 1990). These enamel defects can manifest as
pits, furrows, or plane defects (Hillson & Bond,
1997). Enamel hypoplastic defects are linked to
episodic childhood stress, such as malnutrition and
fevers (Hillson, 1996). As such, they are an indica-
tion of general stress, not specific to the oral cavity,
and are therefore not applicable to a study cen-

Figure 3. Example of antemortem tooth loss with
reactive bone and a large gap on the right mandi-
ble.

Dental Anthropology 2019 │ Volume 32 │ Issue 02

tered on dental disease.

Occlusal wear is a reduction in the dental hard tis-
sues related to traumatic injuries to teeth caused by
abrasion, attrition, and/or erosion (Ibsen & Phelan,
2018; Langlais et al., 2017). Although these injuries
may lead to reduced function of the dentition due
to loss or alteration of dental hard tissues, the oc-
clusal wear itself is not a disease process, but is the
result of either (1) wearing away of tooth structure
from a repetitive mechanical habit (abrasion), (2)
wearing away of tooth structure due to tooth-tooth
contact (attrition), or (3) loss of tooth structure re-
sulting from chemical action not of bacterial origin
(erosion). Unless the processes or results of occlu-
sal wear can be specifically identified as pathologi-
cal, such as there is associated pulp exposure with
infection, general wear is not an indicator of dental
disease. It is likely more related to the time span of
life (often expressed as age), consumed foods, the
use of teeth as tools, sex, bite force, malocclusion,
environmental or salivary factors (Dahl et al.,
1993).

Tooth size/morphology/agenesis are all condi-
tions that are considered highly heritable and
should be studied as separate conditions. Tooth
size may be related to non-specific indicators of
childhood or maternal stress (Pilloud & Kenyhercz,
2016), and therefore is not related to studies of den-
tal disease. Moreover, there are no good data to
show that morphology or dental agenesis are relat-
ed to stress or a disease process.

Chipping is related to microtrauma and therefore a
reflection of biting force and potentially diet and
tool use (Scott & Winn, 2011). Chipping also may
be due to blunt force, or an eventual result of wear.
Unless the chipping leads to pulp exposure and
infection, or possibly radiographic signs of second-
ary dentin formation as a result of the trauma, it is
not a disease process on its own.

Cleft palate is a congenital defect that is also not
related to any active disease process, and it should
be considered separately. Even though it may af-
fect overall function of the oral cavity, there is
much variation in expression and severity and due
to its relative rarity in the archaeological record, it
should be considered independently in studies of
pathological conditions of the oral cavity.

Discussion and Conclusions

The study of pathological conditions of the oral
cavity in the past are an important aspect of ar-
chaeological research. These conditions can inform
our understanding of diet, disease loads, activity,
and genetic composition of past populations. We
argue that this research is an important endeavor
that is only lacking in a level of clinical standardi-
zation and appreciation. Measures of dental dis-
ease in the archaeological record that can conform
to current measures of dental disease will improve
the relevance and understanding of disease pro-
cesses that can be related over the continuum of
human history. This manuscript is meant to start
the discussion of standardizing research on dental
disease with an emphasis on clinical research. This
work is not meant to be the definitive word on bio-
archaeological research on oral health or dental
disease; instead, we hope to generate a discussion
on this research and work towards an integrated
approach that fully intertwines bioarchaeological
research within a clinical reality that embraces the
accurate use of terms.

Acknowledgments
We thank all the participants who were part of the
original symposium on oral health at the American
Association of Physical Anthropology annual
meetings in Austin, Texas in 2018. We also thank
the Dental Anthropology Association for sponsor-
ing the symposium from which this paper stems.
And, we thank Başak Boz for reviewing this paper.

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