H C p h G C n 2 Ethics, Medicine and Public Health 30 (2023) 100931 Available online at ScienceDirect www.sciencedirect.com UMANITIES IN HEALTH ross-regional assessment of dental athologies: Evidence for predicting oral ealth and intra-vitam stress among hanaian ancestors P.S.N.O. Lampteya,b,∗, P. Charliera,c,d a Laboratoire anthropologie, archéologie, biologie (LAAB), université Paris-Saclay (UVSQ), UFR des sciences de la santé, 2, avenue de la Source de la Bièvre, 78180 Montigny-le-Bretonneux, France b Department of Archaeology and Heritage Studies (DAHS), University of Ghana, P.O. Box LG 3, Accra, Ghana c Département de la recherche et de l’enseignement, direction, musée du quai Branly-Jacques-Chirac, 222, rue de l’Université, 75007 Paris, France d Fondation anthropologie, archéologie, biologie (FAAB), institut de France, palais de l’Institut, 23, quai de Conti, 75006 Paris, France Received 10 February 2023; accepted 18 August 2023 Available online 21 September 2023 KEYWORDS Summary Dental pathologies; Background and aim. — WHO’s definition of oral health extends beyond the state of the teeth Developmental and and dental pathologies. However, dental pathologies form a significant component of oral health Functional stress; and impact a person’s quality of life. Thus, dental pathologies can elucidate intra-vitam oral Dietetics; health and dietetics of ancient or contemporary populations. This paper aimed at predicting the Oral health oral health and intra-vitam stress of past inhabitants across five regions in Ghana from dentalpathologies. Method. — The study employed the mixed research approach involving standard anthropo- logical observational scoring systems to examine five dental pathologies: caries, calculus, abscess, enamel hypoplasia, and cementum hyperplasia. The scores were translated into absent (0)/present (1) pathology categories and the frequency was calculated in an Excel sheet. Abbreviations: Ab, Abscess; AMP, Anterior medial palatine; CEJ, Cemento enamel junction; CER, Caries expression rate; Cl, Calculus; Cr, aries; DPs, Dental pathologies; Eh, Enamel hypoplasia; Hc, Hypercementosis; IN, Incisive; LEH, Linear enamel hypoplasia; MNI, Minimum umber of individuals; PMP, Posterior medial palatine; TP, Transverse palatine; WHO, World Health Organization; XRF, X-ray fluorescence. ∗ Corresponding author: Faculté de médecine, université Paris-Saclay, 63, rue Gabriel-Péri, 94276 Le Kremlin-Bicêtre cedex, France. E-mail address: pearllamptey42@gmail.com (P.S.N.O. Lamptey). https://doi.org/10.1016/j.jemep.2023.100931 352-5525/© 2023 Elsevier Masson SAS. All rights reserved. P.S.N.O. Lamptey and P. Charlier Results and discussion. — Dental pathologies constituted 60% of the total pathologies recorded on human remains, with calculus being dominant (35%), followed by caries (30%), enamel hypoplasia (21%), abscess (9%), and hypercementosis (7%). In general, the individuals from Sekondi presented the highest percentage of dental pathologies, i.e., 69% caries, 66% calculus, 50% abscess, 44% enamel hypoplasia, and 5% hypercementosis. Begho and Yapei individuals had equal percentages of abscesses, enamel hypoplasia, and calculus, while hypercementosis was relatively low in all cases. More than one individual combined multiple dental pathologies, while 6 had none. Grounded on the high caries and calculus expression rates and their direct influ- ence on other dental pathologies, the individual’s oral health could have been compromised by dietary patterns, developmental factors, functional stress on the teeth, and inadequate oral hygiene. Conclusion. — The assessment of the dental pathologies of these Ghanaian ancestors offered valuable insights into dietetics, oral health, and some intra-vitam developmental and functional stress on the teeth. © 2023 Elsevier Masson SAS. All rights reserved. I L t O m a F d M p g A d w a e c i a & p r i M c a p 4 c 2 i O r s t b p ( h w S t a a d n c h N o 1 p & h e c i p t o r a c o e M f ( ntroduction ne particular intra-vitam concern is oral health which has n index on the quality of life of individuals/populations [1]. or clinicians and bioarchaeologists, dental pathologies are irect pointers for the oral health of ancient and recent opulations. Assessing oral infections and dental patholo- ies can shed light on a spectrum of customs, diseases, and ietary composition to aid the reconstruction of individual nd group dietetics [2] and health. For instance, caries and alculus data have been used to infer population dietetics s indirect reconstructions of carbohydrate intake among opulations [3]. According to WHO [1], orofacial pain, oral nfections, and dental pathologies impact masticatory pro- esses, speaking, and smiling, as well as an individual’s sychosocial well-being. The examination (including suffi- ient documentation) of the dental pathologies of ancient ndividuals/populations is as important as that of contempo- ary groups because it provides a comparative platform for he evolutionary evaluation of causes and severities to com- lement the understanding of dental