Pathogenesis of apical periodontal cysts: guidelines for diagnosis in palaeopathology

Apical periodontal cysts are benign lesions developing in relation to the apices of non‐vital teeth due to inflammatory response from the infective pulp. These are epithelium‐lined bony cavities containing fluid. Despite being widely reported in medical/dental literature, this common condition is poorly diagnosed and documented in the archaeological literature. We aim to clarify the correct terminology, demonstrate bony manifestations at different stages of pathogenesis of chronic periapical dental lesions into granuloma and apical periodontal cysts, and to describe diagnostic criteria which would provide practical guidelines for the diagnosis of these conditions. Three identified skulls from the International Exchange Collection, housed in the Anthropological Museum at the University of Coimbra, are used to identify the progression of this condition from a small periapical granuloma to a large apical periodontal cyst with expansion of alveolar and facial bones. The pathogenesis of this condition is described, together with its surgical management in the early 20^th century in Portugal, which is the period in which these individuals lived. Confusion resulting from the different terminologies can be avoided if the term periapical granuloma is used to define apical bony lesions smaller than 3 mm at their maximum intra‐bony diameter, and the term apical periodontal cysts for the larger lesions. We recommend that these terminologies and parameters be used as a standard in future studies. This will make inter‐observer and inter‐population comparisons more accurate. Copyright © 2007 John Wiley & Sons, Ltd.     

Skeletal Manifestations of Skin Ulcer in the Lower Leg

Skin ulcers of the lower leg are known to cause both destructive and, more commonly, bone‐forming lesions. Typically, bone‐forming lesions in this disorder have clearly defined margins although there may be extensive reactive bone formation involving much or all of the adjacent diaphysis. These lesions are best described in patients from tropical areas, and in these environmental contexts, these are known as tropical ulcers, but leg ulcers can be caused by a variety of diseases and conditions, of which vascular insufficiency plays an important role among the elderly. The lesions are important clinically because of the disability associated with the ulcer and because of complications that can develop including osteomyelitis and cancer. In most cases, the bone lesions caused by ulcer are easily diagnosed in archaeological human skeletal remains and provide some insight into the prevalence of this disorder in antiquity. In this paper, we review the gross and radiological manifestations of bone lesions resulting from overlying skin ulcer in tibiae of 13 cases including archaeological and modern medically documented skeletons. In two of the cases, there is medical documentation regarding the presence of a chronic ulcer on the lower leg. The objectives of this paper were to explore the diversity of bone lesions associated with ulcers of the tibia and to provide an improved basis for the diagnosis of this disorder in human skeletal remains. Copyright © 2011 John Wiley & Sons, Ltd.     

Metastatic carcinoma in a 14th–19th century skeleton from Constância (Portugal)

During 2002, the extensive archaeological excavations of the ancient Constância necropolis (Centre of Portugal), dated from 14th–19th centuries, resulted in the exhumation of 151 individuals. Among the several paleopathological cases, a middle‐aged female skeleton with osteolytic lesions in her skull, axial skeleton, upper limbs and femurs was observed. These pathological findings are characterised by an asymmetric pattern with osteolytic focus of distinct size and irregular shape. Some skeletal elements display both osteolytic and osteoblastic lesions. The latter exhibit deposition of fine layers of woven bone. Lesions were observed macroscopically and radiology was used as a complementary method of scrutiny, especially in cases of unclear observation. The case was diagnosed as that of a probable metastatic carcinoma due to the multifocal distribution of the lesions in areas of intense haematopoietic activity, their morphology and some osteoblastic responses, as well as the presence of pathological fractures in the ribs. The skeleton's sex and age at death are in agreement with the proposed diagnostic, constituting the first case of malignant carcinoma detected in non‐identified Portuguese human skeletal remains. Copyright © 2009 John Wiley & Sons, Ltd.     

