J. Periodontal Res.

13: 550-562, 1978

The natural history of periodontal disease in man

Study design and baseline data
HARALD LOE, AGE ANERUD. HANS BOYSEN AND MARTYN SMITH

School of Dental Medicine, University of Connecticut, Farmington, CT, U.S.A. This is the first in a series of reports on a longitudinal investigation of the initiatioti and progress of periodontal disease in man. One group was established in Norway in 1969 and consisted of 565 male students and teachers between 17 and 30+ years. A second group of comparable age was established in Sri Lanka in 1970 and consisted of 480 tea laborers. Both groups were scored for various disease parameters at start and at intervals during the subsequent seven years. This paper describes the design of the investigation and the periodontal state of the two groups at baseline. The results show that the Norwegian group had good to excellent oral hygiene and mild gingivitis. Supra- and subgingival calculus were inconspicuous and untreated gingival caries rare. Deficient margins of fillings and other restorations were commonplace. Slight loss of attachment was apparent in the youngest group and increased slowly with age. The mean loss of attachment in the 30+ year old was less than one millimeter. The Sri Lankan tea laborers showed poor oral hygiene, abundance of calculus and generalized moderate to severe gingivitis. Caries and dental restorations were non-existent. Slight loss of attachment was seen in the 15 year old and increased through the twenties. The 30+ years old Sri Lankan tea laborer showed a mean loss of more than 3 mm and a substantial number of teeth exhibited attachment loss in excess of 10 mm. The baseline analysis indicates that due to the choice of study groups and design, the longitudinal data will lend themselves to describing the initiation, pattern of development and the rate of progress of periodontal disease during major portions of the adult life of these people. (Accepted for publication April 13, I97SI

Introduction A study of the literature shows that a considerable body of knowledge on the distribution and severity of periodontal disease has been accumulated. For review of the epidemiology of periodontal disease, see Loe (1962), Scherp (1964), Waerhaug (1966). The data indicate (1) that the distribution of this disease is universal, (2) that there is an increase in prevalence and severity from

childhood to old age, (3) that gingivitis constitutes the initial lesion in periodontal disease, and that although all gingival lesions may not progress to periodontitis, wherever periodontal breakdown has occurred it has most likely been preceded by gingivitis, (4) that some population groups have more periodontal disease and greater severity than others, and (5) that the number ol teeth lost due to periodontal disease in creases with advancing age.

T H E

N A T U R A L

H I S T O R Y

O F P E R I O D O N T A L

D I S E A S E

Sfudy Design Norway

AGE

1969

1971

1973

1975
3 and subsequent r

Fig. 1. The semi-longitudtn I study design, the age cohorts at t Norwegian group.

Almost all our knowledge of periodontal morbidity and tooth mortality of tbe human dentition stems from cross-sectional studies of populations of different age and in various geographic areas. Longitudinal investigations in which the total sequence from initial development, progression of the disease into deeper parts of the periodontium and resultant tooth loss is assessed as a function of time, are virtually non-existent. Ideally, such surveys should be made in populations which are historically continuous; i.e., a study should start with a group of children and be carried out in such a way that the same group of individuals would be reexamined at intervals through adolescence and adult life for a total period of 40-50 years. Since there are obvious problems pertaining to such a life-long individual approach, we decided to utilize a study design in

which groups of individuals who were between 15 and 3 0 + years of age at the start of the investigation would be subjected to periodic examinations over 15 to 20 years. By using this study design (Figs. 1 & 2), we felt that it would be possible to describe the pattern and rate of periodonta! breakdown during man's adult life, their dynamic relationship to the nature of the early lesion, to the amount of mineralized and nonmineraiized tooth deposits and to other local factors. Such a semi-longitudinal approach would allow for the detection of changes over time in the study population. If chronological changes do not occur, this would be strong indication that cross-sectional estimates are valid in describing the course of the disease. The material presented in this and subsequent reports is derived from an ongoing investigation of the natural history of perio-

LOE. A N E R U D , B O Y S E N A N D SMITH Study Design Sri Lonka AGE AGE

1970
Fig. 2. The semi-lo Sri Lankan group.

1971

1973

1977

dontal disease in population groups in Norway and Sri Lanka. The two groups show geographical, racial, cultural, socio-economic and educational differences and they represent extremes both as to general health care delivery systems and to dental care. Thus, the primary objective of this study was not to explain possible differences in the various disease parameters in these groups. Rather the results might form a set of baseline data against which populations with similar or different characteristics may be compared. Tbe purpose of tbis paper was: to describe the study populations and the design of the investigation .- to characterize the periodontal situation in the two groups on tbe basis of the initial cross-sectional data.

