AMENHOTEP III was one of ancient Egypt鈥檚 greatest pharaohs. His rule was a golden age, when the Egyptian empire was powerful, peaceful and fabulously wealthy. He built palaces and temples and raised statues to the gods. He wanted to be remembered. And he is, but probably not the way he intended. More than 3000 years after he died, Amenhotep is famous for his terrible teeth. X-rays of the pharaoh鈥檚 mummy reveal a gruesome set. Amenhotep must have endured years of pain. His teeth gave him hell 鈥� every mouthful was agony, every meal an ordeal. So why didn鈥檛 he see a dentist?
The explanation is simple, says Judith Miller, a dental surgeon turned Egyptologist: there were no dentists in ancient Egypt, at least none that did more than prescribe a potion or recite a spell. Her exhaustive study of skulls spanning more than 4000 years turned up no trace of any dentist鈥檚 handiwork, despite previous assertions to the contrary (see 鈥淭he dentists who never were鈥�). This is surprising given that ancient Egypt boasted skilled physicians and advanced knowledge of anatomy. It鈥檚 all the more astonishing given the state of people鈥檚 teeth, says Miller. 鈥淢any suffered the ravages of dental disease for most of their lives and many probably died from its effects.鈥� When toothache struck, even the richest and most powerful man in the land had to grin and bear it.
As a practising dentist, Miller spent decades dealing with impacted wisdom teeth, overcrowded jaws and the after-effects of too many sugary snacks before signing up to study forensic Egyptology at the University of Manchester, UK. There she joined the mummy research team, and was soon spending more time examining the teeth of the long-dead than the living. Many ancient Egyptians had badly worn teeth, and earlier studies of skulls and mummies had produced some choice specimens of ravaged dentitions from the greatest pharaohs downwards. But Miller wanted to know if dental health had changed over the millennia. And if it had, were the changes linked to people鈥檚 diet? A more systematic approach was called for.
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In the largest study of its kind, she cast her expert eye over more than 500 Egyptian skulls and jaws from the Duckworth Osteological Collection at the University of Cambridge and the Natural History Museum in London. She scrutinised specimens of children and adults found at sites throughout Egypt dating from predynastic times, some 6000 years ago, to the Roman occupation 4000 years later, omitting only three intermediate periods when social and political upheavals might interfere with her analysis (see Chart). She had seen some dental horrors during her career, but this was truly shocking. These people鈥檚 teeth were much worse than past studies had indicated. 鈥淭here were far more people with very bad teeth than expected,鈥� says Miller. 鈥淎nd their dental disease was more severe than their living conditions would suggest.鈥�
Plenty of individuals had lost at least one tooth during their lives, but missing teeth were probably the least of their worries. Those teeth that remained were often worn to stumps or riddled with cavities, or both. In many cases, infection led to abscesses and the loss of bone in the jaw, sometimes even to a chronic infection of the bone and blood poisoning.
For most of ancient Egyptian history the biggest destroyer of teeth was physical wear. Whatever people were eating, it was flattening the cusps and then stripping off the enamel and eroding the softer dentine beneath (see Graphic). Heavy wear triggers cells inside the tooth to lay down a protective layer of secondary dentine to prevent exposure of the sensitive pulp inside. But in most of Miller鈥檚 long-dead patients, wear outstripped the tooth鈥檚 capacity to make more dentine, and with the pulp exposed, the teeth quickly became infected. Such wear was common from predynastic times, before the appearance of the first pharaoh around 3100 BC, until the arrival of the Greeks in 332 BC, when it suddenly became much less of a problem, little worse than a dentist might see today.
The damage from wear was bad enough, but these people also suffered from caries. Caries begins when carbohydrate residues build up on the teeth to form plaque, which is then colonised by bacteria in the mouth. The bacteria go to work on the carbohydrate, releasing acids that attack enamel and dentine and form cavities. Untreated, cavities provide an entry point for harmful bacteria, which spread through the tubules of dentine and cause inflammation of the pulp. In predynastic times, only 16 per cent of the population had cavities. By the New Kingdom (1567 to 1085 BC), the era of such famous pharaohs as Tutankhamen, Ramesses the Great and the unfortunate Amenhotep III, this figure had risen to 25 per cent. By the Graeco-Roman period the figure had leapt again to 34 per cent. More intriguingly, Miller discovered that over time the cavities had migrated: early on, most were around the neck of the tooth, just below the gumline. But from the Late Period (525 to 332 BC) onwards, caries attacked the enamel on the crowns and between the teeth. There was another difference too: by the time of the Ptolemies (305 BC), children suffered from caries as much as adults.
