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F r a y e r e t a l . O R I G I N A L S C I E N T I F I C P A P E R
Bull Int Assoc Paleodont. Volume 11, Number 1, 2017
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Prehistoric dentistry? P4 rotation, partial M3 impaction,
toothpick grooves and other signs of manipulation in
Krapina Dental Person 20.
• David W. Frayer (1), Joseph Gatti (2), Janet Monge (3), Davorka Radovčić (4) •
1 – Department of Anthropology, University of Kansas, Lawrence, KS, 66045, USA
2 – Gatti Dental Studio, Lawrence, KS 66049, USA
3 – Department of Anthropology, University of Pennsylvania Philadelphia, PA, 19104, USA
4 – Department of Geology and Paleontology, Croatian Natural History Museum, 10000 Zagreb,
Croatia
Address for correspondence:
David W. Frayer
Department of Anthropology, University of Kansas, Lawrence, KS, 66045, USA
E- mail: frayer@ku.edu
Bull Int Assoc Paleodont. 2017;11(1):1-10.
Abstract
Aims:
We describe four associated mandibular
teeth, left P4
–
M3, which show a number of features
consistent with a diagnosis that toothpick grooves and other dental manipulations were associated with
treating multiple eruption abnormalities. Materials and Methods: The four isolated teeth making up Krapina
Dental Person (KDP) 20 were analyzed by eye and with a light microscope to document occlusal wear,
toothpick groove formation, ante mortem enamel, dentin scratches and lingual fractures. Results: Definitive,
stage 4 toothpick grooves (1) occur on all four teeth, but are especially marked on both mesial and distal
faces of the left P4 (tooth #32) and the mesial face of the left M1 (tooth #82). Less distinct interproximal
grooves, defined as stage 2 striations, appear on the distal face of left M1, distal lingual edge of M2 (tooth
#3) and the mesial face of M3 (tooth #8). The left P4 also shows signs of dental probing on the mesial
buccal cusp and all four teeth have fractures on their lingual margins. These features are associated with
malpositioned left P4 and a left M3 with lingual rotation and a crown that is partially impacted. The M3’s
buccal face occupies an occlusal position and shows considerable wear, indicating it was in approximation
with the upper dentition. Conclusion: The anomalous dental eruption features of the P4 and M3 are
associated with several kinds of dental manipulations, which seem to have been palliative measures to
“treat” the dental problems. We consider this a kind of “prehistoric dentistry.”
Keywords:
interproximal groo
ves; ‘premolar problem’; rotated, impacted M3; palliative actions
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Introduction
Numerous studies have documented toothpick
grooves in recent and fossil dentitions. From
work on recent dentitions various authors have
documented the presence of these grooves,
imbedded into the interproximal surfaces of
mandibular and maxillary permanent teeth
from North America, Europe, Africa, Asia,
Australia and the Pacific (2-9). Premolars and
molars are the primary targets, but incisors and
canines are sometimes involved and attributed
to fiber processing when they are combined
with grooves in the occlusal surface (10). We
are unaware of any grooves in deciduous teeth
or in non-Homo taxa (11). This habit is
extended as far back as the earliest Homo in
Africa (12), but also to a wide variety of later
Homo from Europe and Asia (1,13-18) While
some have contended causes other than
palliative measures such as fiber processing
and saliva jetting (8,19,20),
they are most
commonly associated with periodontal disease
or caries in modern groups. Yet, they also
occur with no signs of oral pathology, so they
may be idiosyncratic, the product of a nervous
behavior or without a determinable etiology.
Multiple materials have been proposed to
account for the formation of the grooves, from
bone to grass stems (1,21)
and, again, given
their widespread geographic occurrence and
their appearance in hunter-gatherer and
agricultural groups, it is unlikely a single type of
instrument was the cause.