Materials and Methods

The Norwegian Group Tbe first group was established in Oslo, Norway in 1.969 and consisted of 565 healtby male students and academicians between 17 and 30-f years of age (Table 1). Individuals born between 1934-39 and in 1940, 1942, 1944, 1946 and 1948 were randomly drawn from the census filed with the Central Bureau of Statistics. None ol these participants studied or taught in dental schools. Those born in 19.50 and 1952 were recruited from three high schools in Oslo (Grefsen, Ullern and Fagerborg), selected by the City Board of Education. Starting shortly after World War I, the Cit\ of Oslo developed and continuously adapted and improved a City Dental Prograrr:

T H E

N A T U R A L

H I S T O R Y

O F

P E R I O D O N T A L

D I S E A S E

553

Table 1 Number of Norwegian students and academicians that participated in each survey and the number that participated in ail surveys by birlh cohort. 1969-1975 " Birthysar ' 1940 1942 1969 38 76 1971 za 46 1973 21 37 1975 " 15 31 j^g^^ ^^^^^^^ " 13 22

riod of time other programs have been added to include both preschool ehildren and university students, so that during the last 20 years the dental care program has cov^^^^ j ^ ^ ^^^ ^^^^ j ^ ^ ^ 3 ,^ 23 years. In addition, the City of Oslo has also a well developed system of private practitioners. The ratio of dentists to patients (1:600, Statistical Year Book of Norway 1973) indicates that the density of dental care pro-

i
1948 1950 ^^^ Total ~

*
78 62 ^^ 5C5

f ^
58 33 381

50 S3 292

I
40 20 245

5
26 13 167

viders in this area is one of the greatest in

the world. Recent data confirm that cbil^jj.^^ ^^^ youths who had chosen not to participate in the school dentistry program ] () per cent) Continued to see their private family dentists on a regular basis (Hansen 1976. Hansen & Johansen 1976). Indeed, there are probably very few population groups in the world, who in 197.') and at the age of 4-0 years, could docunaent an exposure to systematic dental care similar to that of those participating in this investigation. The natural fluoride content in the drinking water in this area is 0.03 ppm. Since 1963 the program has included supervised brushing with 0.2 per eent sodium fluoride 4 times per year before the 14th year. In addition, each time the students saw their dentist during the year they rinsed with a 0.2 per cent sodium fluoride solution. Since 1947 each child in grades 1 through 7 has received individual itistruction or reinstruction in oral hygiene techniques once ^ ^,^^^ .j.),lj motivation, instruction and reinforcement was performed by dental hygienists (Engh 1978). The Sri Lankan Group A second group was established in Sn Lan{^^ j , ^ igjQ g^d coHSisted of 480 male tea laborers between 15 a n d 3 0 - ^ years of age who worked at the Dunsinane and Harrow y^^ Eslates (Table 2). These two plantations are situated in the central highland approximately 50 miles from Kandy and their population totals approximately 5,000. The par-

through which every school child was offered systematic dental care including preventative, restorative, endodontic, orthodontic and surgical therapy. From 1936 (Gythfeldt 1937) all children have been entitled to comprehensive examinations and treatment on an annual recall schedule. Throughout the last 40 years (1936-1976) more than 90 per cent of the eligible ehildren have participated in this scheme (Ramm 1952, 1954, Engh 1978). Over the same pe-

Table 2 Number ot Sri Lankan tea laborers that participated in eaeh survey and the number that participated in aii surveys by birth cohort. t970-t97T ITall
1940

^942 1944 S 1950 1952

-.nc.

36 61 ^7 62 69
yi-7

32 52 65 54 63
An

27 46 S 51 54
T ;

9 30 S 27 33
??