pathologies and oral ealth over time. In this paper, we attempt to predict, by examining den- al pathologies, the intra-vitam oral health of 21 Ghanaian ncestors across five sites and provide a glimpse into their utritional and occupational stress. To illuminate the oral ealth and stress of the past Ghanaian populations, the bjectives were to determine the expression rate of each athology (calculus, caries, abscess, enamel hypoplasia, and ypercementosis) per site and individual and to discuss the haracteristics and causes and effects of the respective athologies. Calculus, for instance, preserves micro-remains f food, oral microbiomes, and non-dietary fiber, whose nalysis sheds light on the health and dietary patterns f individuals and populations [4—7]. Additionally, caries xpose bacterial activity and oral hygiene of individuals. ( oreover, abscess, the periapical offshoot of pulpitis, results m rom caries, dental infections, and extreme dental wear [8] a which compounds the spread of bacteria in the alveoli). 7 2 astly, enamel hypoplasia reflects individuals’ developmen- al and nutritional stress, while hypercementosis relates ore to occupational and masticatory stress on teeth. aterials n MNI (minimum number of individuals) of 21 individuals as subjected to the study. They were excavated by differ- nt researchers in the early and mid-20th century from sites n the Western (Sekondi), Bono (Begho), Savannah (Ntereso Yapei), and Northeast (Yikpabongo) regions of Ghana. The emains have since been stored (in wooden boxes) in the useum of Archaeology at the Department of Archaeology nd Heritage Studies, University of Ghana [9]. From Sekondi; 56’2.40’’ N-1 42’49.32’’ W (Fig. 1), the individuals (< 25% & 5%—75% complete) were excavated from an area near Fort range in 1954 associated with ostrich shell beads, green- tone celts, and some stone beads. The remains have not een dated. In the Bono region; 7 51’00’’ N 2 29’00’’ W Fig. 1), the Begho individuals (25%—75% & > 75% complete) ere excavated in 1970 in the Brong Quarter of the site. ome of the individuals were associated with potsherds and nimal (dog) bones. Although the remains have not been ated, site chronology places them between the 10th—19th enturies. In the Savannah region are Ntereso; 9 7’ 46’’ 1 12’ 17’’ W and Yapei; 9 9’ 4’’ N 1 8’ 59’’ W (Fig. ). The context of the individuals (25%—75%, and 25%—75% > 75% complete, respectively) is unavailable but probably xcavated in 1960 and 1970, respectively. While one Yapei ndividual dated to the mid-18th and early 19th century BC, he Ntereso remains have not been dated. The Yikpabongo emains were excavated in 2007, although not dated, site hronology places it between the 6th—12th century BC. The Sekondi individuals had completely isolated teethpartially damaged crowns and roots). From Begho, the iddle adult male BG’21-F 73.116 (70 B1) had complete rches, and the middle adult male (?) BG’21-E 73.115 (Bg. 0, E) had all teeth but 24, 26, 31, 41, and 36, 45 & 46 Ethics, Medicine and Public H a e [ a m p fi b t p a R A t r c a w s Y p a b l o h p h 6 h F c w ( o v f t e p e d f A w o b 4 m A M wg w C i q u s c a d m s C t f g t t g T m D o i [ a igure 1. Map of Ghana. crowns destroyed by caries). The teeth of the other indi- iduals were isolated with damaged roots (some) impossible o side or situate into the upper or lower arches. The Yik- abongo calvarium was accompanied by two extensively amaged isolated teeth (impossible to assess pathologies). lso, the teeth of some individuals within the assemblage ere unavailable. Skeletal collections including neonate, aby, & child of < 25% complete were exempted. ethods ombining the mixed research method (quantitative and ualitative) with bioanthropological research standards or coring systems, the dental pathologies: caries, calculus, bscess, and hypercementosis were assessed through non- etric observation of the maxillary and mandibular teeth. aries were observed on the occlusal and interproximal sur- aces, and at the root & cemento-enamel junction of the eeth. The absence, presence, and extent of the patholo- ies were coded according to Buikstra & Ubelaker [10]. he presence and quantity/accumulation degree (small, edium, and large) of calculus were assessed on teeth in cclusion and isolated at the buccal, lingual, and interprox- mal surfaces and coded according to Buikstra &Ubelaker C 10]. Abscesses (fenestrations or drainage channels in the a lveolar at the root apex) were observed on the buccal e 3 ealth 30 (2023) 100931 nd lingual surfaces of the maxillae and mandibles, lat- rally and bilaterally, according to Buikstra & Ubelaker 10]. We acknowledge, however, that visual identification of bscesses based on the presence and absence of perforations ay limit the prevalence assessment of the lesion among opulations [11] because of the possibility of non-external stulas. Lastly, dental enamel hypoplasia was recorded ased on the number of hypoplastic lines and pits on the eeth [12], and hypercementosis was noted based on the hysical observation of the appearance of teeth roots