Dispelling Some Myths: Rotten teeth

Despite the best efforts of historians, the internet is still awash with misconceptions about the Middle Ages. Many of these ideas were the product of Victorian writers and historians reflecting Medieval life through the lens of their own society, as was done by antiquarians before and by historians since. However, after more than a century in popular culture, and taught in schools, these sometimes broad, sweeping assertions remain deeply rooted in everyday consciousness, especially when repeatedly reinforced online, in social media, on television and in the movies. Before addressing one such notion, it is worth remembering that the Mediæval period lasted roughly 1,000 years during which peoples’ lives and experiences varied according to time, place and circumstance.

Comparing dental (or medical) care in the Mediæval world, or even earlier, to modern standards is much the same as comparing apples to oranges. Yet, in one key area Mediæval folk had one less worry about dental care as their diet contained far less refined starches, sugars and acids. By contrast modern diets are, in many cases, laden with additives that damage tooth enamel and encourage gum disease. Sugary drinks, coffee, chocolate and other sweets for example are all detrimental to the health of teeth. While natural sugars such as honey were frequently used in the past, it was not until the 16th-century that sugar from the New World began to appear in quantity in Britain.

Tudor adventurers  An age of discovery transformed Tudor life where exploration, conquest, colonisation and trade all had their impact in various guises. The middling sort benefited from a boom in trade prospering from the new goods becoming available. New items and imported luxuries from food to furniture were one way for Tudors to signal their wealth and status, and it was in the dining room that the taste for the new and exotic was clearly visible. Overseas trade brought new goods, such as tobacco, potatoes, tomatoes and chilli peppers, and the abundance of things that were previously rare. In the newly discovered distant Americas, the mass production began of a substance that was so valuable, and delicious, that it would become known as white gold - sugar.

Sugar had been a fantastically expensive commodity throughout the Middle Ages but during the reign of Elizabeth I the employment of slave labour in the colonies kept production costs low and the sugar price dropped sharply. The Mediæval diet of bread, pottage, beans, lentils, oats, dairy and eggs, occasional meat, and vegetables, began to be enhanced with sugar. Sold in cones, the sugar had to be broken into lumps with a hammer or shaved off the cone. To produce icing sugar to sprinkle over things the granules would have to been ground even finer in a pestle and mortar before being pushed through a silk sieve. Given the hours of work needed, it is perhaps easy to see why sugar was an expensive luxury.

Banqueting  After a meal, diners in the early Tudor period would have stood and drunk sweet wine and spices while the tables were cleared, or “voided” by the servants. Dishes and linens were removed, and the boards taken from the trestles to put the tables away. The voide would not be replaced with the more familiar dessert until much later in the 17th-century. To avoid the noise and disturbance of clearing away, it became increasingly popular for diners on the top table to withdraw to another room to enjoy special luxuries, or “banquettes”.

Today we think of a banquet as the full meal, but when banqueting became fashionable in Elizabeth I's reign, the word applied only to a final course of cakes, biscuits, sticky preserves and candied fruits, or “suckets”. All these tasty delights featured sugar in varying degrees, but the centrepiece of any banquet would be of decorative marchpane (marzipan), itself made from sugar, rosewater and almonds, which could be moulded into elaborate shapes. Eating these sugary treats meant sticky fingers. So, over time the double-ended fork and spoon combination (pictured), known as “sucket forks” gained widespread use, especially amongst the fashionable upper classes. Even so, forks were not used at table and did not become popular until much later in the 17th-century. Today few of us sit down to a feast, a banquet or a simple meal without a fork being present.

Hidden Killer  All that lovely sweet sugar was a must have for society folk, but it was not without its dangers. Queen Elizabeth’s love of sweets and her fear of the barber surgeon contributed to severe tooth decay and tooth loss to such an extent that foreign ambassadors reported difficulty understanding her speech. André Hurault de Maisse, Ambassador Extraordinary from King Henry IV of France, for example reported an audience with the queen during which he noticed:

“Her teeth are very yellow and unequal...and on the left side less than on the right. Many of them are missing, so that one cannot understand her easily when she speaks quickly.”

By Elizabeth’s day, after-dinner “comfits” were eaten to freshen breath. Comfits, however, were sweets consisting of a nut, seed, or other centre coated in sugar. This conspicuous consumption of sugary or starchy food and drink merely encouraged the growth of bacteria in plaque leading in many cases to decay and a dental abscess. The latter is a collection of pus that can form inside the teeth, in the gums or in the bone that holds the teeth in place. It is caused by a bacterial infection that without treatment can lead to sepsis (blood poisoning). It was this unforeseen consequence of too much sugar that proved to be a hidden killer in Tudor England.

Dental hygiene  Although Mediæval and earlier diets were far less laden with damaging ingredients, people still took care of their dental hygiene. To our eyes some of the methods used may seem basic:

• “Toothpicks” were used to clean between the teeth. Indeed, a 2016 study of some of the oldest human remains in Europe found microscopic evidence of indigestible wood fibres preserved inside calcified plaque [1] suggesting prehistoric people used crude toothpicks to clean their teeth.