Wear and caries can both lead to periodontal disease, and Miller found plenty of cases from every period. Working from skulls, she was able to identify only the worst examples, where infection had gone beyond the periodontal membrane lining the tooth socket and spread into the underlying bone, causing inflammation. Like wear, periodontal disease was worst during the New Kingdom, evident in 43 per cent of Miller鈥檚 skulls. The New Kingdom Egyptians also lost the most teeth and suffered the largest number of abscesses.
So dental health deteriorated down the dynasties, but was a changing diet to blame? To find out, Miller pieced together a timeline of eating habits and checked her findings against it. There is a wealth of information about the foods people ate in ancient Egypt. Archaeologists have uncovered rubbish heaps from very early settlements that contained the remains of molluscs, fish and the bones of game animals, as well as tools for hunting and preparing food. From later periods, there are papyri that list the rations issued to soldiers and workmen. Inscriptions in temples record the foods offered to the gods. Wall paintings portray tables groaning with delicacies. Tombs contained the real thing 鈥� from baskets of grain and loaves of bread to mummified joints of beef and jars of wine and beer, all intended to sustain the dead in the afterlife.
Throughout most of Egypt鈥檚 history, people ate a varied diet. Before the pharaohs, hunting and gathering provided food rich in protein. Around 4000 BC, people started settling along the banks of the Nile and took up agriculture, switching to a diet richer in carbohydrates. By the time of the first pharaoh, around 3100 BC, people farmed and grazed livestock, their lives regulated by the rise and fall of the Nile. Flooding or drought brought famine and hunger, which left telltale signs in the arrested development of bones and teeth, but in general people ate an impressive variety of foods. They grew barley and emmer wheat to make beer and bread, supplementing these staples with a wide range of vegetables, pulses and fruits. They also fished, kept ducks and geese, drank milk and perhaps made cheese. Most people were primarily vegetarian, with meat a rare luxury, although kings and priests had a plentiful supply of beef.
If their diet was so healthy, why were their teeth so bad? For much of Egypt鈥檚 history the worst culprit was bread. The ancient Egyptians made at least 40 varieties of bread, but it was all baked with flour made from emmer (Triticum dicoccum), the small-grained ancestral species of wheat. Analyses of surviving loaves show that the bread was invariably contaminated with grit 鈥� fine grains ground off the millstone, sand blown in as the bread baked in outdoor ovens, or even particles deliberately added to help grind finer flour. Neither miller nor baker made much effort to remove the tough, fibrous husks either. The resulting bread was grainy, gritty and so abrasive it quickly wore teeth down to the pulp. With the arrival of the Greeks in the 4th century BC, tastes changed and coarse emmer loaves were replaced by fine white bread made from durum wheat (Triticum durum). Now that consumers were pickier about the quality of their bread, bakers took more care to remove the husks and grit.
Bread is the prime suspect for root caries, too. Bread made from emmer wheat is very sticky when chewed, and there is no evidence that the Egyptians ever cleaned their teeth, so gooey bits would have clung around the base of the teeth long after mealtimes. The resulting plaque would have pushed down the gumline, allowing bacteria to attack the root.
But bread cannot be blamed for the later wave of cavities on the upper parts of the teeth. Instead an increasingly sweet tooth was the culprit. Honey was the most sugary food around, but until the time of the Ptolemies it was reserved for kings and as offerings to the gods. Once the Ptolemies took over, consumption soared 鈥� along with cases of caries. In the meantime, those who hankered for sweetness added sugary fruits such as dates or figs or fruit juices to their food. The Egyptians of the prosperous New Kingdom 鈥� Amenhotep III included 鈥� suffered a double whammy, eating gritty, sticky emmer bread and sugary foods. It鈥檚 hardly surprising that they were hit hardest by abscesses, bone loss and severe periodontal disease.
What mystifies Miller is why people so bedevilled by dental disease didn鈥檛 treat it when Egyptian medical care was so advanced. 鈥淭hey performed amputations. They recognised and treated mental illness. So why not teeth?鈥� In many cases, the remedy would have been simple: pull out the tooth. Many of the teeth Miller examined had so little supporting bone they would have been loose enough to extract with a finger and thumb. But there is no evidence the Egyptians performed extractions, she says. Lancing an abscess to release the pus would have been relatively easy too and would have saved lives.