2S 28 2-* 28
16

1956 Totai

40

34

29

480

422

370

228

196

LOE, ANERUD,

BOYSEN

AND

SMITH

Table 3 Cumulative number of observations in each age category for all participants and for those who appeared in all four surveys (in parenthesis)
Age. Years 1969-1975 Norwegian students and academicians 1970-1977 Sri Lankan tea laborers 77 127 162 196 203 199 170 145 85 57 19 19 (34) (58) (72) (95) (98) (104) (91) (85) (59) (38) (18) (16)

15-16 17-18 19-20 21 22 23-24 25-26 27-28 29-30 31-32 33-34 35-36 37-38 +

81 127 150 216 232 232 174 147 75 33 14

(21) (34) (60) (97) (102) (111) (98) (70) (44) (22) (9)

ticipatits were all tamils and descendents of groups who 2-3 generations ago emigrated from Southern India. The population was considered stable since there were few opportunities for them to work outside the plantation. The tea laborers were essentially iUiterate and had very little communication with life outside the estate. They were healthy and well-built by local standards and their nutritional condition was clinically fair. The food which was partly provided by the estate administration, consisted mainly of rice and vegetables, fish or meat curry, consumed at noon and before bedtime. During the working hours the laborers drank tea sweetened with sugar. The fluoride content in the drinking water was .02-. .07 ppm. Adding tea to the water did not appreciably increase the fluoride content. The workers in these two estates had never been exposed to any programs or incidents relative to prevention or treatment of dental diseases and toothbrushing was unknown. Bete! chewing was common. The Clinical Examinations The Norwegian group was first examined

in 1969. Subsequent examinations took place in 1971, 1973 and in 1975. Future examinations are scheduled in 1979, 1983 and 1987. The Sri Lankan groups were examined initially in 1970, in 1971, 1973 and in 1977. Re-examinations are tentatively scheduled for 1981, 1985 and 1989. The time span between the first and fourth examinations was, in Oslo 6 years and 3 months, and in Sri Lanka 7 years and 6 months. At each appointment the participants answered questions regarding personal dental care and oral hygiene practices (Norway), smoking (Norway and Sri Lanka), and betel chewing habits (Sri Lanka). Missing teeth were recorded in all participants at each appointment (Loe et al. 1978a). The clinical examination of the periodontal tissues and adjacent portions of the dentition included measurements and scoring of indices on all mesial and facial surfaces of all teeth, except third molars. The following indices or measurements were recorded: Gingival Index (GT) (Loe & Silness 1963) Loss of Attachment (LA) (Glavind & Loe 1967) Plaque Index (Pll) (Silness & Loe 1964) Calculus Index (Cl) (Loe 1967) Gingival Caries Index (Cal) (Loe 1967) Filling Margin index (FI) (Loe 1967) At each examination throughout the study the same indices were scored by the same two investigators, who were both wefltrained and experieticed periodontists. One always scored the periodontal situation (Gl and LA). The other always scored for local exogenous factors (Pll, CI. Cal and FI). Each participant had all teeth scored for 6 indices at two sites per tooth, totalling in case of complete dentition, 336 recordings for each individual at each examination. Al! scores were dictated to the chairside assistant who recorded the scores on a special scoring chart (Fig. 3). The sequence of scoring was always tht same: piaque, calculus, fillings and carie?

T H E

N A T U R A L

H I S T O R Y

OF

P E R I O D O N T A L

D I S E A S E

7
1
CALCU

+ 1

&

&

a
FILLIN OS

JTC
1 1 1
*

III

oiNatv*

> 1
ACHMENt

IJDM ,M X
1 1 1 , * 1 1

. 1

DC

Fig. 3. Patient data card and record used during all examinations.

were first assessed in that order by investigator A using a pointed probe. The participant would then move over to another chair where investigator B would score for gingivitis and measure loss of attachment from the cementum-enamel junction (Loe et al. 1978b). These measurements were made with a blunt probe graded at 1, 2. 3, 4, 5, 7, 9, 11 millimeters. The same probes were used at all examinations in Norway and Sri Lanka. The diameter of the probes was 0.6 mm. Intra-examiner reproducibility for each index was tested at baseline and repeated periodically in both the Norwegian and Sri Lankan groups throughout the study. In the Norwegian group, 29 subjects were scored twice during the first session in 1969. The individuals were selected for re-examination at random by the secretary of the project. Usually the participants were requested to report back the next day, but due to various circumstances some were scored twice the

same day. Every effort was made to keep the examiners blind at the second scoring. In Sri Lanka 35 tea laborers were selected at random in 1970 and re-examined once according to the protocol used in Oslo in 1%9. The overall percentage of agreement for each index by tooth and surface type are given in Tables 4 and 5. For each index a reproducibility matrix was produced (Smith, Table 4 Percentage Agreement for Each Index by Surface and Tooth Type in 29 Norwegians
Index Mesial B u c GI LA Pll Calculus Fillings Caries 806 64 2 75.0 87.8 93.5 97.0 866 65.3 69 4 94.0 90.1 96.5 Sicijspids in.cisors