• 
  The earliest known toothbrushes dating to 3,500 BC were found in Egyptian tombs next to their owners. Used for thousands of years, all over the world, these “chew sticks” rely on their frayed, fibrous ends to whisk away debris. Where available, the chewed root of the Liquorice (Glycyrrhiza glabra) plant (pictured) was well suited as a simple yet effective toothbrush particularly as some research in 2020 suggests that liquorice extract may help reduce the growth of Streptococcus mutans bacteria in the mouth. This, in turn, lessens environmental acidity around the teeth and helps to prevent dental cavities from forming.

• Teeth were rubbed with a clean cloth to wipe off tartar build-up and remove any left-over food particles from the teeth.

• 
  Teeth were cleaned with a mixture of ground pumice (volcanic stone) and coral to remove tartar. The Roman used ground oyster shell in a similar way. Such abrasives will gradually remove tooth enamel over time however increasing the chance of tooth decay. Moreover, the powder tasted horrid, but could be sweetened with honey or sugar, which somewhat defeats the objective.

• Powdered sage or the ashes of burnt rosemary were used to whiten teeth.

• To freshen breath, herbs such as mint, cloves, cinnamon or sage were chewed.

• Water was used as a basic mouthwash to remove debris from the mouth, as was a mixture of mint and vinegar. A mix of acetic acid and water, vinegar has been used for thousands of years as a common disinfectant to kill bacteria, while the mint would freshen breath.

The evidence from the archaeological record reveals that, despite showing signs of wear, plaque and tartar buildup [2], Mediæval teeth often have surprisingly fewer cavities. Yet it is far from uncommon to observe the untreated buildup of tartar resulting in gum disease, tooth loss and infections. As already mentioned, sepsis caused by the latter could lead to death even among young, otherwise healthy people. So, what treatments were available to Mediæval people?

Dental treatments  Anderson’s (2004) article “Dental treatment in Medieval England” published in the British Dental Journal is well worth reading. In it Anderson notes that documentary evidence in “medical literature from the 12th- to 14th-century suggests care of the teeth was largely limited to non-invasive treatment.” The various texts cited by Anderson reveal herbal remedies, charms and amulets were the favoured cures mainly for toothache, which was itself believed to be the caused by a “tooth worm”.

The article emphasises that medical and dental practitioners at the time were heavily influenced by humoral theory, a system of medicine describing a supposed makeup and workings of the human body adopted by ancient Greek and Roman physicians and philosophers. The most famous model comprises the four humours described by Hippocrates [3] and developed further by Galen [4]. In simple terms, the four humours are black bile, yellow bile, phlegm, and blood where each corresponds to one of the traditional four temperaments. Based on Hippocratic medicine, it was therefore believed that for a body to be healthy, the four humours should be balanced in amount and strength to achieve eukrasia. Thus, in accordance with humoral theory, bloodletting was advised for certain types of toothache.

The treatises cited provide documentary evidence for powders and liquids for cleaning and/or whitening teeth, as mentioned above, together with methods for removing calculus and compounds for filling cavities. Evidence for surgical interventions for oral cancer and facial fracture is also presented, along with treating post-operative infection and abscess formation, and the mention of early forms of dentures made of human teeth or cow bone. That said, medical texts would have been expensive, and their possession limited to an elite group of physicians or surgeons most likely based in either the university towns or the larger Mediæval cities. Unsurprisingly, only the richer townsfolk would be able to afford their high fees. For most commonfolk living in small villages or isolated communities, they would have to rely largely on local barber surgeons and their own traditional remedies to treat dental problems. Regardless, the evidence suggests that people living in the Mediæval world understood that dental hygiene was important and took measures to protect their teeth as best they could. The introduction of new, exotic foodstuffs began to change diets, and the uptake of starchy, sugary ingredients did lead to increased tooth decay and loss; a problem still faced today in many western societies. But did all Mediæval people have rotten teeth as the movies and urban myths make out? No, not really.

Bon appétit!

Reference:

Anderson, T., (2004), “Dental treatment in Medieval England”, British Dental Journal 197, pp. 419–425, Available online (accessed 21 September 2024).

Endnotes:

1. Plaque is sticky film deposited on the teeth in which bacteria proliferate.

2. Tartar forms when plaque hardens on the teeth. Tartar build-up can irritate the gums, leading to gingivitis or periodontitis (gum disease) causing pain and discomfort. Tartar can trap bacteria against the tooth surface, leading to tooth decay and cavities, and can expose the sensitive areas of the teeth, leading to increased sensitivity and pain when consuming hot, cold, or sweet foods. In severe cases, tartar can lead to infections that may cause significant pain and swelling.

3. Hippocrates of Kos (c. 460 – c. 370 BC), also known as Hippocrates II, was a Greek physician and philosopher of the classical period referred to as the "Father of Medicine" in recognition of his lasting contributions to the field, such as the use of prognosis and clinical observation, the systematic categorization of diseases, and the (however misguided) formulation of humoral theory.

4. Aelius Galenus (September AD 129 – AD 216), often anglicised as Galen, was a Roman and Greek physician, surgeon, and philosopher from Pergamon. He is considered one of the most accomplished of all medical researchers of antiquity influential in the development of various scientific disciplines including anatomy, physiology, pathology, pharmacology, and neurology, as well as philosophy and logic.