The tooth set KDP 20. Krapina Dental Person
(KDP) 20 is represented by four mandibular
teeth. Wolpoff (22) assembled many of the
Krapina isolated teeth into tooth sets, which he
called a Krapina Dental Person. He based
these associations on similar morphological
features, occlusal wear and, especially,
interlocking interproximal facets. Consisting of
P
4
-M
3
, he originally labeled this specimen as
mandible M (22), but later in the Krapina
Catalog (23), it was re-labeled as KDP 20. The
specimen is interesting because it shows
evidence of a buccally displaced P
4
, a partially
impacted, lingually rotated M
3
, a number of
toothpick grooves in the interproximal spaces
of all four teeth (16),
a series of scratches on
the superior labial surface of P
4
and what
appear to be ante mortem lingual chips on at
least M
1
-M
2
. Added together these features
suggest that the Krapina Neandertal (KDP 20)
was having dental irritation or pain associated
with the abnormal tooth eruption and was
attempting palliative maneuvers through
toothpicking, dental probing and, maybe, other
more drastic measures.
Dental state. The P
4
-M
3
set shows some
occlusal wear (Figure 1a). P
4
has polishing of
the labial and lingual cusps, but no dentin
exposure. M
1
is the most worn with flattening
of all the occlusal cusps and dentin exposure
on all cusps, but especially the entoconulid
(cusp 4) and the hypoconulid – cusp 5 (24) that
are highly polished. The M
2
has only flattening
and polishing of the occlusal cusps plus very
faint dots of dentine exposure on two mesial
cusps (protoconid, cusp 1, and metaconid,
cusp 2). M
3
is anomalous in that the crown
surface is rotated lingually, so that the top half
of the buccal face is in the occlusal plane.
Rotation of the tooth results in no wear on the
lingual aspect of the occlusal surface, which
was has been completely twisted, inferiorly out
of the occlusal plane. According to Wolpoff
(22) KDP 20 is 19, but the individual may have
been older at death based on the depth of the
toothpick grooves and the occlusal wear on
M
3
. In any event, age at death of KDP 20 does
not affect our diagnosis.
Interproximal grooving. As described by
Frayer and Russell (16) the four teeth making
up KDP 20 have a total of six toothpick
grooves: two each on the mesial and distal
faces of P
4
(#32) and M
1
(#82), one on the
distal of M
2
(#3) and one on the mesial of M
3
(#5). Grooves on the distal M
1
and M
2
and
mesial M
3
are very faint compared to the deep
grooves on the P
4
and mesial M
1
(Figure 2).
We scored them as stage 4 (1).
These grooves
have been described in detail for KDP 20, so
we limit our description of them. The most
impressive is the long, deep groove running
along nearly the entire cervical, mesial border
of M
1
(#82). (Figure 2a). This groove is highest
on the buccal edge and tapers lingually,
suggesting the toothpick was inserted buccally
and used repeatedly given the depth of the
groove. Areas with cementum build-up occur
below the groove and striations within the
groove suggest the tool was inserted in a back
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Figure 1
.
Three views of the four articulated teeth making up KDP 20. a. occlusal view showing lingually placed
mesial interproximal wear facet on P4 (arrow) and buccal wear on M3; b. lingual view showing a mesially
placed interproximal wear facet on P4 (arrow), chips from lingual faces of all teeth and rotated, partially
impacted M3; c. buccal view showing rotated buccal face of M3 (arrow) and hypercementosis on its root.
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and forth, horizontal action. A much less
distinct groove occurs on the distal face of #82.