Mesial Bucca 1 Mesial Buccal 82.3 77.2 70.7 86.4 94.4 97.0 81.5 73.9 68.1 98.7 99.1 yy.1 80.3 71.9 66.7 85.5 91.6 98.0 77.7 79.4 60.3 96.2 97.7

LDE, A N E R U D , B O Y S EN A N D

SMITH

Percentage Agreement for Each Index by Surface and Tooth Type for 35 Sri Lankans
Index Mei GI LA PM Calculus Fillings Cartes 70.7 58.4 94.6 81.32 NA 97.7 73.2 66.5 86.8 69.3 NA 98.4 69.2 67.4 93.4 79.9 NA 98.2 78.4 69.2 72.5 69.2 NA 98.2 75,3 63.4 93.8 74.3 NA 98.6 Molars Bicu spidt ncis o,s jccai

peutic measures were undertaken during the scoring sessions. Actually, the investigators made special efforts to avoid any disruption of any habits, home-care practices or any other activity pertaining to the oral health status of the participants in Norway as well as in Sri Lanka. Data Analysis The data for eaeh examination in Norway and Sri Lanka were computerized and updated on an ongoing basis and finally have begun to be subjected to detailed analysis. Each population was divided into two-year age cohorts to facilitate the analysis. As with most studies of this size, a certain number of the population dropped out and could not be followed-up. Tables 1 and 2 give the number of individuals who participated in each survey by birth cohort. In Oslo the 1975 yield of 43 per cent of the original was reasonable considering resources were not available to provide transportation to the examination site. It is anticipated that future examinations of the Oslo population will yield a higher return. The Sri Lankan group suffered from a repatriation program which was unknown to the investigators at the start of the study. During the last scoring (1977) Sri Lankan authorities confirmed that the program had been terminated and there were no plans for its reactivation. In both populations the loss to follow-up individuals appears to be independent of age. In the analysis of the development of periodontal disease the most interesting groups are those individuals who were present in all surveys (I.A.S.). Also, analyses were performed on an all valid observation group (A.V.O.). The I.A.S. group was compared to the total A.V.O. group on each specified parameter to determine if those lost to follow-up were significantly differeni from those that remained in the study. Thi-' A.V.O. group was useful for estimating eer

Anerud & Loe 1977); mean differences were tested using the t test, and distributional differences were tested using the ChiSq test. In both groups the lowest percentage agreement occurred in the measurement of loss of attachment. However, 98 per cent of the measurements were within one mm of each other. The reproducibility measures for each individual index will be reported in their respective papers. The results do indicate that both examiners were consistent in their criteria for all clinical indicies. The examinations of the Norwegians took place at a facility provided by the Oslo University Faculty of Dentistry, equipped with two dental chairs, scialitic lamps, compressed air and saliva ejectors. Each examiner had two chairside assistants, one attending directly to the process of patient examination., the other was assigned to recording the scores. The plantation group in Sri Lanka were scored in an outdoor facility comprising two portable dental chairs and supporting equipment, but no compressed air and saliva ejectors. Two dental students as-iisted each investigator during the scoring and in iccording the scores, much in the same way as the chairside assistants did in Oslo. Since the purpose of this investigation was to study the natural development of periodontal disease, no preventive or thera-

T H E

N A T U R A L

H I S T O R Y

OF

P E R I O D O N T A L

D I S E A S E

fOOTH NUMBER 1969-1970 MESIAL SURFACES

3 0 * YEARS. rEA LABORERS

3.3 MM

l 5 E A i ) S . rCA LABORERS

\7 YEARS, N O R W

17 YEARS, N O R W

IS YEARS. TEA LABORERS 3 0 * YSARS, N O W

30+ YEARS, TEA LABORERS

-2 -2.5 -3.0 -3.3 MM

y TOOTH NUMBER

Fig. 4. Me; groups in f

of attachment ind Sri Lanka.

the youngest and oldest age

tain population parameters. Certain rates such as the cumulative tooth mortality rate were based on all individuals who appeared at both tbe first and fourth surveys (Loe et al. 1978a). When no significant changes in the estimates of the parameters occurred over time, the birth cohorts were collapsed into age cohorts to give a picture of each population over 25 years. This cumulative number of age cohorts observations are presented in Table 3. Slight differences in numbers of individual measurements of each parameter were due to scoring difficulties or losses due to data entry error.