The absence of dentists is very odd, agrees John Taylor from the British Museum in London. The ancient Egyptians had medical and surgical skills that could easily have been adapted to dentistry and they would never have been short of patients. 鈥淭hey had such terrible teeth you would think it would be the obvious thing to do.鈥� And it wasn鈥檛 as if they believed the gods would frown on them if they turned up in the afterlife with a few more teeth missing or the odd false tooth. Although the purpose of mummifying people was so they would be intact in the next world, artificial parts were apparently acceptable. 鈥淭here are mummies with prostheses, such as for toes that were missing,鈥� says Taylor. 鈥淏ut there are no false teeth.鈥� Even Amenhotep III went to the next world with his front teeth missing. 鈥淭here was no attempt to fill the gap with false teeth, which suggests that in religious terms teeth weren鈥檛 necessary.鈥�
Why the ancient Egyptians didn鈥檛 perform dentistry is mystifying, but Miller鈥檚 study certainly suggests a reluctance to pull or probe even when it might have relieved excruciating pain or saved a life. Perhaps the most compelling evidence for the absence of dentists comes from the pharaohs themselves. Amenhotep III was not alone in being plagued by his teeth. The greatest pharaoh of them all, Ramesses II, had spectacularly awful teeth, worse even than his predecessor. His teeth were worn down to pegs, periodontal disease had eaten away at the bone, and he had a massive and potentially fatal dental abscess in his lower jaw. 鈥淪urely if there was any dental treatment going,鈥� says Miller, 鈥渢hen Ramesses II would have had it.鈥�
The dentists who never were
SINCE the early days of forensic Egyptology, there has been a question mark over whether the ancient Egyptians ever performed dental surgery. Some of the famous 鈥渕edical papyri鈥� include a handful of recipes for treating toothache and even for a sort of glue to prevent a loose tooth falling out. Inscriptions in tombs record the existence of seven people who counted 鈥渢ooth doctor鈥� among their titles. Over the years, archaeologists have claimed to have seen signs of dentistry, but none bears close scrutiny.
At the start of the 20th century, for example, American Egyptologist James Breasted was convinced that the Egyptians sometimes lanced abscesses by drilling through the jaw bone with a bronze 鈥渇ire drill鈥�. He had seen suspiciously neat holes in many jaws. But no drill has ever been found. What鈥檚 more, as dentist turned Egyptologist Judith Miller from the University of Manchester, UK, points out, when an abscess penetrates the bone, it produces precisely this type of hole.
Another questionable lead came in 1914, when German archaeologist Hermann Junker was excavating an Old Kingdom tomb at Giza. He discovered what he thought was a dental bridge, a device intended to stabilise a loose tooth by tying it to a more stable neighbouring one. His bridge consisted of a second and third molar tied together by a fine gold wire. But it is almost certainly not a bridge. Second molars erupt around six years before third molars, yet here the second was much less worn than the third. And the teeth were wide apart when they should be touching. Most damning of all, Junker found no skull in his tomb. Junker鈥檚 bridge is now thought to be an amulet.
That leaves the seven putative 鈥渄entists鈥�. Strangely, six of them lived during the Old Kingdom and the seventh some 1500 years later, with none between. Their titles are also open to interpretation. Two were described as ibH (tooth) and swnw (doctor), but they might have done little more than incant a few powerful words or mix a potion to ease toothache. The other five had an impressive collection of titles.
Hesy Re, for instance, who lived at the time of Djoser, the pharaoh who built the first step pyramid, was Chief of Physicians, Overseer of Scribes, Overseer of Draughtsmen, Elder of Builders and Chief of Taxes, as well as Chief of Dentists. As for Khuwy, he was not only Chief of Dentists and Chief of Physicians of Lower and Upper Egypt and Doyen of Physicians of the Palace, he was also Interpreter of the Organs and Guardian of the Anus, a role which might have put off any prospective dental patients.
In short, these men were high officials in charge of a whole range of activities. 鈥淚 certainly can鈥檛 see them sitting in the surgery doing dentistry,鈥� says Miller. 鈥淏ut it does suggest they recognised there was a problem.鈥�
