Dental health of elderly confederate veterans Evidence from the Texas State Cemetery.код для вставкиСкачать
AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 124:59 –72 (2004) Dental Health of Elderly Confederate Veterans: Evidence From the Texas State Cemetery Helen Danzeiser Wols* and Joan E. Baker U.S. Army Central Identiﬁcation Laboratory, Hawaii, Hickam Air Force Base, Hawaii 96853-5530 KEY WORDS abscess paleopathology; Civil War; hypoplasia; caries; antemortem tooth loss; dental ABSTRACT Analysis of the skeletal remains of 50 Confederate veterans provided a unique opportunity to explore the dental health of a geriatric sample. These men, who died between 1907–1932, had an average age at death of 76.7 years. Ninety percent were institutionalized at the Confederate Home for Men (Austin, TX) prior to their deaths. This elderly sample was assessed in terms of caries, antemortem tooth loss (AMTL), abscesses, and linear enamel hypoplasias. On a per tooth basis, the AMTL rate was 57.2%. Of 39 dentate men, 33 (84.6%) had dental caries, and 24.4% (121 of 496) of teeth were carious. Ten (25.0%) of the dentate men had hypoplastic teeth. At least one abscess was seen in 14 (28%) of 50 individuals. Results from this geriatric institutionalized sample are compared to contemporaneous historical samples. Disparities in dental health among these groups may be due to differences in average age at death, and these comparisons allow a better understanding of dental changes that occur with age. The sample is also compared to modern elderly samples: modern groups have higher caries rates, possibly because they retained more teeth. This ﬁnding may be due in part to diets in the United States becoming increasingly cariogenic over time. In addition, dental care has moved from the reactive practices seen in the nineteenth and early twentieth centuries (such as tooth extractions) to modern proactive solutions dedicated to preserving and restoring teeth (such as tooth brushing, ﬂuoride treatments, and dental ﬁllings). Am J Phys Anthropol 124: 59 –72, 2004. © 2004 Wiley-Liss, Inc. Recent studies show that institutionalized elderly people have poorer dental health than that of the independent elderly (Loesche et al., 1995; Vigild, 1989; Weyant et al., 1993). In general, institutionalized elderly have higher rates of edentulism, caries, and other oral/dental conditions. Poor dental health has a negative impact on the aged in terms of chewing difﬁculties that can result in nutritional deﬁciencies, weight loss, speech difﬁculties, and low self-esteem (Banting, 1973; Garcia, 1995; Loesche et al., 1995). Although the dentition of elderly people, institutionalized and independent, has been welldocumented in modern medical literature, archaeological samples with a large sample of elderly people are rare. Because of this, it has not been possible to assess and compare dental health of past and present elderly populations, nor to assess dental health of the elderly from a historical perspective. The goal of this paper is to describe the dental health of a historical geriatric population, an opportunity provided by the excavation and analysis of a sample of 50 Confederate veterans, all of whom were over age 60 years at time of death. Furthermore, almost all of the veterans (90%) were institutionalized in the Confederate Home for Men (CHM) for some period of time prior to death, providing insights into historical institutionalized populations. In an effort to characterize the dental health of this population, the veterans are compared to a number of groups with similar demographic and/or social characteristics, including modern institutionalized elderly, historical institutionalized populations, and eighteenth and nineteenth century soldiers. Due to improvements in preventive and corrective dentistry over the last 100 years, modern institutionalized populations are expected to have lower rates of dental pathology than historical ones. In contrast, contemporaneous historical institutionalized populations are expected to have similar rates of dental pathology, due to similar life circumstances. However, most of the dental disorders (i.e., antemortem tooth loss, dental caries, and abscesses) examined in this study are expected to be age-cumulative, so samples with greater average ages at death are anticipated to have higher rates of dental disease. Likewise, groups of soldiers from the same time © 2004 WILEY-LISS, INC. Grant sponsor: Prewitt and Associates, Inc. *Correspondence to: Helen Danzeiser Wols, U.S. Army Central Identiﬁcation Laboratory, Hawaii, 310 Worchester Ave., Hickam Air Force Base, HI 96853-5530. E-mail: firstname.lastname@example.org Received 16 August 2002; accepted 22 March 2003 DOI 10.1002/ajpa.10334 Published online 11 August 2003 in Wiley InterScience (www. interscience.wiley.com). 60 H.D. WOLS AND J.E. BAKER TABLE 1. Summary historical data for Confederate veterans in TSC sample Range Low High Average 1 Year of birth Year of move to Texas Age at death Age when moved to Texas Length of time in Texas in years Age at beginning of Civil War Length of time spent in CHM (in months) 1814 1847 1836 1902 60.0 95.0 76.7 1.01 71.0 25.9 5 88 51 14.0 47.0 26.6 1.0 232.0 57.2 Excluding native Texans. period might be expected to have comparable rates of dental pathology due to shared experiences (i.e., military service), barring differences in average ages at death. MATERIALS AND METHODS In 1886, the CHM was established in Austin, Texas, by a group of veterans who were responsible for maintaining the facility until the State of Texas took over in 1893 (Barkley, 1963). Initially, 16 acres of land were purchased to build the CHM; disabled and dependent veterans of the Confederate States Army began to use the home in 1891. Eventually, 10 additional acres of land were purchased, and a hospital was constructed (Barkley, 1963; Webb, 1952). One man who stayed at the CHM described it as follows: “Now, as for the Confederate Home it is like h–’s half acre [sic]. It needs enlarging. It is on a beautiful hill; was made for honorable soldiers to rest in their declining days, who had no place to stay. . . It is looked on by the public as a place of peace. . . far from that. . . it is not the place it ought to be by any means. . .” (Gautier, 1902, p. 53). In reference to the burials provided by the CHM for veterans, however, he wrote, “You are buried neatly and nicely and in a beautiful place: a nice monument to each grave, your home and age, residence, everything in ﬁrst class order” (Gautier, 1902, p. 53). The place of which he spoke is the Texas State Cemetery (TSC), located near downtown Austin and still in use today. The TSC is a burial ground for the interment of members/former members (and their spouses) of the Texas legislature, elected state ofﬁcials, some appointed state ofﬁcials, and Confederate veterans (Dockall et al., 1996). The ﬁrst interment occurred in 1851, and the cemetery continues to be used. In summer 1995, the State Cemetery underwent a multimillion-dollar renovation. As part of this renovation, an archaeological consulting ﬁrm was hired to relocate 57 graves to another location within the cemetery; 50 of these contained the remains of Confederate veterans. The graves were marked with headstones documenting, minimally, name, regiment, date of death, and age at death. Therefore, age at death for these Confederate veterans, with one exception, is known. These Civil War survivors varied in age from 60 –95 years old, with an average age at death of 76.7 years (Dockall and Baker, 1996; Table 1). Most of the men (44%) comprising this Fig. 1. 