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 perio-
dontal 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 gen-
eralized 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

childhood to old age, (3) that gingivitis con-

Introduction
A study of the literature shows that a con-
siderable body of knowledge on the distribu-
tion and severity of periodontal disease has
been accumulated. For review of the epi-
demiology 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
stitutes the initial lesion in periodontal dis-
ease, 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
Sfudy Design Norway
AGE
1969 1971
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 vari-
ous geographic areas. Longitudinal investi-
gations in which the total sequence from
initial development, progression of the dis-
ease 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 continu-
ous; 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 pertain-
ing to such a life-long individual approach,
we decided to utilize a study design in
O F P E R I O D O N T A L D I S E A S E
1973 1975
3 and subsequent r
which groups of individuals who were be-
tween 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! break-
down during man's adult life, their dynamic
relationship to the nature of the early le-
sion, to the amount of mineralized and non-
mineraiized tooth deposits and to other
local factors. Such a semi-longitudinal ap-
proach 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-sec-
tional estimates are valid in describing the
course of the disease.
The material presented in this and sub-
sequent 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
1970 1971
Fig. 2. The semi-lo
Sri Lankan group.
dontal disease in population groups in Nor-
way and Sri Lanka. The two groups show
geographical, racial, cultural, socio-econom-
ic and educational differences and they rep-
resent 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 situa-
tion in the two groups on tbe basis of
the initial cross-sectional data.
AGE
1973 1977
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 be-
tween 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 den-
tal schools. Those born in 19.50 and 1952
were recruited from three high schools in
Oslo (Grefsen, Ullern and Fagerborg), se-
lected 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 riod of time other programs have been ad-

Number of Norwegian students and academi- ded to include both preschool ehildren and
cians that participated in each survey and the university students, so that during the last
number that participated in ail surveys by 20 years the dental care program has cov-
birlh cohort. 1969-1975 ^^^^ j ^ ^ ^^^ ^^^^ j ^ ^ ^ 3 ,^ 23 years. In
" j^g^^ addition, the City of Oslo has also a well
Birthysar 1969 1971 1973 1975 ^^^^^^^ developed system of private practitioners.
' " " The ratio of dentists to patients (1:600,
1940 38 za 21 15 13 Statistical Year Book of Norway 1973) in-
1942 76 46 37 31 22 dicates that the density of dental care pro-
i * f^ I 5 viders in this area is one of the greatest in
1948 78 58 50 40 26 the world. Recent data confirm that cbil-
1950 62 33 S3 20 13 ^jj.^^ ^^^ youths who had chosen not to
^^^ ^^ participate in the school dentistry program
Total 5C5 381 292 245 167 ] () per cent) Continued to see their pri-
~ vate family dentists on a regular basis (Han-
sen 1976. Hansen & Johansen 1976). In-
through which every school child was of- deed, there are probably very few popula-
fered systematic dental care including pre- tion groups in the world, who in 197.') and
ventative, restorative, endodontic, orthodon- at the age of 4-0 years, could docunaent an
tic and surgical therapy. From 1936 (Gyth- exposure to systematic dental care similar
feldt 1937) all children have been entitled to that of those participating in this investi-
to comprehensive examinations and treat- gation. The natural fluoride content in the
ment on an annual recall schedule. Through- drinking water in this area is 0.03 ppm.
out the last 40 years (1936-1976) more Since 1963 the program has included super-
than 90 per cent of the eligible ehildren vised brushing with 0.2 per eent sodium
have participated in this scheme (Ramm fluoride 4 times per year before the 14th
1952, 1954, Engh 1978). Over the same pe- year. In addition, each time the students
saw their dentist during the year they rinsed
with a 0.2 per cent sodium fluoride solution.
Table 2 Since 1947 each child in grades 1 through 7
Number ot Sri Lankan tea laborers that has received individual itistruction or re-
participated in eaeh survey and the number instruction in oral hygiene techniques once
that participated in aii surveys by birth cohort. ^ ^,^^^ .j.),lj motivation, instruction and re-
t970-t97T inforcement was performed by dental hy-
ITall gienists (Engh 1978).