Consisting mainly of polishing below the
cemento-enamel junction, we classify this as a
stage 2 groove. (Figure 2b) Mesial and distal
grooves on the left P
4
(#32) are stage 4 and
impressive in their extent and depth (Figure 3a,
b). The distal groove does not run across the
entire distal face, but is confined to the lingual-
most edge. Unlike the matching groove on the
M
1
, this groove is considerably shorter and
confined to the lingual half of the P
4
’s cervical
border. The groove is more angled than the
one on the mesial M
1
and widest lingually. The
wide gap between the P
4
’s distal face and the
mesial face of M
1
allowed for a large
interproximal opening, which may account for
the different orientation of the toothpick
grooves in the P
4
and M
1
. It may be that this
groove was produced by a different action than
the mesial interproximal groove on M
1
. In tooth
#32 the mesial interproximal facet is the
smallest of the three. Like the mesial M
1
groove, it runs horizontally across the mesial
face, but extends over only the lingual third of
the root and is oval in shape. Signs of
interproximal grooving are much less
pronounced on the M
2
and M
3
. For the M
2
(tooth #3) there is a small facet on the lingual
edge of the distal root face, which is a faint
toothpick groove. This corresponds to a
polished area on the enamel of the mesial face
of M
3
(tooth #8). Both of these are little more
than polishing of the surface and represent a
stage 2 expression (1).
Rotated P
4
.
As described by Rougier et al. (25)
four Krapina mandibles show rotated P
3
s, all
from the left side, based on teeth or angled
root sockets. When teeth are preserved, there
are no associated toothpick grooves in any of
these specimens. They briefly described KDP
20 (25) and argued that the mesial
interproximal facet on the P
4
“can only be
explained by a clockwise rotated P
3
whose
lingual face was in contact with the fourth
premolar” (p. 276). We disagree with this
interpretation. In our view the P
4
mesial
interproximal facet occupies a very lingual
position, well off the center of the mesial face
(Figure 3a, b). In the rotated P
3
’s of other
Krapina specimens (especially, KDP 4, 10, and
28) the mesial interproximal facet is buccally
oriented. In KDP 20 when the distal facet is
articulated with the M
1
, the P
4
protrudes
buccally from the lateral plane defined by the
M
1
and M
2
, as shown in Figure 1a. The
combined positions of the mesial and distal
interproximal facets suggest this is an example
of P
4
malposition. This occurs on the left side
as in all of the other rotated mandibular
premolars at Krapina. The buccal positioning of
the P
4
is consistent with the shape and
orientation of the deep interproximal grooves
on it.
Figure 2. Toothpick grooves on the left M1. a.
mesial view of a deep toothpick groove running
across the entire cervical margin; b. distal surface
showing polished surface (arrow) representing a
shallow toothpick groove.
Partially
impacted and rotated left M
3
.
This
tooth is clearly rotated from its normal position
so that most of the normal occlusal plane faces
lingually. The occlusal lingual cusps are
unworn, while the buccal surface of the tooth
shows considerable wear (Figure 1a). Dentin is
not exposed on this buccal face, but there are
two large wear facets on the mesial buccal and
distal buccal cusps. These are ‘cratered’ and
the buccal face enamel is definitely polished
and thinned, so that it is translucent (Fig. 1a/c).
Other evidence for this rotation consists of the
abnormal condition of the interproximal facets
on the distal M
2
and mesial M
3
.
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Figure 3. Toothpick grooves, irregular interproximal
facets and other anomalies on the left P4. a. mesial face
with a small toothpick groove on the mesial-lingual edge. Above it is a very lingually positioned interproximal
wear facet (arrow); b. distal surface with a deep toothpick groove and an interproximal wear facet that has an
abnormal lingual location (arrow); c. chips from the occlusal/lingual margin; d. probing striations on the
mesial/buccal facet.
On the M
2
the distal facet is lingually oriented
and deeply etched into the enamel so that the
dentin is almost exposed. The matching mesial
interproximal facet on the M
3
is superiorly
positioned so that it is contiguous with the
occlusal face. When articulated with the M
2
interproximal facet, the normal occlusal face is
oblique, tilted lingual to the occlusal plane
(~45º) and the buccal edge is the new occlusal
face. From the depth of the interproximal
facets on M
2
and M
3
it is clear that these teeth
rocked against each for some time producing
the deep gouges in both surfaces. While the
sample is small, KDP 20 is the only specimen
from the site with a mal-aligned P
4
and a
rotated, partially impacted M
3
.