50). Age composition of Confederate veterans at TSC (N ⫽ sample were in their seventies when they died (Fig. 1). Prior to their deaths, the majority (90%) had been residents of the CHM in Austin and, as such, were wards of the State of Texas for some period during their last few years of life. Indeed, the average length of stay at the Confederate Home was 4.76 years, with a range from 1 month to 19 years (Table 1, Fig. 2). Most of the men died in 1907 or 1908, but a few survived until the 1930s. Despite the fact that all of the men died in Texas, only three were born and raised in the state. The rest, with two exceptions, were from other parts of the South. Those who immigrated from elsewhere lived in Texas for varied lengths of time, from 5– 88 years, with an average of 51 years (Table 1). In terms of the men’s shared history of ﬁghting in the Civil War, their average age at the beginning of the war was 26.6 years, with a range from 14 – 47 years (Table 1). Due to time constraints imposed by projected completion dates for cemetery renovations, analysis was limited to approximately 5 hr per individual. The remains were assessed using standard metric and nonmetric techniques (Buikstra and Ubelaker, 1994). Because age and sex were known, demographic information came from headstones and other archival information. Due to ﬁnancial, logistical, and temporal constraints, analyses of dental pathology were limited to macroscopic examination of teeth and supporting skeletal elements. Evidence for the dental health and dental care of Confederate veterans at the turn of the century was determined through analyses of linear enamel hypoplasias, caries, abscesses, and antemortem tooth loss. Taken together, these dental pathologies pro- DENTAL HEALTH OF ELDERLY CONFEDERATE VETERANS 61 For comparative purposes, the dental disorders described here are presented using a tooth-count method, as well as on a per individual basis. When appropriate and comparable data are available, the results from Confederate veterans at the TSC are compared with other historical archaeological samples (Table 2), as well as modern samples. RESULTS Linear enamel hypoplasias Fig. 2. Length of stay at CHM (N ⫽ 45). vide data on diet, disease, childhood stress, dental hygiene, and historic dental practices. Linear enamel hypoplasias (LEH) are nonspeciﬁc indicators of stress occurring during childhood, forming from 5 months in utero to age 7 years and then from approximately 10 –16 years (Goodman et al., 1984; Skinner and Goodman, 1992). The number of hypoplastic events per tooth was recorded. Only enamel hypoplasias of a linear type (characterized as type 4; Goodman and Rose, 1990) were recorded for these individuals, and all teeth not obscured by adhering dental calculus were examined for hypoplasias. In order to be coded as a hypoplastic defect, the deﬁciency had to be apparent without the use of any magniﬁcation (Goodman and Rose, 1990). Carious lesions result from an infectious disease process that results in localized demineralization of enamel and/or dentin. Carbohydrate level in the diet plays a large role in carious lesion frequency, since high-carbohydrate foods raise bacterial activity, which in turn increases production of organic acids (Larsen, 1997, p. 65; Powell, 1985, p. 313; Hillson, 1996). Early stages of caries development are characterized by opaque areas in the enamel, and later stages appear as rough areas (Hillson, 1996). Because of the difﬁculty of assessing these opacities in archaeological samples, only those caries in a later state of development (i.e., pits) were identiﬁed as carious lesions for this study. The locations, types, and sizes of carious lesions were recorded on all observable teeth. Following Lukacs (1989), a probe was used when recording small caries, to insure that normal pits were not coded as carious lesions. Dental abscesses result from dental caries or from extreme dental wear that allows exposure and subsequent infection of the pulp chamber. Dental abscesses were coded according to type (i.e., cervical or periapical), location, and size. Because taphonomic processes can easily damage the thin, fragile structure of alveolar bone, care was taken to ensure that only lesions with smooth, rounded edges were coded as abscesses. Antemortem tooth loss (AMTL) can occur for a variety of reasons, including extreme dental wear, severe alveolar resorption, caries, and abscesses (Lukacs, 1989). Locations of AMTL were recorded when the alveolus was partially or fully resorbed. Ten of 39 dentate men (25.6%) had at least one tooth with a hypoplasia. Seven men (17.9%) had three or fewer teeth with LEH, while three (7.7%) had six or more teeth with hypoplasias. Of 450 teeth that could be coded for LEH, 37 (8.2%) had at least one hypoplastic line. Of teeth with LEH, the majority had two hypoplastic lines (54.1%), followed by one line (27.0%). Five teeth (13.5%) had three LEH, while two teeth (5.4%) had four lines. Incisors and canines were the only teeth to display three or more hypoplastic events. In terms of observed LEH per tooth type at the TSC, prevalence ranged from a low of 0% of maxillary premolars and molars to a high of 18.2% of maxillary canines (Table 3). As expected, incisors and canines had the highest prevalence. Caries Of 39 men with teeth that could be coded for carious lesions, 33 (84.6%) showed at least one occurrence. Using a tooth-count method, 24.4% (or 121 of 496) of the Confederate veterans’ teeth had carious lesions. While only 121 carious teeth were recorded, there was a total of 140 carious lesions, since some teeth had as many as three lesions. Each tooth type bore evidence of caries, with rates of occurrence varying from a low of 8.8% of mandibular premolars to a high of 38.8% of maxillary molars (Table 3). In general, maxillary teeth were more likely to have lesions than mandibular teeth. Not surprisingly, given their more complex morphology, molars were the most common teeth to have carious lesions (Powell, 1985). The mean number of carious lesions per mouth was 3.5,1 suggestive of a high-carbohydrate diet (Rose et al., 1984). The majority of carious lesions were located on the mesial and distal cervical margins (30.7%), followed by the interproximal margins of the crowns (25.0%). Almost 13% of carious lesions were occlusal in nature, while 9.3% were buccal and 4.3% were lingual. Nearly 18% of carious lesions were too large to make an assessment as to their point of origin. Four of the 50 men (8%) had dental ﬁllings. Of the 121 carious teeth observed in these elderly Confederate veterans, only four teeth had dental ﬁllings (3.3%). Three of the ﬁllings were of a possible dental amalgam, while one was gold. Of the four teeth with 1 This ﬁgure is based on dentate people; when all people are considered, the rate of dental caries per mouth drops to 2.8. 