The mean Plaque Index for the 17 year old Norwegian students was PII = 1.26. Approximately 65 per cent of all surfaces scored Plaque Index = 0 or 1, and 35 per cent scored PII ::r 2 or higher (Fig. 5). Plaque index scores were generally lower in the anterior teeth and on facial tooth surfaces and did not differ significantly from that of the 3 0 + years old academicians (Pil := L17 - Table 6). Calculus was also scarce (mean CI = 0.06 - Table 6) and occurred mainly as supragingival calculus in mandibular anterior

LOE. A N E R U D , B O Y S E N A N D

SMITH

Mean scores and standard deviations for the various disease parameters in Norwegian students and academicians (N) and Sri Lankan tea laborers (SL) at baseline. 1969-1970

^^

OQ

1.22 .1:1 .33 1.97

Plaque

1 ,19 57 .27 1.98

1.16 ^fl .28 1 .97

1.17
0"^
OR

2.00

GlngiviMs (Survey 2)

teeth and to a lesser extent in maxillary first molars. The differences between calculus scores in the youngest and the older age groups were small (Table 6). Approximately 4 per cent of the total number of tooth surfaces examined had subgingival calculus and occurred mainly in the older age groups, The caries experience of this group was generally high and had been met with regular treatment. The mean index for untreated caries in the gingival area was Cal = 0.5 for the 17 year olds and Cal = 0.3 for the 30-|- years old (Table 6), Gingivai caries occurred in less than 10 per cent of all surfaces. There was no major difference in the frequency of untreated gingival caries between different teeth or age

groups. It is also apparent from Table 6 that there is no major difference in mean Filling Index in the younger and older individuals. However, in contrast, the frequency of fillings scoring FI = 1, 2, 3, varied from zero in mandibular anterior teeth to almost 100 per cent in maxillary and mandibtilar first molars. The mean Gingival Index for 17 year old students was Gl =1 0.72. There was a tendency toward higher scores in the older age groups but the mean index did not exceed Gl = 1.04 for any groups (Table 6). Within the dentition, the anterior teeth showed the lowest and the posterior teeth showed the highest scores. The scores for individual tooth surfaces varied between Gl = O and Gl 2, and a score of Gl 3 was ex-

T H E

N A T U R A L

H I S T O R Y

O F

P E R I O D O N T A L

D I S E A S E

559

NORWAY

SRI LANKA

100-

50-

Ffg. 5. Per cent scor of P/i -: 2 (upper lett) and PII 1 (lower left] right) and GI 1 (low right) (or Norwegians (hatched) and Sri LanKan

and per cent scores ot GI ^ 2 (upper (solid) at baselina 1969-1970.

tremely rare. Approximately 10 per cent of all gingival surfaces scored GI = 2 and the rest scored GI = 0 or 1 (Fig. 5). The most common score for individual surfaces was GI = 1. Loss of attachment was a rare finding among 17 year old Norwegians (mean LA = .02 mm - Fig. 4). Out of 4438 measurements in 1969, 99 per cent measured 0 or 1 mm LA and 0.6 per cent measured between 24 mm. No measurement over 3 mm was recorded (Table 7). Loss of attachment when present, occurred mainly on the facial surfaces of maxillary and mandibular first bicuspids and first molars. A slow increase in LA was recorded during the twenties (Fig. 4). The 30-f- year old academicians showed a mean LA of 0.98 mm. Over 73 per cent of all surfaces measured 0-1 mm and the maximum LA for a surface was 5 mm (Table 7). The Sri Lankan tea laborers did not per-

form any conventional oral hygiene measures and consequently displayed quite uniformly large aggregates of mineralized and non-mineralized debris and stain on their teeth. The mean PII for 15 year olds was Pll = 1.99 and did not differ from that of the other age cohorts (Table 6), Among all tooth surfaces examined at baseline, only 3 surfaces scored PII = 0, approximately 96 per cent scored Pll = 2, the remainder scored Pll = 1 (Fig. 5). This frequency distribution did not vary appreciably in different groups of teeth or age cohorts. The amount of supra- and subgingival calculus was conspicuous in the entire group, but did vary somewhat within the dentition and did increase with age. Already at 15 years of age, both supra- and subgingival calculus was frequently found (mean CI = 0.87, Table 6). With no possibility for active removal, these aggregates could grow to be quite monstrous forma-