P4 scratches. In addition to the toothpick
grooves in the interproximal space, this tooth
shows a series of scratches on the face of the
mesial buccal cusp. (Figure 3c) At least ten
striations run up the buccal face, from below
the occlusal surface to its face. These run from
the mesial face to the occlusal surface and are
wider and deeper than scratches produced by
dietary items. They are roughly parallel,
oblique to the occlusal plane and resemble
striations found on the Krapina Neandertal
incisors and canines (26). These scratches
were produced by some hard probe, which
was inserted into the mouth and rubbed
against the mesial face of the P
4
crown.
Lingual chipping. All four teeth show chips
removed from the enamel on the lingual edge.
The smallest are two small chips missing from
the distal lingual edge of P
4
(Figure 3b).
Chipping of the M
1
and M
2
is much more
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extensive and completely limited to the lingual
side. For the M
1
the whole lingual face is
missing from the occlusal surface to the
cervical border. The break barely extends to
the root surface on its most mesial aspect
(Figure 1b). The lingual break on the M
2
is
smaller than on the M
1
with the broken surface
starting from the midpoint of mesial lingual
cusp (Figure 1b). The break continues to the
distal interproximal facet and extends down the
root some 5mm below the cervical border. This
lingual break has a wide U-shape, similar to
the break on M
1
. For M
3
there is a chip missing
from the distal lingual edge. This chip is
different from the ones on the M
1
and M
2
in
that it is confined to the crown and more
obliquely angled (Figure 1b). In every
specimen, the impacts causing the missing
sections were delivered to the occlusal face
and spalled off the lingual edge. There are
clear impact fractures with spalling of the more
inferior portions, whether on the enamel or
root. The exposed surfaces on all the molars
show smooth dentin surfaces and are without
surface scratches. The surfaces have a
creamy appearance as if the dentin was
stained, but this could be due to discoloration
from cave sediments. There are secondary
chips from the fractured edges, especially on
the M
1
and M
2
. On the M
1
the occlusal-most
edge of the lingual fracture shows microchips
with smoothing and other signs of wear along
its border (Figure 4a). On the M
2
secondary
microchipping occurs within the primary
fracture and the edges are smoothed and
polished. (Figure 4b) Another aspect of the
lingual chipping is the different angulations of
the chips removed from the surface. On the P
4
the chips are small and angled at ~45º to the
occlusal plane. The large chip removed from
the M
1
shows a completely vertical orientation
with spall fractures at the lingual, cervical
border. On M
2
the chip is also vertically placed,
but is more distally oriented and on the M
3
the
chip is confined to the crown on the
distal/lingual surface and slightly angled to the
occlusal plane. (Figures 1a & b) The M
3
chip
shows no polishing. These chips were
removed in separate actions and, especially on
the M
1
and M
2
, appear to be ante mortem.
While it is unclear what caused the lingual
chipping, it happened before the death of the
KDP individual.
Roots. All teeth show some root damage. The
most extensive is the P
4
with at least half of its
root missing. There is a sharp break across the
root from the lingual to the buccal side. The
exposed surface appears lighter than the
breaks on the molar surfaces and there are a
few patches of hypercementosis, especially on
the mesial aspect. M
1
shows some slight
damage to the mesial root tip and the inferior
ends of the mesial and distal roots show
hypercementosis. M
2
has the base of the root
broken away, exposing the inferior pulp canal.
The root surfaces are smooth and free of
hypercementosis. The M
3
shows some
damage to the inferior-most root, but this area
is covered with hypercementosis, which is
mostly confined to the root tip (Figure 1c).
Adhering cave sediment obscures the root tip.
None of the roots bear evidence of surface
erosion or pitting associated with periodontal
disease.
Discussion.