62 H.D. WOLS AND J.E. BAKER TABLE 2. Comparative historical bioarchaeological samples Sample N Date Reference Average age at death (in years) TSC Fort Laurens Colonial–Civil War Snake Hill–War of 1812 Indian Wars Civil War Glorieta Pass Little Bighorn Belleville Rural Texas Belleview Plantation Weir family Monroe County poorhouse 501 211,2 291 261 141 491 301 91 229 16 31 20 296 891 102 40 1907–1932 1779 1675–1879 1812–1814 1870–1899 1861–1865 1862 1876 1821–1874 1850–1880 ⬃1738–1760s 1830s–1907 1826–1863 1826–1863 1860–1895 1880–1900 Dockall et al., 1996 Sciulli and Gramly, 1989; Sledzik and Sandberg, 2002 Angel, 1976 Sledzik and Moore-Jansen, 1991 Sledzik and Moore-Jansen, 1991 Sledzik and Moore-Jansen, 1991 Sledzik and Sandberg, 2002 Sledzik and Sandberg, 2002 Saunders et al., 1997 Winchell et al., 1995 Rathbun and Scurry, 1991 Little et al., 1992 Lanphear, 1988 Sutter, 1995 Phillips, 2001 Phillips, 2001 76.7 23.52 39.6 21.6 33.6 27.1 23.5 27.4 42.5 ⬍30.0 30.3 40.0 nd 35.1 nd nd Oneida County asylum Albany almshouse 1 2 Males only. According to Sledzik and Sandberg (2002), N ⫽ 19 and average age at death ⫽ 23.9 years. TABLE 3. Frequency of dental pathologies per tooth type in elderly Confederate veterans LEH Maxillary Incisors Canines Premolars Molars Subtotal Mandibular Incisors Canines Premolars Molars Subtotal Total Caries Abscesses % affected N % affected N % affected 16.7 18.2 0.0 0.0 7.4 54 33 52 63 202 24.2 22.5 23.8 38.8 28.6 66 40 58 67 231 1.3 3.7 2.0 1.3 1.8 15.5 13.2 3.9 2.1 8.9 8.2 71 53 76 48 248 450 22.4 25.5 8.8 31.5 20.8 24.4 76 55 80 54 265 496 1.0 1.9 0.5 1.3 1.1 1.4 ﬁllings, three were third molars, and one was a ﬁrst molar. In discussing caries, we focus strictly on the number of observable teeth with lesions. However, calculation of a decayed-and-missing index allows an evaluation of the total caries rate in a sample determined by including information pertaining to observable carious lesions and to antemortem tooth loss (Kelley et al., 1991). This index assumes that all teeth lost prior to death were lost due to caries, rather than extreme dental wear, local trauma to the tooth, or severe periodontal disease. When this index is applied to the TSC data, results show that as many as 48% of teeth may have had caries, as opposed to 24.4% based only on observable teeth. Abscesses At least one dental abscess was noted in 14 of the 50 males (28.0%), yielding a total of 19 abscesses. Of 1,366 observable dental sockets, only 1.4% (n ⫽ 19) showed evidence of abscesses (Table 3). Of these, 11 were periapical, and the rest were alveolar (cervical). Compared to rates of other dental disorders, these rates are low, varying from less than 1% of mandibular premolars to 3.7% of maxillary canines. AMTL N % affected N 160 81 150 157 548 50.0 45.5 54.1 54.8 51.8 154 77 135 157 523 204 104 209 301 818 1,366 49.5 37.5 56.2 80.8 61.0 57.2 192 96 194 271 753 1276 This low abscess rate was unexpected, given the high average age of individuals in this sample and the high caries rate. The low abscess prevalence, however, suggests that teeth were extracted prior to pulp exposure and infection. It is also possible that some abscessed teeth were lost long before death, and the surrounding alveolus remodeled to the extent that no visible signs of abscessing remained at the time of an individual’s death. Antemortem tooth loss High rates of AMTL were observed in these Confederate veterans, as expected given the age-cumulative nature of tooth loss and the advanced age of people in this sample. Eleven men (22.0%) exhibited AMTL in all observable alveoli; three men were buried with dentures. An additional seven veterans had lost between 75–99% of all observable teeth prior to death, while half had lost more than 50% of their teeth. Only two men (4%) did not display any AMTL (based on observable alveoli). AMTL calculated on a tooth-count basis shows a high rate of 57.2%. An average of 10.9 teeth were retained per mouth (i.e., an average of 14.6 teeth were lost per mouth). When determined by tooth type, AMTL varied from a low 63 DENTAL HEALTH OF ELDERLY CONFEDERATE VETERANS TABLE 4. Antemortem tooth loss by age categories1 Totals 0% 1–24% 25–49% 50–74% 75–99% 100% Age in years No. % No. % No. % No. % No. % No. % No. % 60–69 70–79 Subtotal (60–79) 80–89 90–99 Subtotal (80–99) Unknown Totals 11 22 33 11 5 16 1 50 22 44 66 22 10 32 2 100 0 1 1 0 1 1 0 2 0 2 2 0 2 2 0 4 3 6 9 1 1 2 0 11 6 12 18 2 2 4 0 22 3 6 9 2 1 3 0 12 6 12 18 4 2 6 0 24 2 5 7 0 0 0 0 7 4 10 14 0 0 0 0 14 1 3 4 3 0 3 0 7 2 6 8 3 0 6 0 14 2 1 3 5 2 7 1 11 4 2 6 10 4 14 2 22 Percentages shown were calculated as percent of total sample (N ⫽ 50). Category headings represent proportion of teeth lost (i.e., 100% category includes edentulous people, while 0% category includes people who retained all of their natural teeth). of 37.5% of the mandibular canines to a high of 80.8% of the mandibular molars (Table 3). When maxillary and mandibular dentitions were combined so that AMTL was calculated based on the number of observable dental sockets per tooth type, the canines showed the lowest percentage of AMTL (41.0%), while the molars had the highest rate (71.3%). When AMTL is examined by age, several signiﬁcant patterns emerge (Table 4). Complete edentulism (AMTL of all teeth in observable alveoli) occurs in all age categories. However, it is most common among 80 – 89 year olds, at 10% of the total sample. Because the number of individuals in each 10-year age category is so small, age-cumulative patterns of AMTL are more clearly seen when the data are viewed in terms of two 20-year age groups (60 –79 years and 80 –99 years; Table 4). Edentulism is the most common state among 80 –99 year olds, with 7 of 16 men (44%) in this age group experiencing 100% AMTL. Retention of all teeth in observable alveoli (0% AMTL) occurs in both age categories. When viewed as a percentage of the total sample, completely edentulous 80 –99 year olds represent 14% of the total sample (7 of 50 men), while edentulous 60 –79 year olds make up only 6% of the total sample (3 of 50 men). In this study, men in the older age category were more than twice as likely to have lost all their teeth when compared to the younger men. From the opposite perspective, younger individuals (60 –79 years old) were four and a half times more likely (18%, or nine individuals) to have retained more than 75% of their teeth, as opposed to the older group (4%, or two individuals). Given the advanced age of the men in this sample, it is not surprising that 50% of the Confederate veterans experienced AMTL of more than half their teeth. DISCUSSION Comparison with archaeological samples The LEH rate of Confederate veterans excavated from the TSC (25.6% of dentate men) is lower than that observed in other historical samples. The rate is signiﬁcantly lower than the rate of 73% of indigent people at the Monroe County Institutional Cemetery (Lanphear, 1988, Table 43), and is also lower than 56% of adults from a mid- to late 1800s rural cemetery in Texas (Winchell et al., 1995). Based on LEH rates, it would appear that these Confederate veterans were relatively healthy as children. This difference suggests that they did not represent a stressed or socially marginal subset of the population, as seen in the study by Lanphear (1988) of the Monroe County Poorhouse sample in New York. Because the men shared the commonalities of having fought in the Civil War and having been institutionalized at the CHM, it is tempting to assume that all had similar backgrounds of rural childhoods in Texas. However, only three men (6%) in this sample were born and raised in Texas. Most spent their growing years in other regions, and moved to Texas relatively late in life. It is possible that the relatively low rate of LEH observed in this elderly sample is an artifact of the high AMTL rate, such that teeth displaying LEH were lost prior to death. Speciﬁcally, 49.7% of incisors and 41% of canines of these Confederate veterans were lost prior to death (as determined from data provided in Table 3; see also Dockall and Baker, 1996, Table 23). These teeth are the most likely to display episodes of LEH, but they are also single-rooted teeth and potentially more prone to loss; their absence could artiﬁcially lower the sample numbers. Table 5 documents the rate of carious lesions of the TSC Confederate veterans by tooth type, as compared to three historical U.S. military samples. The caries rates of the Confederate veterans are generally higher than the comparative samples. However, when the TSC Confederate veterans are compared to Civil War soldiers (a sample that includes both Union and Confederate war dead), the latter have higher rates of caries in their mandibular canines and molars, in spite of the fact that their average age at death (27.1 years) is much lower than that of the TSC Confederate veterans (Sledzik and MooreJansen, 1991). This disparity is presumably due to the age-cumulative nature of AMTL, in that many of the carious teeth of younger individuals would have been either naturally exfoliated or manually extracted had they lived to the ages achieved by the Confederate veterans. 