560

LOE, ANERUD.

B O Y S E N A N D S M I T H Table 7

Frequency and degree of attachment loss {LA) in mesial and buccai root surfaces Norwegian students and academicians (N) and Sri Lankan tea iaborers (SL) at baseiine. 1969-1970
No, o t T ooth surfac red N 15 17 19 21 23 25 27 29 30 + SL 2160 2604 3818 3389 4180 2890 3332 1858 1816 N Mear 1 LA mn Percisnt measurements of a ttachment loss 0-1 1 N SL 96.39 95.51 91,62 85.26 78.73 74.01 67.68 50.78 30.67 2-4 rT,m. N SL 1.80 3.26 6.71 12.74 17.71 20-25 29.26 33.09 43.67 5-9 mm. N SL 0.24 0.16 0.56 1.04 2.46 4.21 2.37 11.37 21.14 N 10 mm. SL 0.0 0.0 0.0 0.06 0.09 0.24 0.06 1.03 2-93

Age

SL 0.17 0.23 0.40 0.68 0.92 1.14 1.23 2.06 3.11

4438 3336 4256 5170 5238 4122 2048 2144

0.06 0.15 0.41 0,52 0.66 0.74 0.78 0.98

99.03 97,42 90.74 89.89 85.24 79,96 79.44 73.27

0.59 2,22 7.43 8.84 12.12 15.31 16.80 20.33

0 0 0.09 0.21 0.31 0.54 0.25 0.94

0 0 0 0 0 0 0 0

tions in the 3 0 + year olds (mean CI 1.96). Gingival caries were extremely scarce and fillings were essentially non-existenl. The mean Gingival Index for 15 year olds was GI = 1.74 and that of the 30 + years old GI =^ J.94 (Table 6). Virtually all gingival units exhibited inflammatory changes and 75 per cent scored GI = 2, with small variations between different teeth and age groups (Fig. 5). The 15 year old Sri Lankan had no significant attachment loss (mean LA = 0.17 mm). Approximately 96 per cent of the tooth surfaces measured 0 or 1 mm LA (Table 7), and approximately 2 per cent of the surfaces measured between 2 and 9 mm. When this loss of attachment occurred, it was mainly confined to maxillary and mandibular molars and incisors (Fig. 4). There was a dramatic increase in the genera! destruction of the periodontium of the tea laborers throughout the twenties, in the age group 30+ years, the mean LA was 3.11 mm and only 30 per cent of the root surfaces measured 0 or 1 mm (Table 7). Loss of attachment for individual surfaces was generally below 7 mm, but approximately 3 per cent of all surfaces measured 10 mm or more.

Discussion

These cross-sectional data from 1969-70 examinations have shown that oral hygiene in Norwegian students and academicians is good to excellent; calculus is a relatively small problem; untreated gingiva! caries is rare, while gingival fillings with overhang, surface roughness and/or other deficiencies are commonplace. The gingiva is relatively healthy or shows a mild degree of inflammation with very little difference between the 17 and 30+ years old. A slight loss of attachment has occurred around the first molars and first bicuspids of both jaws at 17 years of age. During the twenties there is a steady, slow increase in the general attachment loss, with a calculated rate of approximately 0.05 mm per year. At the age of 30+ the mean loss of attachment is still less than 1 millimeter and no tooth exhibits more than 5 mm loss (Loe et al. 1978b). The Sri Lankan tea laborers, on the other hand, show poor oral hygiene; supra- and subgingival calculus is abundant already among the younger individuals and increases with age. Caries and dental restorations are non-existent. Gingiva is characterized by moderate to severe inflammation.