The oldest toothpick grooves
discovered so far occur in the isolated left and
right P
3
s of a Homo habilis
specimen from Omo
(L894-1a/c) dated at 1.84 mya (12). These are
nearly matched in age by the isolated right M
3
(OH 60) from Olduvai Gorge dated between
1.7-2.1 mya (11)
. In this specimen, a single
interproximal groove occurs on its mesial face.
As in the Omo teeth, there are no signs of
pathology. Later Homo specimens from Dmanisi
(15), Sima del Elefante (14)
and Konso (27)
are
dated between 1.77-1.42 mya. Of these latte
r
cases the involved teeth are still located in jaws
and each mandible shows signs of periodontal
disease. Dmanisi mandible D2735
has a right
M
1
with a distal toothpick groove and “local
marginal periodontitis” (15) (p. 17280).
Sima del
Elefante ATE 9-1
has signs of alveolar pitting
and it has a deep toothpick groove on the P
4
.
Konso 10-1
has multiple toothpick grooves on
its P
4
-M
3
with associated periodontal disease
(27).
A few other cases of toothpick grooves
occur among Neandertals, such as
Cova
Forada 28 and Banyoles 17,
which also show
signs of periodontitis.
None of these specimens involve impacted
teeth and, indeed, impacted teeth are rarely
found in the human fossil record. There are
two cases in Neandertals, both involving
anterior teeth, but neither have an occlusal
eruption.
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Figure 4. Ante mortem wear on broken edges of teeth #82 and # 3. a. view from the occlusal
perspective of
the M1 with arrows indicating segments of polishing and smoothing after the main chip was removed.
Brownish circular patches on the occlusal surface are dentin exposures from wear. b. lingual view of the M2
with arrows showing polished and smoothed surfaces on the secondarily flaked edge.
The Moustier 1 mandible is estimated to date
to about 40 kyrs ago and is thought to be a
15.5 year old male (29).
As described by
Bilsborough and Thompson (30) the left
permanent canine is impacted below the
alveolar border and is associated with a
retained, heavily worn left deciduous canine. In
Le Moustier 1 there are no toothpick grooves
or other signs of dental manipulation, but the
deciduous canine experienced heavy,
anomalous occlusal wear. The second case of
a Neandertal impacted tooth comes from El
Sidròn 2, where an adult, left mandible shows
a horizontally placed permanent canine crown
and root well below the root apices of the left
M
3
(31). Like in Le Moustier 1 the left
deciduous canine is retained in its occlusal
position. Given its anomalous position in the
mandibular corpus, this permanent canine
would never have erupted. Toothpick grooves
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occur on the right I
1
and on the associated
right I
2
, but these are unrelated to the impacted
canine (1).
In KDP 20 we do not have the mandibular
bone to check for other dental problems and
periodontal disease, but these four isolated
teeth exhibit evidence that a Neandertal made
attempts to ‘treat’ the rotated P
4
and partially
impacted M
3
. Even without the bone, we can
propose that the six toothpick grooves, the
scratches on the P
4
and, possibly, the lingual
chips on all four teeth are the result of attempts
to get at the pain and irritation of the dental
eruption problems involving the misplaced P
4
and, especially, the partially impacted M
3
.
The cause of the lingual chipping is the most
difficult to explain. One could argue that the
broken surfaces are due to post mortem
causes, --- the result of trampling, cave
sediment damage or carnivore activity. But, we
rule these out since the broken lingual edges
are at different angles to each other and
appear to have occurred at different times. We
expect carnivore damage would be more
organized, occurring in single incident and
leaving a more consistent pattern of damage.