64 H.D. WOLS AND J.E. BAKER TABLE 5. Frequency of dental pathologies per tooth type of elderly Confederate veterans and military samples TSC1 Civil War2,3 Maxillary Mandibular Maxillary 24.2 22.5 23.8 38.8 22.4 25.5 8.8 31.5 10.5 7.4 18.4 27.4 1.3 3.7 2.0 1.3 1.0 1.9 0.5 1.3 3.1 3.2 5.8 6.2 50.0 45.5 54.1 54.8 49.5 37.5 56.2 80.8 3.7 Caries Incisors Canines Premolars Molars Abscesses Incisors Canines Premolars Molars AMTL Incisors Canines Premolars Molars Snake Hill2,4 Mandibular Mandibular Maxillary Mandibular 10.1 5.1 13.2 23.3 2.2 3.3 26.5 5.5 6.7 13.9 30.2 18.4 1.2 1.1 1.8 5.0 4.5 6.8 5.8 11.1 14.8 13.0 2.3 21.4 7.2 2.5 3.7 11.5 4.1 21.2 7.7 3.7 9.3 31.2 3.1 13.6 28.6 43.3 5.3 13.0 Indian Wars2,5 Maxillary Average age at death ⫽ 76.7 years. Data from Sledzik and Moore-Jansen (1991, Table 5). 3 Average age at death ⫽ 27.1 years. 4 Average age at death ⫽ 21.6 years. 5 Average age at death ⫽ 33.6 years. 1 2 TABLE 6. Comparison of caries rates among historical archaeological samples Sample TSC Fort Laurens Glorieta Pass3 Little Bighorn3 Colonial-Civil War4 Belleville5 Rural Texas6 Monroe County poorhouse7 Monroe County poorhouse8 Belleview Plantation9 Oneida County asylum10 Albany almshouse Per mouth (no.) 3.51 3.91,2 2.41 5.63 1.45 2.7 1 Tooth count (%) 24.41 16.62,3 17.91 22.11 27.0 8.9 10.41 36.11 16.91 Average age at death 76.71 23.51,2 23.51 27.41 39.61 42.5 ⬍30.0 nd 35.11 30.3 nd nd 1 Males only. Scuilli and Gramly, 1989. 3 Sledzik and Sandberg, 2002. 4 Angel, 1976. 5 Saunders et al., 1997. 6 Winchell et al., 1995. 7 Lanphear, 1988. 8 Sutter, 1995. 9 Rathbun and Scurry, 1991. 10 Phillips, 2001. 2 Other discrepancies occur when caries are compared on a per-mouth basis to other archaeological samples (Table 6). The Confederate veterans have a caries rate that is relatively high compared to other historical archaeological samples, with the exception of the Belleville sample, which has the highest per-mouth caries rate of the comparative samples. It is possible that the Belleville sample has a high caries rate per mouth because their average age at death (42.5 years) is such that they may have developed the maximum number of caries possible before loss of the affected teeth due to related dental diseases (e.g., gingivitis, infection). Thus, as individuals age, caries incidence remains high, but the num- ber of retained teeth (particularly those affected with caries) decreases. This is reﬂected in the data by a somewhat lower number of carious lesions per mouth in older individuals. Analysis based on percent of carious lesions using a tooth-count method shows a high caries rate for the Confederate veteran sample, as well as for the nineteenth-century Canadian sample (Belleville; Table 6). The per-tooth caries rate for Confederate veterans, however, is lower than that of another long-term care facility, the Oneida County asylum, but higher than the Albany almshouse sample. This discrepancy is probably due to differences in length of residency at the various facilities. While the Confederate veterans lived in a government-run institution, most of them arrived when they were elderly and therefore were not long-term (i.e., lifetime) residents of the home. In contrast, residents of the Oneida County asylum usually arrived as young adults and stayed until their deaths, while residents of the Albany almshouse typically stayed for only a few days or weeks after having fallen on hard times (Phillips, 2001). The differences in caries rates in these samples may also be related to economic factors and the availability of dental care, since the TSC veterans probably had access to regular dental care prior to their admittance into the home, while individuals in the asylum did not (Phillips, 2001). Although the per-mouth rates of carious lesions are similar in the TSC and Fort Laurens samples, the per-tooth caries rate for the two samples differs. The per-tooth rate in the TSC sample (24.4% of teeth) is higher than that cited for the Fort Laurens sample (16.6%; Sledzik and Sandberg, 2002). Again, this difference is probably related to the age-cumulative nature of both caries and AMTL (cf. Saunders et al., 2002), i.e., the Confederate veterans had fewer teeth per mouth, and were more likely to have caries DENTAL HEALTH OF ELDERLY CONFEDERATE VETERANS in their remaining teeth than the younger Fort Laurens individuals. Dental ﬁllings in the TSC sample were rare, present in only 3.3% of carious teeth, and in only 8% of the men. All four ﬁllings were in the molars, and only one was gold. During the Civil War, gold was the most commonly used dental ﬁlling material, but tin ﬁllings were used when the lesion was especially large (Dammann, 1984). Amalgams were a more practical choice for Confederate soldiers, because they were inexpensive and easy to insert. The material composing the three nongold ﬁllings is unknown, but they may have been an amalgam, tin, or even thorium, all materials known to have been used to ﬁll cavities during the Civil War era (Bollet, 2002; Glenner et al., 1996). Sledzik and Moore-Jansen (1991) noted that of the U.S. military samples they examined (i.e., samples from the War of 1812, the Civil War, and the Indian Wars), the only examples of dental ﬁllings were observed in Civil War dentitions. They observed four individuals out of 49 Civil War cases (8.2%) with ﬁllings, accounting for 1.5% of carious teeth (Sledzik and Moore-Jansen, 1991, p. 218). The Weir family cemetery, a wealthy Anglo-American family cemetery in Virginia dating between the 1830s and 1907, had a high rate of dental ﬁllings (9.6% of teeth, 38.9% of individuals; Little et al., 1992). Over 50% of the carious lesions observed in that sample were ﬁlled with gold or gold and an amalgam (Little et al., 1992, p. 407). In the Belleville sample, dating from 1821–1874, 18 of 229 adults (7.9%) had dental restorations (Saunders et al., 1997, p. 80), but it is unclear what percentage of carious teeth was ﬁlled. At the Oneida asylum, 5 of 285 carious teeth (1.8%) had drilled holes; four of these were gold-ﬁlled, while the material used to ﬁll the ﬁfth could not be determined (Phillips, 2001, p. 91). These ﬁve ﬁllings came from three individuals, for a sample rate of 2.9% (3 of 102 people; Phillips, 2001, p. 105). Phillips (2001) suggested that the presence of gold ﬁllings in the Oneida sample was due to dental care received prior to institutionalization, and that they may have reﬂected the socioeconomic status of some of the residents and their families. The Albany almshouse sample had no evidence of dental care (Phillips, 2001, p. 91). Regardless of time period, when comparisons are made among the historical samples, they are consistent in terms of dental ﬁllings, with the exception of the wealthy Weir family. In general, it appears that relatively few people during the nineteenth century were able to afford ﬁllings, or perhaps any dental care at all. Compared to a military sample from Colonial-period Fort Laurens, the rate of abscesses at the TSC is lower. For example, elderly Confederate veterans had 0.38 abscesses per mouth vs. 1.7 abscesses per mouth among a sample of young soldiers from Fort Laurens (Sciulli and Gramly, 1989). However, this pattern does not hold true when the Confederate veterans are compared to other military samples, 65 based on percent of tooth type affected (Table 5). In general, the