The Sri Lankan Group

1940
^942 36 32 27 9 A second group was established in Sn Lan-
1944 61 52 46 30 2S {^^ j , ^ igjQ g^d coHSisted of 480 male tea
S ^7 65 S S 28 laborers between 15 a n d 3 0 - ^ years of age
1950 62 54 51 27 2-* who worked at the Dunsinane and Harrow
1952 69 63 54 33 28 y^^ Eslates (Table 2). These two plantations
-.nc. yi-7 An T ; ?? 16

1956 40 34 29 are situated in the central highland approxi-

228 196
mately 50 miles from Kandy and their pop-
Totai 480 422 370
ulation totals approximately 5,000. The par-
 LOE, ANERUD, BOYSEN AND SMITH

Table 3 in 1969. Subsequent examinations took

Cumulative number of observations in each place in 1971, 1973 and in 1975. Future ex-
age category for all participants and for those aminations are scheduled in 1979, 1983 and
who appeared in all four surveys 1987. The Sri Lankan groups were exam-
(in parenthesis)
ined initially in 1970, in 1971, 1973 and in
1969-1975 1970-1977 1977. Re-examinations are tentatively sched-
Age. Years Norwegian students Sri Lankan uled for 1981, 1985 and 1989. The time
and academicians tea laborers
span between the first and fourth examina-
15-16 77 (34) tions was, in Oslo 6 years and 3 months,
17-18 81 (21) 127 (58) and in Sri Lanka 7 years and 6 months.
19-20 127 (34) 162 (72)
21 22 150 (60) 196 (95) At each appointment the participants
23-24 216 (97) 203 (98) answered questions regarding personal den-
25-26 232 (102) 199 (104)
tal care and oral hygiene practices (Nor-
27-28 232 (111) 170 (91)
29-30 174 (98) 145 (85) way), smoking (Norway and Sri Lanka),
31-32 147 (70) 85 (59) and betel chewing habits (Sri Lanka). Mis-
33-34 75 (44) 57 (38)
35-36 33 (22) 19 (18)
sing teeth were recorded in all participants
37-38 + 14 (9) 19 (16) at each appointment (Loe et al. 1978a). The
clinical examination of the periodontal tis-
sues and adjacent portions of the dentition
ticipatits were all tamils and descendents of included measurements and scoring of in-
groups who 2-3 generations ago emigrated dices on all mesial and facial surfaces of all
from Southern India. The population was teeth, except third molars. The following
considered stable since there were few op- indices or measurements were recorded:
portunities for them to work outside the Gingival Index (GT) (Loe & Silness 1963)
plantation. The tea laborers were essentially Loss of Attachment (LA) (Glavind & Loe
iUiterate and had very little communication 1967)
with life outside the estate. They were Plaque Index (Pll) (Silness & Loe 1964)
healthy and well-built by local standards Calculus Index (Cl) (Loe 1967)
and their nutritional condition was clinically Gingival Caries Index (Cal) (Loe 1967)
fair. The food which was partly provided by Filling Margin index (FI) (Loe 1967)
the estate administration, consisted mainly At each examination throughout the study
of rice and vegetables, fish or meat curry, the same indices were scored by the same
consumed at noon and before bedtime. two investigators, who were both wefl-
During the working hours the laborers trained and experieticed periodontists. One
drank tea sweetened with sugar. The fluo- always scored the periodontal situation (Gl
ride content in the drinking water was .02-. and LA). The other always scored for local
.07 ppm. Adding tea to the water did not exogenous factors (Pll, CI. Cal and FI).
appreciably increase the fluoride content. Each participant had all teeth scored for 6
The workers in these two estates had never indices at two sites per tooth, totalling in
been exposed to any programs or incidents case of complete dentition, 336 recordings
relative to prevention or treatment of den- for each individual at each examination. Al!
tal diseases and toothbrushing was un- scores were dictated to the chairside assis-
known. Bete! chewing was common. tant who recorded the scores on a special
scoring chart (Fig. 3).
The Clinical Examinations The sequence of scoring was always tht
The Norwegian group was first examined 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 6 5 4 3 2 1 + 1 2 3 4 5 & 7 7 6 5 4 3 2 1 - 1 2 3 4 5 & 7

CALCU
a
JTC
FILLIN OS
3 * 1 1
1 1 1 1

III
oiNatv*
> 1 IJDM ,M X
ACHMENt

. 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 investi- same day. Every effort was made to keep
gator A using a pointed probe. The partici- the examiners blind at the second scoring.
pant would then move over to another chair In Sri Lanka 35 tea laborers were selected
where investigator B would score for gingi- at random in 1970 and re-examined once
vitis and measure loss of attachment from according to the protocol used in Oslo in
the cementum-enamel junction (Loe et al. 1%9.
1978b). These measurements were made The overall percentage of agreement for
with a blunt probe graded at 1, 2. 3, 4, 5, 7, each index by tooth and surface type are
9, 11 millimeters. The same probes were given in Tables 4 and 5. For each index a
used at all examinations in Norway and Sri reproducibility matrix was produced (Smith,
Lanka. The diameter of the probes was 0.6
mm. Table 4
Intra-examiner reproducibility for each
Percentage Agreement for Each Index by
index was tested at baseline and repeated Surface and Tooth Type in 29 Norwegians
periodically in both the Norwegian and Sri
Lankan groups throughout the study. In the Index Sicijspids in.cisors