The same is expected for trampling or
sediment damage. There are also secondary
fractures within the primary fractured surfaces
on the M
1
and M
2
and smoothing and polishing
occur on the occlusal-most portions of the
fractured areas. These are signals that the
breaks are ante mortem. The most likely factor
accounting for the main lingual fractures is
normal mastication. In modern dentistry
mandibular posterior teeth commonly show
chipped lingual margins, mainly the result of
chewing forces. For example, Bader, Martin
and Shugars (32) found in a large clinical
sample that lingual cusps of mandibular teeth
showed incidence rates for noncarious
fractures (fractures/1000 teeth/year) of .4 for
P
3
, 3.1 for P
4
, 15.1 for M
1
, 7.7 for M
2
and 4.0
for M
3
. On a per/tooth basis these represent
1.8 % for P
3
, 14.1% for P
4
, 48.5% for M
1
,
30.7% for M
2
and 4.9% for M
3
. Clearly the
molars are more likely to show lingual fractures
than the premolars. They also found that the
fracture “almost always exposed dentin” and
that occasionally the fracture extended below
the cemento-enamel junction, as in tooth #82
and #3. Surveying Inuit and two Medieval
samples from Norway and Spain, Scott and
Winn (33) came to similar results, in that the
posterior teeth, especially M
1
and M
2
, were
more likely to have ante mortem fractures in
the Inuit hunter-gatherers. In a review of 15
skeletal samples Milner and Larsen (34)
reported more involvement of the posterior
teeth and common lingual surface chipping in
the mandibular molars.
Following Milner and Larsen’s suggestions for
separating ante mortem from post mortem, the
broken lingual faces show ante mortem
changes, especially near the occlusal border.
On the M
1
and M
2
secondary fractures,
blunting and smoothing occurs on the broken
occlusal edges. We think this damage
occurred before death, but given its limited
extent there was little time between the breaks
and the death of the KDP 20 Neandertal.
From the toothpick grooves and scratches on
the mesio-buccal edge of the P
4
, it is possible
there was some kind of intervention in an
attempt to ‘treat’ the dental problems by
removing the lingual edges, but we think it is
more likely the fractures occurred due to
chewing stress. However, such interventions
should not be unexpected given other
evidence that Neandertals used plants for self-
medication (35). In a recent study of plants
consumed by the El Sidrón Neandertals
Weyrick et al. (36) found small percentages of
genetic sequences of a natural painkiller
(poplar) and penicillin (fungal components) in
the calculus of El Sidrón 2. El Sidrón 2 also
has two large, draining abscesses on the right
mandible --- one under the I
2
root and the other
below the roots of P
4
and M
1
. While many
different animals self-medicate (37), most of
these relate to treatment for parasites and
none have been documented for a dental
infection. It seems likely that as more
Neandertal calculus is analyzed, especially in
specimens with dental pathologies, other
examples will be found where Neandertals are
using natural products to alleviate dental pain
and infection. We have no similar paleogenetic
data for KDP 20; some remnants of calculus
are present, but these have not been analyzed.
Conclusion.
The individual represented by KDP 20 appears
to have been making a direct, mechanical
approach to her (his) problems of the mis-
alignment in the P
4
and the partial impaction of
the M
3
. The toothpick grooves and enamel
scratching on the P4 seem to be aimed at
these problems, with very distinct tooth pick
grooves on the mesial and distal surfaces of
the P
4
and the mesial face of M
1
. Lingual
breaks on all four teeth are more difficult to
interpret, but some are clearly ante mortem
and are likely related to altered masticatory
F r a y e r e t a l . O R I G I N A L S C I E N T I F I C P A P E R
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forces related to the two mis-aligned teeth.
However, given the other interventions, it is
impossible to rule out that these fractures were
intentionally done to ‘treat’ the irritation caused
by partially impacted M
3
.
Acknowledgements
We want to especially acknowledge Milford
Wolpoff’s contribution to our work with KDP 20.
Nearly 40 years ago, the isolated teeth were
uncataloged and in separate boxes in the
Croatian Museum of Natural History. Wolpoff
convinced the director, Ivan Crnolatac, to
consecutively number the almost 200 isolated
teeth and combine them into one collection for
easier analysis. W olpoff was able to assemble
some of the isolated teeth into associated units
or tooth sets, a kind of scientific lego
reconstruction. Without his contribution, our
work would have not been possible. We thank
Luka Mjeda (Zagreb) for Figure 1.
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