rate of abscesses in the maxillary dentition is lower in the older Confederate veterans, especially when compared to soldiers killed during the Indian Wars. Rates of mandibular abscesses observed in the Confederate veterans are very similar to rates observed in samples of much younger males killed in the Civil War, the War of 1812, and the Indian Wars (Sledzik and Moore-Jansen, 1991). In addition, the rate of abscesses per mouth seen in the Confederate veterans is lower than that observed in the skeletal sample of white males from the Colonial to Civil War period (1.9 abscesses per mouth; Angel, 1976). The seemingly lower rate of alveolar abscessing observed in the elderly Confederate sample may be the result of healing to the bone after an abscessed tooth had been extracted. Conversely, it may be the result of dental treatment in the form of extractions that occurred prior to infection of the pulp chamber and resultant bone loss. Table 5 displays AMTL rates by tooth type for Confederate veterans at the TSC and young nineteenth-century U.S. military men who were killed during the Battle of Snake Hill, the Indian Wars, or the Civil War. As expected, the AMTL rate is significantly higher in the Confederate veterans than in the soldiers killed in battle (Sledzik and MooreJansen, 1991). Similarly, compared to rates of tooth loss recorded in other archaeological samples, the overall AMTL rate of Confederate veterans at the TSC is much higher (AMTL of 14.6 teeth per mouth, or 57.2% of teeth; Table 7). Notably, the next highest AMTL rate (23.6% by tooth count) was documented in Belleville population, the sample with the next oldest age at death (42.5 years; Saunders et al., 1997). Much of the difference between the AMTL seen in the TSC sample vs. the others is probably explained by the markedly disparate age at death (see Table 2). Average age at death for these comparative samples ranged from 23.5 years (Fort Laurens and Glorieta Pass; Sciulli and Gramly, 1989; Sledzik and Sandberg, 2002) to 42.5 years for Belleville (Saunders et al., 1997), as compared to 76.7 years for the TSC sample. Comparison with modern samples The rate of dental caries in modern elderly samples is higher than that seen in the Confederate veterans from the TSC. Although 84.6% of dentate Confederate veterans had caries, a modern, living sample from Department of Veteran Affairs nursing home care units showed a higher caries rate of 93% (Weyant et al., 1993). Another study of institutionalized elderly documented a caries rate of 90% (Vigild, 1989, p. 104). In addition, 95% of a sample of noninstitutionalized seniors from Florida had at least one carious lesion (Heft and Gilbert, 1991). This difference may be related to the fact that modern elderly people have a higher number of teeth per mouth than the Confederate veterans (described 66 H.D. WOLS AND J.E. BAKER TABLE 7. Comparison of AMTL rates among historical archaeological samples Sample TSC Fort Laurens Belleville4 Belleview Plantation5 Colonial to Civil War6 Little Bighorn3 Glorieta Pass3 Snake Hill3 Average number of teeth lost per mouth Percent of teeth lost (tooth count method) Average age at death 14.61 0.91,2 6.65 8.01 6.91 57.21 4.11,3 23.6 76.71 23.51,2 42.5 30.3 39.61 27.41 23.51 21.61 7.31 2.21 8.81 1 Males only. Scuilli and Gramly, 1989. 3 Sledzik and Sandberg, 2002. 4 Saunders et al., 1997. 5 Rathbun and Scurry, 1991. 6 Angel, 1976. 2 later in text), as well as modern populations’ increasing intake of sugar and highly processed foods (cf. Saunders et al., 2002). However, some of the factors resulting in high dental caries in modern samples were probably also issues for Confederate veterans. For example, high caries rates and poor dental health in general may be due to physical and mental disabilities, ﬁnancial limitations, and lack of access to prior dental care (Kambhu et al., 1996; Vigild, 1989). While AMTL is higher at the TSC compared to archaeological samples, this trend is not maintained when the Confederate Home sample is compared to modern samples in terms of rates of edentulism. For example, the rate of edentulism at the TSC (22% of individuals) is lower than that documented at longterm care facilities of modern veterans (51.1%; Weyant et al., 1993). This sample, composed primarily of white males whose average age at death is 71.8 years, is demographically more similar to the TSC sample than any of the others. Another study of long-term care veterans documented an edentulism rate of 37% of individuals (Niessen and Weyant, 1989). Even noninstitutionalized modern samples have higher rates of edentulism than observed at the TSC. A survey of tooth loss in the elderly showed that 41% of modern patients are edentulous (Marcus et al., 1994). Edentulism rates in a rural Iowan sample (38.1%, males only; Hunt et al., 1985) and a Florida sample (28%, males only; Heft and Gilbert, 1991) are also higher than observed at the TSC. However, when the mean number of teeth per mouth is compared, rather than edentulism rates, modern samples of seniors exhibit a higher number of teeth per mouth, regardless of whether the people are institutionalized or not. One of the institutionalized comparative samples averaged 16.9 teeth per mouth (Niessen and Weyant, 1989), higher than the TSC’s rate of 10.9. The survey of seniors by Marcus et al. (1994) documented an average of 17.2 remaining teeth per mouth, while the study by Heft and Gilbert (1991) of Floridians showed an average of 17.0 teeth remaining. These disparities are almost certainly due to advances in and the relative affordability and availability of dental care in modern populations. Modern veterans generally have access to free or nearly free dental care. This may be one reason for the higher rate of edentulism in modern veterans; since they would have a higher degree of access to dentures as a form of dental treatment (although notably, several sets of dentures were recovered from the TSC), professional extractions may have contributed to the discrepancy between modern and Confederate veterans. In modern cases, dental extraction is sometimes suggested for problem teeth over “tooth-saving” options, especially when dealing with the institutionalized elderly (Kambhu et al., 1996, p. 23). At the same time, increased access to preventive dental care may account for the higher number of teeth per mouth for the modern elderly samples. That is, modern elderly people who do not undergo extractions for the purpose of ﬁtting dentures are more likely to retain more teeth than their early twentieth century counterparts, simply because of contemporary dental practices (e.g., toothbrushes, ﬂuoridated water). Diet, hygiene, and dental care in the Civil War through Postreconstruction eras The TSC Confederate veterans’ lives encompassed a relatively long period: the earliest date of birth was 1814, and the latest date of death was 1932 (Dockall et al., 1996, p. 53–56). These were turbulent years in the United States, with numerous political, economic, social, and scientiﬁc changes. It is difﬁcult to say how much inﬂuence any of these factors had on the health of these men, or which period of an individual’s life was the most important to his dental welfare. Below, particular emphasis is placed on Civil War-era and turn-of-the century lifestyles. Although the Civil War lasted only a few years (a relatively short period in the lives of these elderly veterans), service during the war was an experience common to all of them; therefore, it is important to discuss the quality of life during this DENTAL HEALTH OF ELDERLY CONFEDERATE VETERANS period and its potential impact on dental health. Another common life experience among all but ﬁve of the veterans was residency at the CHM. According to Confederate