for bnormal thickness and opacity. esults ll the results are displayed in Table 1 and Figs. 2—5. Den- al pathologies constituted 60% of the total pathologies ecorded on the individuals through the bioanthropologi- al assessment. Of this percentage, calculus was dominant, ccounting for 35% in 15/21 individuals, followed by caries hich constituted 30% in 13/21 individuals. Caries expres- ion rate (CER) in the skeletal assemblage of all sites, but ikpabongo was 18 on the occlusal surface, 7 on the inter- roximal region, 11 at the cemento-enamel junction, three t the root level, and three cases of teeth partially destroyed y caries. Caries were expressed more in molars and premo- ars, and calculus was on either the buccal or the labial teeth r both. The rest of the pathologies followed as enamel ypoplasia, abscess, and hypercementosis in that order of revalence. In general, the Sekondi individuals recorded the ighest percentage of dental pathologies, i.e., 69% caries, 6% calculus, 50% abscess, 44% enamel hypoplasia, and 5% ypercementosis. Begho and Yapei individuals had equal per- entages of abscesses, enamel hypoplasia, and calculus, hile hypercementosis was relatively low in all cases. Six f the 21 individuals had none of the dental pathologies, our combined caries and calculus, three combined caries, namel hypoplasia, and calculus. Two individuals had both namel hypoplasia and calculus, while six combined up to our dental pathologies on multiple levels of the teeth. The ratio of males to females with two or multiple types f dental pathologies, including caries and calculus, was :6. However, the sex of some of the individuals was deter- ined using only the skull (designated as male?/female?). s a result of the vast percentage of undeterminable cases, e could not conclude the sex prevalence of dental patholo- ies. The ratio of individuals with two or more dental lesions hose sex could not be determined and undeterminable ndividuals with no pathologies was 5:6. Due to the irreg- larities in age distribution, a correlation between the age ategories and dental pathologies could not be established iscretely. Nevertheless, cumulatively, all adults in the study ample except teeth lost antemortem and postmortem had wo or more different dental lesions, the adolescent in the roup had minimal calculus and two hypoplastic lines on ooth 12, while the sub-adults presented no pathologies. iscussionaries result from prolonged bacterial activity in the mouth nd the consequent demineralization or degradation of the namel, dentine, and roots of the teeth [2]. WHO, in 2017, tey a e i c i c P.S.N.O. Lamp stimated caries as globally prevalent [1], and Hillson notes aries as a ‘‘pervasive and important disease’’ [3]. Some c ndividuals had multi-level caries and a combination of cal- h ulus, abscess, and enamel hypoplasia (Fig. 4). The CER f Table 1 Osteobiographies and details of the dental pathologi 1. Site & ID Sekondi SK’21- A 73.80 MNI 1 Age Middle adult 25—29 (IN + PMP); or above? Sex Female? Dental pathologies Calculus: minimal (stage 1) on 2 On isolated un-sided molars: sta Caries: at the interproximal sur isolated molars Abscess: none Enamel hypoplasia: none Hypercementosis: none 2. Site & ID Sekondi SK’21-C 73.88 MNI 1 Age Middle-old adult (based on avai Sex Undeterminable Dental pathologies Calculus: minimal (stage 1) on 1 37 & 48, and large (stage 3) on Caries: on the occlusal surface Abscess: none Enamel hypoplasia: 1 hypoplast Hypercementosis: general in av 3. Site & ID Sekondi SK’21- D 73.81 MNI 2 (two right halves of the tempo Age Young-old adult (two different w which individual the teeth belon Sex Female? (for both individuals ba Dental pathologies Calculus: minimal (stage 1) on 1 rest (teeth were absent) Caries: at the cemento-enamel Abscess: none Enamel hypoplasia: none Hypercementosis: none 4. Site & ID Sekondi SK’21-E 73.82 MNI 1 Age Adolescent Sex Undeterminable Dental pathologies Calculus: minimal (stage 1) on 4 unobservable on the occlusal an Caries: absent on the labial and interproximal surfaces Abscess: absent on the labial an surfaces due to soil endo-crania Enamel hypoplasia: 2 hypoplast Hypercementosis: none 5. Site & ID Sekondi SK’21-F 73.94 MNI 1 Age Adult Sex Male? 4 nd P. Charlier s high among populations with increased consumption of arbohydrate-rich foods [13,14], sugar-rich foods, and a igh intake of fruits (including dates), honey, and starchy oods/cereals [15]. This custom is not unusual across the es presented by the individuals. 