T H E

N A T U R A L

H I S T O R Y

O F P E R I O D O N T A L

D I S E A S E

Slight loss of attachment is present in first molars and incisors of the 15 year old and progresses from this age on with a calculated rate of approximately 0.20 inni per year. At the age of 3 0 + the mean loss of attachment is more than 3 mm, a substantial number of root surfaces exhibit attachment loss in excess of 10 mm (Loe et al. 1978b). As a whole, the results from these baseline examinations show that all stages of periodontal health and disease are preseni in these two populations. The detailed recording systems used and the frequent scheduling of reexaminalions of the participants leave little doubt that the longitudinal data will lend themselves to describing the initiation, pattern of development and the rate of progress of periodontal disease during major portions of the adult life of these people. Although direct comparison and detailed discussion of previously published data and the present material must await the publishing of tbe detail reports (Loe ct aL 1978a, b), these initial studies suggest that the Norwegian group, periodontal destruction advances at a slow rate, whereas the Sri Lanka tea laborers display a much greater rate of destruction. These basic observations indicate that the chosen population groups may indeed represent extremes as far as the natural history of periodontal disease is concerned.

Kandy, without whose wholehearted support this study could not have been undertaken and continued. Thanks are also due to Oslo University and its Faculty of Dentistry for providing clinical facilities during the examinations, to the public school authorities in Oslo and the university administration for their support during all phases ot this work.

References ngh, O. 1978. Personal communication. Glavind, L. & Loe, H. 1967. Errors in the clinical assessment of periodonta] destruction. /. PeriodofUa! Res. I: 180-184. Gythfeidt, T. 1937. Oslo kommunale tannklinikker. Oslo. Hansen, B. F. 1976. Dental conditions in a 35 year old Norwegian urban population. Thesis University of Oslo. Hansen, B. F. & Johansen, J. R. ]976. Dental vi.sits, teeth remaining and posthetic appliances in a Norwegian urban population. Comm. Dent. Epidemiol, 4: 176-181. Loe, H. 1962. Epidemiology of periodanta! disease. Odontol T. 71: 479-503. Loe, H. 1967. The Gingivai Index, the Plaque Index and the Retention Index Systems. /. Peviodonwl. 36: 610-^16, Loe, H. & Silness, .1. 1963. Periodontal disease in pregnancy. J. Prevalence and severity. Acla Odontol. Scand, 21: 533-551. Loe. H., Anerud, A., Boysen, H. & Smith, M. R. 1978a. The natural history of periodontaf disease in man. Tooth mortality rates before 40 years of age. J. Periodontal Res. 13: 563572. Loe, H., Anerud, A., Boysen, H. & Smith, M. R. 1978b. The natural history of periodonta] disease in man. The rate of periodonta] destruction before 40 years of age. J. Periodontol, 49 (in press). Ramm. J. 1952. Litt om den kommuna]e tannpteie: Oslo. Munnpleien 45: 1-5. Ramm, J. 1954. Offentiig tannpleic i Norge. Munnpleien 47: 1-22. Scherp, H. W. 1964. Current concepts in periodontal disease research: Epidemiological contributions. J. Amer, Dent. Assoc, 68: 667675.

Acknowledgment This sludy was supported by grants from the Danish Research Council, the Royal Danish Foreign Ministry (DANIDA) and the University of Connecticut Research Foundation. The authors would like to express their gratitude to Professor S. B. DJssanayake, his colleagues, staff and students at the University of Sri Lanka in Paradeniya, to the staff at the tea plantations and lo the many others in Colombo and

562

LOE, ANERUD,

B O Y S E N A N D S M I T H

Silness, J. & Loe, H. 1964. Periodontal disease in pregnancy. II. Correlation between ora! hygiene and periodontai condition. A eta Odontol. Scand. 22: 112-135. Smith, M. R., Anerud, A. & Loe, H. 1977. Analyzing the reproducibility of the gingival index and other ordinal indices. J. Dent. Res. 56: Special Issue B 590. Waerhaug, J. 1966. Epidemiology of periodontal disease. Review of literature. In: World

Workshop in Periodontics. (eds,) Ramfjord, S. P., Kerr, D. A. & Ash. M. M. pp. 181-203. Ann Arbor: The University of Michigan Press. Address: University of Connecticut Health Center School of Dental Medicine Farmington, Connecticut 06032, U.S.A.