Possible cases of leprosy and tuberculosis in medieval Sigtuna,Sweden

In Sigtuna, Sweden, a medieval cemetery, including 227 skeletons, was analysed in 2006. On the outskirts of the churchyard, six skeletons with bone changes indicating systemic inflammatory disease were observed. Two out of three individuals with well‐preserved facial bone regions displayed signs of rhinomaxillary remodelling. Four of the afflicted exhibit severe bilateral alterations of the lower legs and phalanges of the feet and concentric atrophy of the metatarsals. In addition, one of the individuals exhibited a kyphosis in the lumbar vertebrae. In a discussion about alternative diagnoses, lepromatous leprosy and tuberculosis were identified as the causes of the destructive lesions in two individuals. Though the skeletal changes of the lower legs and feet in four cases demonstrate a close resemblance to secondary lesions of leprosy, the disease could not be confirmed. The skeletal changes of the last individual were unspecific and the possible causes several, rendering diagnosis difficult. The burial locations imply that the afflicted persons belonged to a lower social stratum. Due to the significantly higher frequency of pathological changes in the cemetery compared to other cemeteries in the town, the individuals could be regarded as fellow sufferers among others with various medical conditions. The bioarchaeological identification of systemic infectious diseases of a group of individuals of this size is unique to north of Scania in Sweden, where only a few cases of leprosy and tuberculosis have previously been diagnosed. The significance of the present study is emphasised by the interconnection between the afflicted, the archaeological context and the knowledge of the medieval society in Sigtuna. Copyright © 2010 John Wiley & Sons, Ltd.     

Adult scurvy in skeletal remains of late 19th century mineworkers in Kimberley,South Africa

Throughout history, scurvy has been a well‐known disease which develops due to restricted resources of fresh fruit and vegetables. The condition results from an extended limited intake of vitamin C. Although skeletal lesions associated with infantile scurvy have been well described by many authors, very little literature is available on adult scurvy and the resulting skeletal lesions. The purpose of this study was to investigate the skeletal remains of a 19th century mining population from Kimberley, South Africa, for any skeletal lesions that may be indicative of adult scurvy. Scurvy was well documented as being extremely prevalent in this population. The skeletal remains of 107 individuals, presumed to have died around 1898, were studied. The majority of these individuals were males between 19 and 45 years of age. It is likely that most individuals were migrant workers at the diamond mines. All bones were visually assessed for macroscopic indications of pathological bone alterations associated with healed scurvy. Bone samples were also taken from ambiguous lesions in order to perform histological investigations. Lesions indicative of possible healed adult scurvy were observed in 16 individuals. These lesions included bilateral ossified haematomas, osteoperiostitic bone changes and periodontal disease. Histological investigation confirmed the presence of ossified haematomas on the anterior tibiae of some individuals. Hospital records and historical documents describing the incidence of scurvy in the local hospitals and the daily diet of the black mine workers supported these findings. Copyright © 2009 John Wiley & Sons, Ltd.     

Health status of the Venda,a post‐antibiotic community in rural South Africa

This paper examines the health status of a rural African community during the emergence of Westernisation. A total of 157 skeletons, which included 120 adults (55 males and 51 females), 37 juveniles, and 14 individuals of unknown age, were analysed. Date of death ranged from 1910 to 1999, with the majority of individuals (52%) being buried after 1960. The bones were examined for infectious diseases, trauma and degenerative changes. More than half of the individuals in the sample had no pathological lesions on their skeletal remains. No cribra orbitalia was present. One case of leprosy and three cases of osteomyelitis were recorded. The most common findings were osteophytes on the vertebral bodies (syndesmophytes) (17%) and osteoarthritis (7%). The low occurrence of chronic disease is unexpected given that malaria was endemic and intestinal worms were common. Explanations for these results include adequate intake of iron from dietary sources, death from acute infectious diseases, administration of antibiotics, and poor preservation of adult skeletal remains. Copyright © 2007 John Wiley & Sons, Ltd.     

Identification of urate crystals in gouty individuals

In paleopathology cases of gout have traditionally been identified using the character of erosive bony lesions, but in clinical medicine identification of monosodium urate crystals in joint fluid plays a central role in diagnosis. Work undertaken on three skeletal individuals who had been buried, demonstrates that crystals can be identified using polarising microscopy. The crystals were identified as monosodium urate. Results from this study appear to demonstrate that identification of monosodium urate crystals could be used to assist in the diagnosis of gout in paleopathology. Further work is required to establish the full range of spatial and temporal contexts from which such crystals might be found.     

New light on the personal identification of a skeleton of a member of Sir John Franklin’s last expedition to the Arctic, 1845

In 1845, an expedition, commanded by Sir John Franklin, set out to try and discover the north-west passage. All 129 men on this ill-fated voyage perished. Over the years, skeletal remains associated with the final throes of the expedition have been located on and near King William Island, Nunavut, in the Canadian arctic. In general, even a tentative personal identification for these remains has proved impossible. An exception is some skeletal remains that were recovered in 1869 and brought back to England and interred beneath the memorial to the Franklin expedition in Greenwich. In the 19th century, these were tentatively identified as of one of HMS Erebus’s lieutenants, Henry Le Vesconte, a conclusion that has been widely accepted in studies of the Franklin voyage. Renovations to the monument in 2009 provided an opportunity for scientific examination of the remains, and to re-evaluate the personal identification made nearly 140 years before. The current work, which is the first modern scientific analysis of a fairly complete skeleton associated with the Franklin voyage, describes the remains and the artefacts interred with them, discusses the pathological conditions present, and evaluates the personal identification using osteological techniques and isotope geochemistry. Results indicate that the remains are of an adult male of European ancestry. Although some writers have suggested that scurvy or tuberculosis may have been important causes of morbidity and mortality on the Franklin expedition, osteological analysis and, in the case of tuberculosis, DNA analysis, provided no evidence for their presence in these remains. Isotopic studies indicate that the personal identification as Le Vesconte is unlikely to be correct. From the isotopic results and forensic facial reconstruction, HDS Goodsir, an assistant surgeon on the expedition, appears a more likely identification, but the results do not allow a firm conclusion.     

Leprosy in a skeleton from the 7th century necropolis of Vicenne‐Campochiaro (Molise,Italy)

Analysis of the skeleton from tomb 144 of the early medieval necropolis of Vicenne‐Campochiaro in Central Italy revealed several features indicative of leprosy. The skeleton belongs to a male estimated to be between 20 and 25 years of age at death. The distal halves of the 1st and 2nd left metatarsals present acro‐osteolysis and both legs show severe subperiosteal bone reaction. The facial skeleton shows changes compatible with a chronic inflammatory process, possibly due to an infectious disease. The anatomical distribution of the lesions and their association with other skeletal lesions seems to be compatible with a near‐lepromatous form of leprosy. A differential diagnosis is made, and the skeletal traits pathognomonic of leprosy are discussed. Copyright © 2005 John Wiley & Sons, Ltd.     

A case of treponematosis from pre‐Columbian Chaco Canyon,New Mexico

Although numerous cases of treponemal infection have been identified in prehispanic New World skeletal remains, none has been reported from Chaco Canyon, New Mexico. Chaco Canyon was the epicentre of a broad culture system that spanned the Four Corners region of the pre‐Columbian Southwestern United States. A burial recovered from the central Great House of Chaco Canyon, Pueblo Bonito, exhibits lesions indicative of treponematosis. However, the pathological condition of this individual has heretofore been only tentatively diagnosed because the skeleton was collected from a commingled context and distributed across four separate catalogue numbers. Now reassociated, these remains exhibit a pattern of pathological changes strongly indicative of treponemal disease. This case not only adds to the growing body of literature on the clinical expression and geographic distribution of pre‐Columbian treponematosis, but also demonstrates the utility of painstaking reassociation of commingled human remains. Copyright © 2009 John Wiley & Sons, Ltd.     

Unequal in life? Human remains from the Danish excavations of Tylos tombs

The Danish excavations in Bahrain of Tylos graves at Sar and from Pylon T158 resulted in the recovery of seventeen skeletons. Apart from a single infant, all remains were of adults with females dying, on average, at a younger age than males. Among the pathological conditions identified, porotic hyperostosis (frequently linked to anaemia) was common. Infectious lesions were observed including two cases tentatively diagnosed as tuberculosis. The only other pathological condition noted was a possible case of skeletal fluorosis. This range of disease is comparable to other skeletal samples dating to the Tylos period. Measurements also indicate that these samples are similar to other Tylos remains from Bahrain. A feature of this period is the disparity in health between males and females, evidenced by differences in robusticity and height. This disparity is more marked than in other periods and it is argued that it is evidence of a greater inequality on the island during this period.     

Pre‐Columbian Tuberculosis in Northwest Argentina: Skeletal Evidence from Rincón Chico 21 Cemetery

Systematic excavation of collective burial sites makes possible the recovery of skeletal series which may show bony evidence of infectious pathological conditions. This paper presents the first evidence of the existence of tuberculosis in prehistoric populations of NW Argentina with a subsistence economy based on agriculture and pastoralism. The study was carried out on individuals from Rincón Chico 21 cemetery, a burial site located in the Santa María Valley, Catamarca, used between the Late Ceramic Period and the onset of the Inca empire expansion (AD 1000–1400). Six individuals out of the 70 so far excavated showed destructive lesions in the vertebral bodies and periosteal reactions in other bones. The morphology and distribution of bone lesions led us to rule out several diseases from a broad spectrum of possible diseases that could have affected the skeletal system. Thus, the lesions were interpreted as caused by mycobacterial infections (Mycobacterium tuberculosis Complex). Considering previous studies on the dynamics of biocultural interactions which take into account information related from contextual associations and chronology, we can conclude that a tuberculosis‐like disease was present in prehistoric populations from NW Argentina. Copyright © 2011 John Wiley & Sons, Ltd.     

Multicentric osteosarcoma associated with DISH,in a 19th century burial from England

Osteosarcoma is a rare type of malignant neoplasm that is most frequent in adolescents and young adults although it can develop at any age. It can metastasize from a primary site in bone to other bones and soft tissues. Usually the disorder causes a single bone‐forming lesion (unicentric) but some cases have multicentric, bone‐forming lesions. Some of these lesions develop at different sites at different times. In a second variant of multicentric osteosarcoma, synchronous bone‐forming lesions develop at multiple sites. Distinguishing between these two types of multicentric osteosarcoma is challenging in a clinical context and the criteria for doing so are unlikely to be met in an archaeological burial. Wolverhampton burial HB 39 was excavated from an early‐nineteenth century cemetery site in England. It consists of the incomplete skeleton of an adult male of at least 45 years of age with multicentric osteosarcoma. The individual represented by this burial also had diffuse idiopathic skeletal hyperostosis (DISH). Three of the bone‐forming lesions associated with osteosarcoma developed on the bony outgrowths related to DISH. Copyright © 2010 John Wiley & Sons, Ltd.     

Severe vertebral collapse in a juvenile from the graveyard (13th/14th–19th centuries) of the São Miguel church (Castelo Branco,Portugal): differential palaeopathological diagnosis

Diseases that culminate into vertebral collapse are of intricate diagnosis both in palaeopathology and modern clinical practice. When analysing human skeletal remains from the archaeological record this difficulty is amplified due to the absence of complementary medical diagnostic information. This is especially evident when the distinction between tuberculous and pyogenic spondylitis is intended. Taking into consideration this challenging task and based on the macroscopic and radiological study of the skeleton number 8, a specimen exhumed from the East necropolis (13th/14th to 19th centuries) of the São Miguel church, at the Portuguese city of Castelo Branco, the aims of the work here presented are to discuss the range of possible aetiological factors, especially infectious ones, ascribable to the striking pathological changes noticed on this 12‐year‐old individual. These included alterations on the axial skeleton, namely extensive vertebral destruction, presenting as a gibbus deformity, and correlated thoracic deformities. Consubstantiated on palaeopathological and clinical research, tuberculous spondylitis seems to be the most probable cause for the reported lesions. However, the scrutiny between this condition and other pyogenic spinal infections is of extreme complexity when analysing ancient human remains and deserves in‐depth future investigations. Within the framework of the Portuguese archaeological record, the specimen here presented is of major relevance since the pattern and severity of the spinal osseous changes observed were not previously reported. Further, if tuberculous spondylitis is assumed as the most probable diagnosis, the case here presented represents one of the earliest skeletal evidence of this condition in Portugal. Copyright © 2009 John Wiley & Sons, Ltd.     

Age estimation by tooth/pulp ratio in canines by peri-apical X-rays: reliability in age determination of Spanish and Italian medieval skeletal remains

Estimation of age at death is an unavoidable step in the process of human identification, both in forensic practice and in the anthropological and palaeopathological study of skeletal remains. In several cases, in which medical or demographic records are completely lacking, a reliable estimation of the age at death becomes very important. Skeletal remains from archaeological contexts suffer from several biasing factors such as post-mortem changes, taphonomy and various burial practices depending on age, sex and social status of the deceased persons.     

Past or present? Differentiating California prehistoric native American remains from forensic cases: An empirical approach

The goal of this project is to provide additional data and statistical analyses for differentiating between prehistoric/historic Native American remains and modern forensic cases that may be potentially confusing. Forensic anthropologists often receive requests from local law enforcement to infer whether skeletal remains are of forensic or non‐forensic significance. Skeletal remains of non‐forensic significance are commonly of Native American ancestry, but the empirical methods common for determining Native American affinity from skeletal remains have not been established for California prehistoric/historic Native Americans. Therefore, forensic anthropologists working in California lack empirical methods for not only identifying prehistoric California Native American remains, but also differentiating them from modern/forensic populations whose skeletal attributes are similar. In particular, skeletal remains of Latin American US immigrants of indigenous origins are becoming more present in the forensic anthropological laboratory, and can exhibit the same suite of skeletal traits classically used to identify Native American affinity. In this article, we initiate an investigation into this issue by analyzing both craniometric and morphoscopic data using a range of statistical methods for differentiating prehistoric Northern California Native Americans from modern Guatemalan Maya. Our discriminant analyses results indicate that by using nine craniometric variables, group classification is 87% correct. In addition, seven morphoscopic variables can predict group classification correctly for 77% of the sample. The results suggest that it is possible to differentiate between our two samples. Such a method contributes to the efficient and empirical determination of temporal and geographic affinity, allowing for the repartriation of Native American remains to their tribes, as well as the accurate analysis of forensically significant remains. Copyright © 2010 John Wiley & Sons, Ltd.     

Injuries to the skeleton due to prolonged activity in hand-to-hand combat

Two complete skeletons from the Hamman-Todd collection of the Cleveland Museum of Natural History (CMNH) show a suite of pathological lesions that suggest the individuals had been involved in boxing or other hand-to-hand combat. These lesions were studied and compared with medical and autopsy records. The aims of the research were to estimate the accumulated damage to the bones over time, to characterize the different types of the damage, and to establish criteria for hand-to-hand combat or violence for archaeological material. Our inspections showed that besides the muscle markings developed and the numerous healed fractures that are expected when someone is involved in such activities, other types of lesion are present that are helpful for a proper differential diagnosis. These are: degenerative changes at the lesser tuberosity of the humerus; focal necrotic changes/bone growth on the trochlea of the humerus; necrotic changes on the distal head of the ulna; bony patches on upper limb bones only; secondary centres of ossification failing to fuse (mainly in vertebrae and acromion); a huge conoid tubercle on the clavicle; bony spurs on the distal articular head of the metacarpals; necrotic changes on the femoral head next to the fovea and on the roof of the acetabulum; and a developed bony ridge for the attachment of the iliotrochanteric ligament. Finally, we propose a set of criteria that will help to identify people in archaeological material who were involved in hand-to-hand combat.     

Scurvy as a factor in the loss of the 1845 Franklin expedition to the Arctic: a reconsideration

In 1845, an expedition, commanded by Sir John Franklin, set out to discover the Northwest Passage. The ships entered the Canadian Arctic, and from September 1846 were beset in ice off King William Island. A note left by the expedition in May 1847 reported all was well, but by April 1848, 24 of the 129 men had died. The ice‐locked ships were deserted in April 1848, but the 105 survivors were so weakened that all perished before they could reach safety. The causes of the morbidity and mortality aboard the ships have long been debated, and many commentators have argued that scurvy was an important factor. This study evaluates the historical evidence for the likely effectiveness of anti‐scorbutic precautions taken on polar voyages at that time, and investigates whether the skeletal remains associated with the expedition provide evidence for scurvy. Skeletal remains available for study were carefully examined for pathological changes, and lesions potentially consistent with scurvy were subject to histological analysis. Where remains were no longer accessible, use was made of published osteological work. It is argued that the anti‐scorbutic measures customarily taken on mid 19^th century British naval polar voyages were such that there is no a priori reason to suppose that scurvy should have been a problem prior to the desertion of the ships. The analysis of the skeletal evidence provided little in the way of bony lesions consistent with the disease, and cannot therefore be used to support the presence of scurvy. Factors other than scurvy may been the main causes of morbidity and mortality in the 11 months prior to the desertion of the ships. Copyright © 2012 John Wiley & Sons, Ltd.     

Metastatic carcinoma in a leper skeleton from a Medieval cemetery in Chichester England

Both leprosy and metastatic cancer are well documented in the literature on human skeletal palaeopathology. The manifestation of both pathological conditions in a single archaeological skeleton has not been reported. A case from a Medieval site in Chichester, England exhibits bone lesions and patterns of skeletal involvement indicative of both these diseases. Evidence of leprosy is largely restricted to the lower tibiae, fibulae and the bones of the feet. Fine destructive foci and reactive fibre bone associated with metastatic cancer are distributed in many of the remaining areas of the skeleton. There is minimal overlap in the areas of the skeleton involved in the two pathological processes.