Home, burial, and pension records, the men in this study served in Army units from many states, including Alabama, Tennessee, Arkansas, Georgia, South Carolina, Mississippi, Missouri, Louisiana, and Virginia (Dockall et al., 1996). They lived in different economic and geographic settings for some periods of time; the majority of them lived in the Confederate Home for various lengths of time (mostly at the turn of the century). Diet. During the ﬁrst half of the nineteenth century, the Southern diet in general relied heavily on pork and corn; these were supplemented by wild game (Larkin, 1988; Silverthorne, 1986). Garden plots of vegetables were common among Texas residents and added variety to their diet (Lowe and Campbell, 1987). The early and mid-nineteenth century saw the addition of new key food crops to Texas agriculture, including sweet potatoes, peas, beans, potatoes, and rice (Campbell and Lowe, 1979; Larkin, 1988). Sugar and molasses were available to some rural families in Texas during the ﬁrst half of the nineteenth century, as sugar cane was planted in greater and greater quantities, peaking in the early 1850s (Silverthorne, 1986). Importantly, Larkin (1988) noted that sugar consumption skyrocketed during the nineteenth century. While they had been luxuries in the eighteenth century, reﬁned sugar and molasses became ubiquitous in the diet (Silverthorne, 1986). White breads and other foods made of white ﬂour also became popular (Larkin, 1988). During the Civil War, the soldiers’ diet varied little. Confederate soldiers relied on salted meats (pork, beef), in addition to cornmeal, rice, beans, potatoes, and ﬂour (Bollet, 2002; Chisolm, 1862; Cunningham, 1958). Fresh vegetables were occasionally foraged, purchased, or taken as spoils of war, and canned or tinned vegetables and fruits sometimes made their way to ﬁeld hospitals (Adams, 1952; Bollet, 2002; Cunningham, 1958). Generally speaking, the wartime diet relied heavily on carbohydrate-laden foods. Due to the poor diet consumed by most soldiers, scurvy was an ailment commonly seen by ﬁeld surgeons (Bollet, 2002; Cunningham, 1958). Civil War physicians were aware that scurvy caused tenderness and bleeding of the gums (with the latter contributing to tooth loss), night blindness, lethargy, and muscle and joint pain, and that it contributed to infections and mortality rates (Bollet, 2002). Signs of the condition usually arose after 2–3 months without vitamin C-rich foods (Bollet, 2002). Desiccated vegetables were provided to the soldiers expressly for their antiscorbutic properties; however, soldiers typically prepared them by boiling them extensively, probably destroying most of the vitamin C in the 67 process (Bollet, 2002). Although Confederate surgeons called for the addition of lime and lemon juice, fresh fruits, onions, sorghum, wine, and other vitamin C-rich foods to the soldiers’ rations, scurvy became more common toward the end of the war (Bollet, 2002; Chisolm, 1862; Cunningham, 1958). Interestingly, a geographic shift in diet occurred during the nineteenth century. In the early 1800s, rural populations were more well-nourished, due to their greater access to fresh foods. As the century wore on, industry and transportation made commercial products more widely available and increased urban access to fresh fruits and vegetables (Ross, 1993; cf. Saunders et al., 2002). Urban dwellers gained access to a wider variety of foods (Ross, 1993). This may have been a particularly important shift to the residents of the CHM, since 25 (50%) of these men listed their occupation as farmer, rancher, cattleman, or stockman (Dockall et al., 1996). This information implies a geographic move from rural areas during their younger days to an urban center (Austin, TX) in their later years, when they resided at the CHM. Presumably, a dietary change would have accompanied this geographical relocation. However, given the shift toward urban dwellers having a wider availability of food products, the impact of the move from rural to urban settings may have been mitigated. In turn-of-thecentury Austin, a wide variety of foods would have been available to residents of the city. An examination of the 1905 city directory reveals no fewer than 139 grocers, 30 meat markets, 25 dairies, 15 confectioners and fruit dealers, and 2 ﬁsh and oyster suppliers. While it might seem logical to assume that the variety of foods available to the veterans living at the CHM was limited due to state budgetary restrictions, there is some evidence to the contrary. In a letter written by Barton (1971) concerning his visits to the home between 1898 –1912, he noted that a variety of foods were served to the residents. He found the fruit served during meals particularly remarkable, since he wrote, “At home we had those fruits only at Xmas [sic].” For those residents with spending money, a concession stand at the Confederate Home offered soda water, confections, and tobacco products (Yearbook for Texas, 1901). Archival evidence for special events at the home also suggests a high-quality diet for the residents. For example, a notice in the Austin Evening News in April of 1894 made special note of a beef and mutton barbecue to be held for “the special beneﬁt of the inmates of the home.” Impact of diet on dental health. The ever-increasing reliance on reﬁned ﬂours and sugars undoubtedly had an effect on dental calculus and the caries rate among the veterans from the TSC. These dental ailments would have contributed greatly to AMTL, either through loss of teeth due to damaged 68 H.D. WOLS AND J.E. BAKER tissues or through dental extraction as a form of health intervention. However, calculus and caries are not the only causes of AMTL; other factors, such as trauma, infection, and vitamin insufﬁciencies, may have played a role. For example, one of the consequences of scurvy is tooth loss (Ortner and Putschar, 1985). Scurvy contributes to AMTL through the weakening of connective tissues, due to bleeding and inﬂammation. Single-rooted (i.e., anterior) teeth are particularly likely to be lost (Ortner and Putschar, 1985). The impact of scurvy on AMTL in the Civil War veterans described here is difﬁcult to determine, in part because medical records speciﬁc to the Confederate military are practically nonexistent. While scurvy was reportedly common during the war (Bollet, 2002; Chisolm, 1862; Cunningham, 1958), few subperiosteal hematomas were found in the TSC sample, and cribra orbitalia (now thought in some cases to be the result of scurvy; Ortner et al., 1999) was limited to two men. However, the potential role of scurvy in AMTL cannot be ignored, particularly in edentulous individuals. It seems likely that dental calculus and caries had a greater inﬂuence on AMTL among these men than scurvy. Diets high in sugars, carbohydrates, and milk proteins provide optimal nutrition for plaque bacteria, so high-carbohydrate diets such as those described above can contribute to dense deposits of plaque, which can further mineralize into calculus (Hillson, 1996). If these deposits are not removed through brushing or other mechanical methods as described below, they can lead to other dental diseases. The Confederate veterans of the TSC displayed numerous examples of calculus; of 39 men for whom this could be assessed, only eight (20.5%) showed no or minor calculus deposits. The rest of the men had teeth with either coalescent or three-dimensional calculus deposits (Dockall, 1996a). Interestingly, Leigh (1925; cited in Hillson, 1996, p. 267) found that populations relying on diets high in corn (such as the Southern diet described above) had the most signiﬁcant rates of alveolar bone loss. While periodontal disease and bone loss are in part related to carbohydrate