7, medium (stage 2) on 17, 21, and large (stage 3) on 26. ges 1 & 2 face of 21 and developing root caries on one of the lable dentition and extensive wear) 6, 23, 33, 36, 42, 45 & 47, medium (stage 2) on 13, 24, 17 & 27 of 14, 15 &16, and at the interproximal surface of 47 ic line on 37, 2 hypoplastic lines on 13, 23 ailable teeth ral bone) ear categories for different dentitions: it is uncertain g to) sed on two gracile right-sided mastoids) 6 & 47 to medium (stage 2) on 48, unobservable for the junction of 46 2; Absent on the labial and buccal surfaces but d interproximal surfaces due to soil buccal surfaces and unobservable on the occlusal and d buccal surfaces and unobservable on the lingual l ic lines on 12 Ethics, Medicine and Public Health 30 (2023) 100931 Table 1 (Continued) Dental pathologies Calculus: minimal (stage 1) on 15, 25, 37 to medium (stage 2) on 16 and 33 Caries: at the cemento-enamel junction of 25 Abscess: on the buccal surface of 35 Enamel hypoplasia: none Hypercementosis: none 6. Site & ID Sekondi SK’21-G 73.83 MNI 2 (from different mandible pieces in size, color, and morphology) Age 1st individual — middle adult? (based on permanent dentition available and significant wear, code 8 for PM1 & PM2. However, code 2 for M3) 2nd individual — adult? Sex Female? & undeterminable for the 2nd Dental pathologies Calculus: minimal (stage 1) on 16, 17, 22 & 27 and medium (stage 2) on 25 Caries: on the occlusal surface of teeth 25 and 36 Abscess: none Enamel hypoplasia: none Hypercementosis: none 7. Site & ID Sekondi SK’21-H 73.84 MNI 1 Age Young adult (significant dental wear) 25-29 (IN + PMP); or above? Sex Female? Dental pathologies Calculus: minimal (stage 1) on possible 16, 17, possible 37, 38, 47 & 48. Medium (stage 2) on probable 18, 26 & 46 and large (stage 3) on the surface of probable 27 (the surface is covered by what looks like calculus) Caries: on occlusal surfaces of 16, 27 (the surface is partly covered by what looks like calculus), and 36 Abscess: none Enamel hypoplasia: 1 hypoplastic line on 36 but absent on available teeth Hypercementosis: present on available teeth roots 8. Site & ID Sekondi SK’21-K 73.85 MNI 1 Age Adult Sex Undeterminable Dental pathologies Calculus: none Caries: none Abscess: none Enamel hypoplasia: none Hypercementosis: none 9. Site & ID Sekondi SK’21-L 73.86 MNI 1 Age Middle adult (based on permanent dentition and extensive wear observed) Sex Female? Dental pathologies Calculus: minimal (stage 1) on 14,15, 17,18, 22, 27, 34, 35—38, 42 & 47. Medium (stage 2) on 13, 21, 41, 46, and 48. Large (stage 3) on 11 Caries: at the cemento-enamel junction of 13, mirror caries at the cemento-enamel junction of 25 & 26 (revealed by CT scan), and on the occlusal surface of 42 Abscess: none observed Enamel hypoplasia: 2 hypoplastic lines on 13 & 41(although the surface is partially concealed by calculus) Hypercementosis: none 10. Site & ID Sekondi SK’21- M 73.875 P.S.N.O. Lamptey and P. Charlier Table 1 (Continued) MNI 1 Age Middle-old adult? (based on significant crown loss of available teeth) Sex Undeterminable Dental pathologies Calculus: minimal (stage 1) on 14, medium (stage 2) on 25, unobservable for the rest (teeth too damaged to assess) Caries: at the occlusal and interproximal surface of 15 and 24, respectively Abscess: none Enamel hypoplasia: none (most teeth had crowns too damaged to assess) Hypercementosis: none 11. Site & ID Sekondi SK’21-73.89 (Pit 1 Extension) MNI 2 From differently sized and colored (black and light brown) bone fragments, especially two right pieces of mandibles Age Adults Sex Male? & Female? Dental pathologies Calculus: minimal (stage 1) on 27, 28, and 46. Medium (stage 2) on 11 (for the male?) Caries: on the occlusal surface of 46 (for the male?) Abscess: none observed Enamel hypoplasia: none observed Hypercementosis: none 12. Site & ID Begho BG’21-F 73.116 (70 B1) MNI 2 Age Middle adult 40—44 (based on auricular surface morphology) 45.2 (based on only vault composite scores) Sex Male Dental pathologies Calculus: minimal (stage 1) on 11, 15, 16, 18, 21, 23, 27, 32, 45, 46, 47 & 48. Medium (stage 2) on 13, 14, 25, 26, 28, 31, 33, 34, 35, 41, 42, 43 & 44. Large (stage 3) on 24 & 36 Caries: none Abscess: none observed Enamel hypoplasia: 2 hypoplastic lines on 18, 33, 34, 43, and one hypoplastic line on 16 & 36 (although calculus is concealing a significant part of the crown surface) Hypercementosis: none 13. Site & ID Begho BG’21-E 73.115 (Bg. 70, E) MNI 1 Age Adult Sex Male? Dental pathologies Calculus: minimal (stage 1) on 18, 17, 15, 14, 21, 22, 23, 25, 27, 32, 31& 47. Medium (stage 2) on 13, 16, 28, 38, 37, 35, 34, 33, 42, 43, 44 & 48 Caries on the occlusal, interproximal and buccal surfaces at 16, 15, 14, 11, 22, 37, 36, 45, 46 & 47 Abscess: labial and buccal perforations at 12 and 26, respectively (Fig. 6). There were also lingual perforations at 45 & 35 with buccal drainage channels at the level of the mandibular foramen. This, coupled with the infection at the level of the teeth, is the cause of the porosity in the mandibular region Enamel hypoplasia: one hypoplastic line on 33 and two hypoplastic lines on 32 (signs of stress or malnutrition during life) Hypercementosis: none 14. Site & ID Begho BG’21-A 73.118 (Bg. 70, A) MNI 1 Age 6 years Sex Undeterminable Dental pathologies None 15. Site & ID Ntereso NT’18-73.90 6 Ethics, Medicine and Public Health 30 (2023) 100931 Table 1 (Continued) MNI 1 Age Adult Sex Undeterminable Dental pathologies Calculus: unobservable Caries: unobservable on teeth in occlusion but absent on isolated teeth Abscess: none Enamel hypoplasia: none Hypercementosis: none 16. Site & ID Ntereso NT’18-73.91 MNI 1 Age Adult Sex Undeterminable Dental pathologies Calculus: minimal (stage 1) on possible 35, 43, and un-sided incisors and premolars. Medium (stage 2) on possible 33, 42, 45, 47, and 48. Large (stage 3) on possible 31, 41 Caries: on the occlusal surface of 43 & 48 at the cemento-enamel junction of probable upper premolar, at the cemento-enamel junction of 47 of the interproximal aspect, and at the cemento-enamel junction of 23 & 33 Abscess: none observed Enamel hypoplasia: two hypoplastic lines on an un-sided upper premolar Hypercementosis: none 17. Site & ID Yapei YP’18-73.106 MNI 1 Age 34.7—41.1 based on the vault and lateral-anterior sutural composite scores 40—44 based on the auricular surface morphology Sex Female Dental pathologies Calculus: minimal (stage 1) on 43 & 44 Caries: on the occlusal surface and at the cemento-enamel junction of 17 Abscess: none observed Enamel hypoplasia: two hypoplastic lines on 43. Indicative of intra-vitam stress or malnutrition Hypercementosis: none 18. Site & ID Yapei YP’18-73.105 MNI 1/2 Age Significant wear on teeth in occlusion and alveoli resorption of 16-18 suggests middle-old adult 25—29 based on the assessment of (IN + PMP) and 25—40 based on (IN + PMP + TP), suggesting young-middle adult 40—44 According to auricular surface morphology Sex Female (based on the presence of the peri-auricular sulcus) Dental pathologies Calculus: minimal (stage 1) on 13 & 14. Medium (stage 2) on 15; and isolated M1 &M2: M1 = 1 and M2 = 2 Caries = mirror caries at the cemento-enamel junction of 14 & 15, and on an isolated un-sided M1 is a non-carious pit or pulp exposure on the lingual surface of the crown. The alveolar margin is extensively resorbed Abscess: at the buccal surface of 14 Enamel hypoplasia: one hypoplastic line on 14 & 15 and 2 hypoplastic lines on 13. Indicative of intra-vitam stress or malnutrition Hypercementosis: present on available teeth 19. Site & ID Yapei ID: foetus MNI 2/2 Age 36 weeks Sex Undeterminable Dental pathologies None 20. Site & ID Yapei YP’18-73.1027 P.S.N.O. Lamptey and P. Charlier Table 1 (Continued) MNI 1 Age Adult Sex Undeterminable Dental pathologies Unobservable 21. Site & ID Yikpabongo YK’21, Unit 1/C3-4 MNI 1 Age Adult? Sex Undeterminable Dental pathologies Unobservable Figure 2. Site prevalence of dental pathologies combined with the total prevalence of each dental pathology. Figure 3. The contribution of each dental pathology represented in each site. 8 Ethics, Medicine and Public Health 30 (2023) 100931 Figure 4. The number of individuals with no or combining multiple types (2+) of dental pathologies among 21 individuals. F of th r b a d c A b w [ M t s e a c t i f o c e t t a T a i f o v e igure 5. Frequency of dental pathologies juxtaposed by the sex egions in Ghana. Note that both caries and calculus are ctively linked to high carbohydrate intake [16]. Extensive aries at the interproximal region and CEJ result from plaque uild-up of/from non-abrasive diets at the respective areas 17], whereas less occlusal surface caries represent a rela- ively coarse diet [18]. In our study, occlusal surface caries were of minimal nd extensive expressions. However, the former was more han the latter. The diet composition of most Ghanaian oods is less coarse across all the regions, made from pro- essed grains/cereals like wheat, rice, maize, millet, and uber crops like cassava, yam, and plantain. Some dishes re also prepared from fermented carbohydrate-rich cere- ls and crops. This dietary orientation is not any different rom paleo-diets, with reference to the C4 plant protein p rientation of a mid-18th — early 19th -century Yapei indi- c idual from a 13 C isotopic value of —10.5%. Additionally, by xtension and via the trajectory of trade with a possible h 9 e individuals in the assemblage. lend of C3 plants including, rice, wheat, and barley, paleo- iets of the Ghanaian region may not have changed much. ccording to Dodd [19], cereals like rice, maize, oats, and heat are cariogenic foods, with wheat being the topmost. oreover, carious lesions are equated to the continued con- umption of fermentable carbohydrates [13,20]. This likely xplains the significant presence of interproximal and CEJ aries. Some studies have attributed high carious lesions n females to the increased peroxidase enzyme and other ral enzyme activities with the elevation in oestrogen lev- ls during pregnancy and menstruation [21—23]: notably, he late gestation phases [24] and before ovulation [25]. hese enzymes impact bacterial cells in the mouth, lead- ng to a decrease in oral pH, thus, lower than the critical H of enamel —5.5 [26]. This extremely acidic environment ontributes to enamel erosion and poor oral health. Furthermore, caries intensify under conditions of induced ydroxyapatite demineralization. For instance, unsaturated tey and P. Charlier s a t i c o s c fl e b o w t t s d e i a Figure 6. Maxilla of an adult (male?), Begho -BG’21-73.115 (Bg. b 70, E), displaying complete deterioration of teeth 24 & 26 by caries, m leading to subsequent damage of the alveoli and abscess at 26. Also, 3 note the abscess at 12. t a a m d b i C p [ a t t e t i c o [ p K t a r w t a r C a c t Figure 7. Mandible of an adult (male?), Begho -BG’21-73.115 (Bg. p 70, E), showing bilateral caries at 36 and 46 and mirror caries t m u  P.S.N.O. Lamp olutions (with pH below the 5.5 critical pH of enamel) such s gastric juice (< 2.0) [26] and fruits (juices) with pH less han 3 [27]. Dawes [27] adds that the extent of enamel dem- neralization is influenced by individual differences in the oncentrations of calcium, phosphate, and hydroxyl ions in ral solutions like saliva and plaque fluids. Given this, these olutions surrounding the teeth tend to be unsaturated and apable of dissolving the enamel. Although saliva and plaque uids are in themselves not threats to the teeth [3,26,27], xtensive calculus accumulation can increase the oral micro- iome and decrease the pH of these oral solutions. The low ral pH can then instigate demineralization. Therefore, it as not surprising that most of the individuals with medium o large calculus accumulation also had carious lesions on he same teeth or elsewhere in the mouth. For these rea- ons, sex dichotomy in caries expression can be attributed to ifferential levels of carbohydrate and acidic foods intake, strogen levels, oral pH, and the avulsion or evulsion of car- ous teeth [14]. Caries predispose individuals to abscesses nd hypercementosis (cementum hyperplasia). For instance, ilateral caries was identified in the mandible of an adult ale from Begho BG’21-73.115 (Bg. 70, E) at the level of 6 and 46 and mirror caries between 45 and 46. The infec- ion involves complete enamel and dentine demineralization nd root destruction at the initial stages. This individual lso presented bilateral abscess and resulting porosity in the andible at the level of caries. The expression of the former irectly links to the latter. Dental calculus results from the mineralization of uilt-up plaques at the gingiva/sub-gingival level and nterproximal regions of maxillary and mandibular teeth. alculus is an active ‘‘storehouse’’ for bacteria, fungi, com- ounds, minerals, as well as food and non-dietary debris 4,7,28—30]. Consequently, their extensive accumulation round the teeth of these individuals permits the predic- ion of dietary patterns and oral health/hygiene. According o Lieverse [31], dental plaques mineralize into calculus as arly as two weeks if not removed. The long-term decay of he debris releases a pungent smell or odor while decreas- ng the pH of the oral solution surrounding the teeth. Dental alculus, like caries, is a high correlate of the consumption f carbohydrate-rich foods. According to Lillie and Richards 32], high carbohydrate and low protein diets increase laque accumulation without proper oral hygiene. However, eenleyside [16] and Šlaus et al. [33] correlate high pro- ein and low carbohydrate intake to increased calculus. It ppears that both protein and carbohydrate play critical oles in caries and calculus manifestations (Figs. 6—7). The 13C and 15 N isotopic values of a Yapei middle adult ere —10.5‰ and 8.8‰ indicative of a high dietary pro- ein orientation to C4 plants like maize, groundnut, beans, nd animal protein from fish (riverine resources) and ter- estrial animals such as sheep, cattle, and chicken. This 4 plant characterization is not exclusive to Yapei; it cuts cross the regions with a high dependence rate on typical arbohydrate-rich food crops dangling across the country via he trade chain. Since Yapei and Ntereso are geographically roximate with similar environmental conditions and subsis- ence patterns, it is anticipated that the Ntereso individuals between 45 and 46. The infections translated into abscesses: sin- ay have similar  13C and  15N values. The Sekondi individ- gle lingual and buccal perforation at 35 and double buccal drainage als, however, would have presented much higher  13C and channels at 45 (at the level of the mental foramen). The porosity 15n values for their dependence on marine resources from at the respective regions results from the two DPs. 10 lic Health 30 (2023) 100931 t t a v e s p r o a t t u r o N m a t fi G a i i r o t Figure 8. Mid-18th — early 19th Century middle adult female t from Yapei (YP’18-73.105) with mirror caries at CEJ and root of b 14 and 15. Additionally, an abscess at the buccal surface of 14, one c h I i o v d w h F l f o a r a r d t w t a i s [ i E i p e r e t t a [ c A b s a i p v a h t o e e p d i Y e e a Ethics, Medicine and Pub he sea and food crops from the suburbs that rushed into he community. Comparatively, the individuals from Begho nd Yikpabongo may have had analogous  13C and  15 n alues, and any variance be associated with regional differ- ntial adaptations, individual preferences, and intermittent carcity of food resources. Furthermore, Posnansky (2004, p. 39—40), noted that Begho inhabitants had a protein- ich diet; an individual animal (domesticated) protein intake f at least 250 g per week, likely to increase in seasons of bundant game resources. The 13 C and 15N isotope revela- ion of the dietary pattern of the Yapei individual enabled he reconstruction of the dietary orientation of the individ- als from the Savannah region to C4 plants in addition to iverine and terrestrial animal protein. By inference, the rientation of the individuals from the Western, Bono, and ortheast regions may be a combination of C3, C4 plants, arine, riverine, and lacustrine resources plus terrestrial nimal protein. Oral accounts agree with this dietary orientation, in hat carbohydrate-rich foods (cereals and tuber crops) and sh, both riverine and lacustrine, are major components of hanaian diets cross-regionally. For instance, the banana, carbohydrate-rich fruit [34] is cultivated on a large scale n Ghana, although not indigenous to the sub-region. Due to ts high carbohydrate content, increased consumption can esult in massive plaque build-up in the absence of proper ral hygiene. Moreover, Barbara Teßmann’s examination of artar from 110 19th-century Musila skulls revealed that he build-up resulted from the extensive consumption of ananas and meat (local conference presentation). Sugar- ane is also not an exception across the Ghanaian regions. n addition to high sugar and carbohydrate intake and poor ral hygiene, Lieverse [31] notes that the composition of rinking water is another source of calculus formation from hich a tone of data (dietetics and health) can be gleaned. or example, through X-ray fluorescence analysis of calculus rom mandibular and maxillary teeth, two Begho individu- ls were found unexposed to industrial pollutants like lead, rsenic, antimony, or mercury [35]. As a reservoir of non- ietary debris such as (cotton) fiber [30], wood and other ork-related (mineral) debris [36], trapped vegetal fiber, nd quartz crystals [4], occupational or extra-masticatory tress on the teeth from the use of teeth as a 3rd hand for ndustrial activities can be inferred from dental calculus. xtensive calculus accumulation increases vulnerability to eriostitis/periapical lesions [37] from the increased bacte- ial activity around the teeth and in the mouth. Periapical lesions or abscesses; offshoots of pulpitis and he subsequent spread of bacteria to the apical region 8] constituted 9% of the dental pathologies recorded. bscess results from pathological conditions such as exten- ive caries, sub-gingival infections/inflammation, dental njury, and extreme dental wear [8,14]. Most of the indi- iduals that presented single or bilateral cases of abscess ad medium to extensive caries on the occlusal surface r the interproximal region, severe dental attrition, and namel hypoplasia or combined all, in addition to other ental pathologies. Particularly, a middle adult female from apei- YP’18-73.105 presented mirror caries at the cemento- E namel junction (with root extension) of 14 & 15 and s xtreme calculus accumulation (removed for XRF analysis u t the time of taking the photograph). The individual also h 11ypoplastic line on 14 & 15, and two hypoplastic lines on 13. There s also about 60% hypercementosis of the roots of 13 & 14. Lateral iew. ad an abscess at the buccal surface of 14, one hypoplastic ine on 14 & 15, significant wear, and two hypoplastic lines n 13, in addition to about 50% of hypercementosis of the oots of the teeth (Fig. 8). This individual must have expe- ienced ample intra-vitam stress. The functional strain on he teeth could be ascribed to severe dental wear (by mas- ication and non-masticatory means) and the exposure and nfection of the pulp via caries as closely linked variables 8,14]. Enamel hypoplasia or linear enamel hypoplasia (LEH) s an antiphon in pits and lines to developmental and nvironmental stress interrupting ameloblastic activity in namel formation [12]. A comparative analysis of den- al hypoplasia can infer dietetics and pathological stress mong populations [38,39]. Enamel hypoplasia is one of the hildhood stress markers that persist into adulthood [40] ecause teeth do not remodel after complete formation, part from mechanical alterations by mutilations (chip- ing and filing [8]), caries, and attrition from masticatory nd non-masticatory activities. Moreover, because hypoplas- ic lines or pits represent a stress-informed deficiency in namel development, it can be observed in deciduous and ermanent teeth of individuals who experienced signif- cant stress at the initial stages of teeth development. namel hypoplasia can aid the reconstruction of intra-vitam tress or malnutrition that disrupted growth in past pop- lations [12,41]. The relatively high expression of enamel ypoplasia in the individuals from Begho, Ntereso, and tey a Y C T n F t r e d a e T r t G b p p a n n r t o a f b a i s e t [ e i r a i p n d c a r w e w c a o t m H a c g a d d h r r I t t p a c t 3 o s o c i r s d a f a t ( G m o s f l s A D t a T d O m R [ t m c g t t m P.S.N.O. Lamp apei posits significant nutritional/environmental stress. hat said, 20th-century groups might have experienced utritional stress partly from the inadequate supply of nutri- ional needs during the 1983 famine in