Norwegian group, 29 subjects were scored Mesial B u c Mesial Bucca 1 Mesial Buccal
twice during the first session in 1969. The
806 866 82.3 81.5 80.3 77.7
individuals were selected for re-examination GI
79.4
LA 64 2 65.3 77.2 73.9 71.9
at random by the secretary of the project. Pll 75.0 69 4 70.7 68.1 66.7 60.3
Usually the participants were requested to Calculus 87.8 94.0 86.4 98.7 85.5 96.2
Fillings 93.5 90.1 94.4 99.1 91.6 97.7
report back the next day, but due to various 97.0 yy.1 98.0
Caries 97.0 96.5
circumstances some were scored twice the
 LDE, A N E R U D , B O Y S EN A N D SMITH

peutic measures were undertaken during

Percentage Agreement for Each Index by the scoring sessions. Actually, the investiga-
Surface and Tooth Type for 35 Sri Lankans tors made special efforts to avoid any dis-
ruption of any habits, home-care practices
Index Molars Bicu spidt ncis o,s
or any other activity pertaining to the oral
Mei jccai health status of the participants in Norway
as well as in Sri Lanka.
GI 70.7 73.2 69.2 78.4 75,3
LA 58.4 66.5 67.4 69.2 63.4
PM 94.6 86.8 93.4 72.5 93.8 Data Analysis
Calculus 81.32 69.3 79.9 69.2 74.3
The data for eaeh examination in Norway
Fillings NA NA NA NA NA
Cartes 97.7 98.4 98.2 98.2 98.6 and Sri Lanka were computerized and up-
dated on an ongoing basis and finally have
begun to be subjected to detailed analysis.
Anerud & Loe 1977); mean differences Each population was divided into two-year
were tested using the t test, and distribu- age cohorts to facilitate the analysis.
tional differences were tested using the Chi- As with most studies of this size, a cer-
Sq test. In both groups the lowest percent- tain number of the population dropped out
age agreement occurred in the measure- and could not be followed-up. Tables 1 and
ment of loss of attachment. However, 98 2 give the number of individuals who parti-
per cent of the measurements were within cipated in each survey by birth cohort. In
one mm of each other. The reproducibility Oslo the 1975 yield of 43 per cent of the
measures for each individual index will be original was reasonable considering re-
reported in their respective papers. The re- sources were not available to provide trans-
sults do indicate that both examiners were portation to the examination site. It is anti-
consistent in their criteria for all clinical in- cipated that future examinations of the Oslo
dicies. population will yield a higher return. The
The examinations of the Norwegians took Sri Lankan group suffered from a repatria-
place at a facility provided by the Oslo Uni- tion program which was unknown to the in-
versity Faculty of Dentistry, equipped with vestigators at the start of the study. During
two dental chairs, scialitic lamps, compres- the last scoring (1977) Sri Lankan authori-
sed air and saliva ejectors. Each examiner ties confirmed that the program had been
had two chairside assistants, one attending terminated and there were no plans for its
directly to the process of patient examina- reactivation. In both populations the loss to
tion., the other was assigned to recording the follow-up individuals appears to be indepen-
scores. dent of age.
The plantation group in Sri Lanka were In the analysis of the development of
scored in an outdoor facility comprising two periodontal disease the most interesting
portable dental chairs and supporting equip- groups are those individuals who were pre-
ment, but no compressed air and saliva sent in all surveys (I.A.S.). Also, analyses
ejectors. Two dental students as-iisted each were performed on an all valid observation
investigator during the scoring and in ic- group (A.V.O.). The I.A.S. group was com-
cording the scores, much in the same way pared to the total A.V.O. group on each
as the chairside assistants did in Oslo. specified parameter to determine if those
Since the purpose of this investigation lost to follow-up were significantly differeni
was to study the natural development of from those that remained in the study. Thi-'
periodontal disease, no preventive or thera- A.V.O. group was useful for estimating eer
 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 3.3 MM
MESIAL SURFACES
3 0 * YEARS. rEA LABORERS

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; of attachment the youngest and oldest age

groups in f ind Sri Lanka.