consumption, sugar seems to the primary factor in the development of caries (Hillson, 1996, p. 282). The increasing availability and consumption of reﬁned sugar seen during the nineteenth century may have contributed to the high number of carious lesions seen in this sample. Hygiene. While toothbrushes and tooth powders were sold in country stores as early as 1820, few people apparently used them. While some people brushed their teeth regularly, many more did not, leading to a picture of “[h]undreds of thousands of Americans [with] at least some of their teeth badly rotted, a source of chronic pain and foul breath to many” (Larkin, 1988, p. 92). In the ﬁrst half of the nineteenth century, almanacs and etiquette manuals issued careful instructions about proper tooth- brushing while proclaiming the importance of the practice, with the implicit assumption that most readers were not in the habit of doing so (Larkin, 1988). Furthermore, modern ﬂuoride treatments, as administered in a dentist’s ofﬁce and as delivered in city water supplies, did not exist until the latter half of the twentieth century (Ring, 1985; Shafer et al., 1983). Hygiene, as well as diet, suffered in camps during the Civil War. Chisolm (1862) stated that all soldiers should carry a toothbrush; however, given that soldiers were often not required to wash their faces (even in stricter training camps; Adams, 1952), it would be surprising to learn that dental hygiene was superlative. For example, Cunningham (1958) described the poor dental health of the soldiers, and noted that toothbrushes were not commonly owned by the rank and ﬁle. Impact of hygiene on dental health. The idea that inadequate dental hygiene results in poor dental health is widely accepted among many modern industrialized populations. However, during the nineteenth century, this idea was new to many people. Dental hygiene, in the form of daily tooth brushing, may have been viewed by many as an eccentricity or an indulgence (Larkin, 1988, p. 93). Poor oral hygiene may cause a number of dental disorders. For example, subgingival plaque deposits may arise in individuals with poor dental hygiene, inﬂaming the gingiva and subsequently leading to periodontal disease (Hillson, 1996). Bone loss may result from repeated episodes of periodontitis, and loss of the tooth may eventually occur (Hillson, 1996). The aftermath of poor dental hygiene was seen among the veterans in the TSC sample to varying degrees, in the form of dental calculus, caries, abscesses, and AMTL. At least theoretically, modern additions to the dentists’ arsenal (such as ﬂuoride and regular toothbrushing) may have contributed to some of the discrepancies between this study and studies of modern veterans. Dental care. Preventive dentistry, aside from the toothbrush and tooth powder, consisted of the use of scalers or dental picks to remove dental calculus from the tooth surfaces (Dammann, 1988). Most dentistry at the time focused on reactive solutions to troublesome teeth (e.g., extractions, ﬁllings, or dentures). Prior to the Civil War, dental extraction was, in practice, the only solution for decaying teeth (Larkin, 1988). Extractions were accomplished using extraction keys during the early stages of the war, and forceps in the later part. In contrast to the pulling motion used with forceps, extraction elevators were sometimes used to pry teeth out of the alveolus. A special tool known as a screw elevator was employed after attempts at extraction failed to remove the roots along with the crown; this typically occurred when the extraction key was used. These tools were literally screwed into the roots of the tooth and used DENTAL HEALTH OF ELDERLY CONFEDERATE VETERANS to lift the broken roots out of the alveolus (Dammann, 1988). Roots left by incomplete tooth extractions, reportedly a common occurrence, could cause infections and other dental problems, such as abscesses (Bollet, 2002). Restorations or dental ﬁllings were made using tin or gold foil. Using excavators and ﬁnger drills, the soft carious part of the tooth was scraped out, and the margins were excavated to prepare the tooth for the ﬁlling. Small pieces of foil were then ﬁrmly pressed into the tooth with a plugger, layer by layer, until the cavity was ﬁlled. Once this was accomplished, small ﬁles and other burnishing tools were used to smooth the restoration (Dammann, 1988). During the mid-nineteenth century, full or partial dentures were available to those requiring them. From 1855 to the 1930s, vulcanized rubber was the best denture material produced, and was the primary material used in their manufacture (Bollet, 2002; Peyton, 1975). It was relatively inexpensive and easy to mold, and so became the standard in denture manufacture (Hagman, 1979; Peyton, 1975). While this material was the best available, there were some disadvantages to it, such as an inadequate aesthetic quality and varying color, taste, and odor (Peyton, 1975). Some 500 dentists were living in the Confederate States at the time of the war. A regular dental corps was never created in the Confederate Army, although dentists were conscripted and served in Confederate hospitals (Bollet, 2002; Cunningham, 1958). Their primary duties included ﬁllings, extractions, the removal of calculus, and treatment of facial injuries. Gold ﬁllings and even dentures were available for an often-astronomical price. Vulcanized rubber or gold-based upper dentures, for example, sold for $1,800 –$4,000 during the war (Cunningham, 1958). Dental extractions, while still costly, were more economically feasible than dental ﬁllings: “the cost of dental operations was more than the average soldier could pay. The charge for a gold ﬁlling, as currency inﬂation sets in, was $120 —more than 6 months’ pay of a private. At the same time dentists charged $20 to extract a tooth” (Cunningham, 1958, p. 243). These prohibitive costs almost certainly contributed to poor dental health, particularly among soldiers from families of modest means. Impact of dentistry on dental health. Glenner et al. (1996, p. 1676) noted that, “During the war, Confederate soldiers were in dire need of dental care because most had been in the service for several years without having had a dental examination. This neglect, coupled with improper diet and lack of toothbrushes, accelerated tooth loss.” The AMTL rate observed in the Confederate veteran sample can be partially explained by the statement of Glenner et al. (1996), but is compounded by loss associated with aging and increases in caries and alveolar resorption. Many problematic teeth may have been extracted rather than resorting to other, more costly 69 dental options. One modern study demonstrated that people of limited ﬁnancial needs were more likely to have teeth extracted, and that “many teeth may have been candidates for extraction . . . due to a belief in the inevitability of disease progression, especially in elderly or medically compromised populations who exhibited low utilization of dental services” (Niessen and Weyant, 1989, p. 21). It is possible that this practice was in effect at the CHM in early twentieth-century Austin, as well as before the men even entered the home. Generally speaking, dentistry as it was practiced in the nineteenth and early twentieth centuries was limited to a number of procedures that were regularly performed. Given the relative lack of preventative care at home, most of these procedures were reactive rather than proactive, and dealt with existing problems such as caries. While there was some direct evidence of dental care (e.g., dentures, ﬁllings) among the Confederate veterans in this sample, there was also indirect evidence for one of the most common procedures: extractions. In one individual, the