Ghana, and its ffect might be reflected by the presence of harris lines nd hypoplastic lines/pits in their long bones and teeth. he absence of hypoplastic lines or pits on an adult denti- ion implies only a partial exclusion of developmental stress ecause the lack of lesions is not the absence of a stress hase. In contrast, its presence in adult dentition may not ecessarily mean the prolongation of the stress factor but ather a childhood acquisition at the developmental stages f the permanent crowns in the alveolar. Some scholars have proposed multi-etiologies to LEH y linking it to various developmental disturbances at the ndividual or population level. From pre and neonatal to arly childhood, especially after weaning — seven years 41,42], stress-related local and systemic events compris- ng deficient diet, malnutrition, infectious diseases, genetic nomalies, and congenital defects such as amelogenesis mperfecta. Additionally, neonatal disturbances such as eonatal hemolytic anaemia, premature birth, hypocal- aemia (the cause of postnatal hypoplasias), maternal ubella, and diabetes [41,43]. Due to these links, which are qually stressors on growth and development, no one cause an be associated with our remains but the acknowledgment f general stress among the individuals. Lastly, hypercementosis was recorded in the assemblage. ypercementosis or cementum hyperplasia is a condition haracterized by the thickening (more prominent than aver- ge) of the tooth root and canal due to the abnormal eposition of cement [44,45]. It is considered an acute esponse to infections like caries and periodontal diseases. rrespective of high caries (30%) and abscesses (9%) in he assemblage, hypercementosis represented only 7% of vailable teeth (with the exception of unexposed roots of eeth in occlusion). This suggests a multifactorial cause f hypercementosis, for example, an external involvement f the teeth within the different environments, includ- ng as a third hand. As gathered from the ethnographic tudy in the various communities of Sekondi, Begho, Yapei, nd Ntereso, (paleo) activities such as fish net mending nd basketry sometimes involve the industrial use of teeth the anterior and first premolar) as a third hand to rip raw aterials and supporting elements. This may have posed ignificant stress on the teeth roots of these past popu- ations. The contemporary inhabitants are at risk of the ame or similar threats due to the continuity in practice. lthough this pathology can be related to teeth func- ion (masticatory and non-masticatory activities), Thoma nd Goldman [46] noted that even non-erupted teeth can evelop cementum hyperplasia owing to genetic factors. ther sources of hypercementosis are inflammation, for- ation of spicules and continuous eruption of the tooth 46], bacterial colonization of teeth [45], and alveolar rauma causing root fracture [47]. In these cases, develop- ental, nutritional, environmental, and occupational stress an be attributed to hypercementosis. As a consequence, eneralized hypercementosis may impact the alveoli and eeth function as well as the effectiveness of tooth root ranslucency for age estimation in anthropological assess- ents. 12nd P. Charlier onclusion rom a nuanced perspective, the dental pathologies ecorded and examined from the study samples are inter- ependent in occurrence and rate of expression. The xpression rate of the dental pathologies significantly eflects compromised oral health and stress among the past hanaian ancestors. We establish a high correlation between athognomic carbohydrate proxies like caries and calculus nd the dietary pattern of the past populations, which is ot vastly different from that of the contemporary popula- ion. For an agrarian country like Ghana, its population is ccustomed to cereals and tuber crops, consumed in dried, resh, and fermented stages and supplemented by animal nd fish proteins. Therefore, high caries and calculus expres- ion among these Ghanaian ancestors stem largely from he dietary composition, while offshoots such as abscess, namel hypoplasia, and cementum hyperplasia may be more elated to function and developmental stress on the teeth. The oral health of the individuals was somewhat com- romised by the expression rate of the dental pathologies iscussed above. Comparing standards of oral hygiene mong past and present populations may be unfair, but hat is certain is that care and access to dental services ere not the same as today. Concerns may have been the vailability of services and public education on the impor- ance of dental care. Additionally, socioeconomic status ay have impacted the quality of one’s oral health: care, nd hygiene. Some factors that aggravate dental patholo- ies and consequently compromise individual health include iet/nutrition, functional stress on teeth, and poor oral ygiene. Currently, the culture of regular dental care in the ural sectors could be improved by ample education on con- rols for DPs such as balanced diets, early treatment, and reventive measures. 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