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 esti-
mates 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. Ap-
proximately 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 sur-
faces 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 supra-
gingival 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

1.22 1 ,19 1.16 1.17

N ^^ OQ .33
.1:1 .27
57 ^fl
.28 0"^ OR
Plaque
1.97 1.98 1 .97 2.00

GlngiviMs
(Survey 2)

teeth and to a lesser extent in maxillary
first molars. The differences between cal-
culus scores in the youngest and the older
age groups were small (Table 6). Approxi-
mately 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 reg-
ular treatment. The mean index for un-
treated 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), Gingi-
vai caries occurred in less than 10 per cent
of all surfaces. There was no major differ-
ence 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 in-
dividuals. However, in contrast, the fre-
quency 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 ten-
dency 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
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
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 measure-
ments 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-
O F P E R I O D O N T A L D I S E A S E 559
and per cent scores ot GI ^ 2 (upper
(solid) at baselina 1969-1970.
form any conventional oral hygiene mea-
sures and consequently displayed quite uni-
formly 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 dis-
tribution did not vary appreciably in dif-
ferent 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 sub-
gingival calculus was frequently found
(mean CI = 0.87, Table 6). With no possi-
bility 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 Percisnt measurements of a ttachment loss

Mear 1 LA
surfac
mn
Age red 0-1 1 2-4 rT,m. 5-9 mm. 10 mm.

N SL N SL N SL N SL N SL N SL

15 2160 0.17 96.39 1.80 0.24 0.0

17 4438 2604 0.06 0.23 99.03 95.51 0.59 3.26 0 0.16 0 0.0
19 3336 3818 0.15 0.40 97,42 91,62 2,22 6.71 0 0.56 0 0.0
21 4256 3389 0.41 0.68 90.74 85.26 7.43 12.74 0.09 1.04 0 0.06
23 5170 4180 0,52 0.92 89.89 78.73 8.84 17.71 0.21 2.46 0 0.09
25 5238 2890 0.66 1.14 85.24 74.01 12.12 20-25 0.31 4.21 0 0.24
27 4122 3332 0.74 1.23 79,96 67.68 15.31 29.26 0.54 2.37 0 0.06
29 2048 1858 0.78 2.06 79.44 50.78 16.80 33.09 0.25 11.37 0 1.03
30 + 2144 1816 0.98 3.11 73.27 30.67 20.33 43.67 0.94 21.14 0 2-93

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 sig-
nificant 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 man-
dibular molars and incisors (Fig. 4). There
was a dramatic increase in the genera! de-
struction 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 sur-
faces 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 ex-
aminations 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 inflam-
mation 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 at-
tachment loss, with a calculated rate of ap-
proximately 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 in-
creases with age. Caries and dental restora-
tions are non-existent. Gingiva is character-
ized by moderate to severe inflammation.
 T H E N A T U R A L H I S T O R Y
Slight loss of attachment is present in first
molars and incisors of the 15 year old and
progresses from this age on with a calcu-
lated 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 substan-
tial number of root surfaces exhibit attach-
ment loss in excess of 10 mm (Loe et al.
1978b).
As a whole, the results from these base-
line examinations show that all stages of
periodontal health and disease are preseni
in these two populations. The detailed re-
cording systems used and the frequent
scheduling of reexaminalions of the partici-
pants 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 dur-
ing major portions of the adult life of these
people. Although direct comparison and de-
tailed 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 de-
struction advances at a slow rate, whereas
the Sri Lanka tea laborers display a much
greater rate of destruction. These basic ob-
servations indicate that the chosen popula-
tion groups may indeed represent extremes
as far as the natural history of periodontal
disease is concerned.
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 ex-
press their gratitude to Professor S. B. DJs-
sanayake, his colleagues, staff and students
at the University of Sri Lanka in Para-
deniya, to the staff at the tea plantations
and lo the many others in Colombo and
O F P E R I O D O N T A L D I S E A S E
Kandy, without whose wholehearted sup-
port this study could not have been under-
taken and continued.
Thanks are also due to Oslo University and
its Faculty of Dentistry for providing clini-
cal 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 clin-
ical assessment of periodonta] destruction.
/. PeriodofUa! Res. I: 180-184.
Gythfeidt, T. 1937. Oslo kommunale tannkli-
nikker. 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 appli-
ances in a Norwegian urban population.
Comm. Dent. Epidemiol, 4: 176-181.
Loe, H. 1962. Epidemiology of periodanta! dis-
ease. 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: 563-
572.
Loe, H., Anerud, A., Boysen, H. & Smith, M.
R. 1978b. The natural history of periodonta]
disease in man. The rate of periodonta] de-
struction before 40 years of age. J. Perio-
dontol, 49 (in press).
Ramm. J. 1952. Litt om den kommuna]e tann-
pteie: Oslo. Munnpleien 45: 1-5.
Ramm, J. 1954. Offentiig tannpleic i Norge.
Munnpleien 47: 1-22.
Scherp, H. W. 1964. Current concepts in peri-
odontal disease research: Epidemiological
contributions. J. Amer, Dent. Assoc, 68: 667-
675.
562 LOE, ANERUD,
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 periodon-
tal disease. Review of literature. In: World
B O Y S E N A N D S M I T H
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.