crown of the fourth premolar was broken off, leaving the roots in situ (Dockall and Baker, 1996). The appearance of this tooth resembled the description by Dammann (1984) of root breakage occurring with the use of an extraction key, and brings to mind the assertion by Bollet (2002) that the roots were often left behind following extraction attempts. Additionally, the presence of dentures suggests deliberate extraction of teeth; even today, older people with few teeth or with diseased dental tissues (e.g., carious or badly fractured teeth, or severe periodontal disease) may have their remaining teeth pulled in order to facilitate the ﬁtting of dentures. In fact, this deliberate extraction of teeth to allow for the ﬁtting of dentures and other modern dental appliances may contribute to discrepancies in edentulism between modern veterans (e.g., Niessen and Weyant, 1989; Weyant et al., 1993) and the Civil War veterans in this sample. Although rates of AMTL and edentulism were high among the Confederate veterans excavated from the TSC, only three men had dentures, manufactured from vulcanized rubber and porcelain. Modern veterans may have greater access to professional dentistry and intervention (in the form of extraction and replacement of teeth with various appliances) than did their predecessors. Finally, the high rate of AMTL in the TSC sample may suggest dental intervention in the form of extraction; given the apparent availability of professional dental extractions (performed by dentists, country doctors, barbers, and others), the assumption that at least some of these teeth were extracted (rather than lost due to progression of dental disease) is reasonable. While several sets of dentures were recovered in this sample, these may not be representative of the number of individuals who actually wore dentures in life. Since dentures were recovered with three 70 H.D. WOLS AND J.E. BAKER Confederate veterans, the practice of burying people with their dental appliances was obviously not unheard of. Iserson (1994) noted that modern embalmers replace dentures in the mouth during the restoration process in order to retain a natural-looking mouth. However, it is not clear if this was a standard mortuary practice at the turn of the century, when most of these men were buried. If this was not the standard, the number of dentures recovered at the TSC may not be representative of the number of individuals who wore them in life. Wealth may have played a larger role in the use and subsequent recovery of dentures; one of the men with dentures was an attorney, one was a judge, and one was a salesman. Furthermore, two of these men did not die while in the CHM, and they were interred in a separate section of the cemetery. The style of their headstones, the casket hardware, and personal effects recovered during excavation indicate relatively greater wealth. The other set of dentures belonged to a man who had been buried by the CHM using state funds (Dockall, 1996b). This pattern of wealthy denture-wearers ﬁts the picture of ﬁnancially based access to dental care painted by Cunningham (1958) and others. CONCLUSIONS This study provided a unique opportunity to assess dental health in the elderly from a historical perspective, and demonstrated that the issues affecting dental health are complex, involving aspects of age, diet, hygiene, access to dental care, environment, and socioeconomic status. This analysis illustrated the age-cumulative nature of many dental diseases and the confounding effects of AMTL. In general, as people age, their dental health worsens, requiring more care. In particular, this study veriﬁed that AMTL is a sequela of old age. Further, this study conﬁrmed the signiﬁcance of the complex interaction between dental disease and AMTL when examining samples composed of older individuals, especially because AMTL can play a role in the apparent frequencies of dental diseases. In general, the TSC sample was dissimilar from archaeological samples of institutionalized and noninstitutionalized populations. Much of this dissimilarity may be due to the signiﬁcantly older age at death of the Confederate veterans from the TSC when compared to archaeological samples drawn from military and institutionalized populations. Any similarities that existed between these historical samples in terms of dental health may well be masked by the elderly age of the men described here. Discrepancies in dental health were also apparent when the TSC population was compared to modern elderly populations (both institutionalized and noninstitutionalized), presumably because of historical differences in diet, the availability and accessibility of dental care, and advances in dentistry. From a historical perspective, socioeconomic and historic factors appear to have inﬂuenced the dental health of the individuals comprising the TSC sample. Improvements in transportation and the introduction of certain crops into new areas made reﬁned sugars, white ﬂour, and other carbohydrate-laden foods more widely available. Some modern methods of maintaining dental hygiene were available during the nineteenth and early twentieth centuries, but were not widely used. We found little evidence that these Confederate veterans from the TSC were receiving adequate dental care, although, as mentioned earlier, the rate of dental extraction is unknown. Dental ﬁllings and dentures demonstrate that some degree of professional dentistry was available to these men, though on a limited basis. Individuals with dental appliances and ﬁllings were clearly in the minority in the TSC sample, and may have represented people of higher socioeconomic status. Hopefully, future studies will focus on similar issues in archaeological noninstitutionalized elderly people or on geriatric samples derived from late 19th or early 20th century anatomical collections. For example, analyses of modern samples documented a trend such that the dental health of the institutionalized elderly tends to be worse than that of the independent elderly, especially in terms of higher rates of tooth loss and caries. So far, an archaeological sample with a similar demographic composition to the Confederate veterans described here, but composed of people who were not wards of the state, is unavailable for comparison to see if this holds true of past populations as well. Such studies may provide further insights into the causes and effects of dental disease in elderly people. ACKNOWLEDGMENTS We are grateful to have had the opportunity to participate in this research, which resulted from a cemetery restoration project jointly managed by Emily Little Architects, the Texas General Services Commission, and the Texas Parks and Wildlife Department. Prewitt and Associates, Inc. (PAI), was responsible for the bioarchaeological and archaeological efforts undertaken as part of the renovations. We extend our sincere gratitude to PAI for their intellectual and ﬁnancial support. Douglas K. Boyd of PAI was especially generous with his time and energy; his enthusiasm for this project was endless. Brenda Baker, Gregory Berg, and James Pokines read and made valuable suggestions on several earlier drafts of this paper. We are most grateful to four anonymous reviewers and to Clark Spencer Larsen, whose helpful comments signiﬁcantly improved the ﬂow of this paper. LITERATURE CITED Adams GW. 1952. Doctors in blue: the medical history of the Union Army in the Civil War. New York: Henry Schuman. Angel JL. 1976. Colonial to modern skeletal change in the U.S.A. Am J Phys Anthropol 45:723–736. Banting DW. 1973. Dental care in long-term hospitals. Can Hosp 50:49 –51. DENTAL HEALTH OF ELDERLY CONFEDERATE VETERANS Barkley MS. 1963. 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