AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 114:242–257 (2001)
Coca Chewing in Prehistoric Coastal Peru:
Dental Evidence
Etty Indriati1* AND Jane E. Buikstra2
1
Laboratory of Bioanthropology and Paleoanthropology, Gadjah Mada University Faculty of Medicine,
Yogyakarta 55281, Indonesia
2
Department of Anthropology, University of New Mexico, Albuquerque, New Mexico 87131-1086
KEY WORDS cervical-root caries; oral pathology; posterior teeth; coca chewing; Peru
ABSTRACT In this study, we describe the dental
health of four prehistoric human populations from the
southern coast of Peru, an area in which independent
archaeological evidence suggests that the practice of coca-
leaf chewing was relatively common. A repeated pattern of
cervical-root caries accompanying root exposure was
found on the buccal surfaces of the posterior dentition,
coinciding with the typical placement of coca quids during
mastication. To further examine the association between
caries patterning and coca chewing, caries site character-
istics of molar teeth were utilized as indicators for esti-
mating the likelihood of coca chewing for adults within
each of the study samples. Likelihood estimates were then
Theories about the prehistoric distribution of co-
ca-leaf chewing in ancient Andean peoples have
been the subject of considerable debate, particularly
the pervasiveness and geographical distribution of
coca chewing (e.g., Leigh, 1937; Murra, 1986;
Naranjo, 1981). In attempting to understand the
distribution of coca chewing in the ancient Andes,
studies have been conducted in multiple disciplines,
including biology (Cartmell et al., 1991; Aufderheide
et al., 1991); dental anthropology (Thompson, 1903;
Leigh, 1937; Klepinger et al., 1977; Elzay et al.,
1977; Turner, 1993; Langsjoen, 1996); archaeology
(Lanning, 1967; Lumbreras, 1974; Menzel, 1977,
Naranjo, 1981; Moseley, 1992); and botany (Molina
et al., 1985; Plowman, 1984, 1985 ). The findings and
conclusions from these reports, however, have not
always been consistent.
Leigh (1937), for example, reports less frequent
coca chewing on the coast than in the highlands,
whereas most other studies suggest a coastal em-
phasis (e.g., Moseley, 1992; Lumbreras, 1974; Lan-
ning, 1967). Archaeological evidence documenting a
predominantly coastal distribution includes: 1) coca
quids distending the cheeks of mummies from the
coastal Cabuza culture, Chile (⬃A.D. 500) (Cartmell
et al., 1991); 2) coca quids found in the mouths of
mummies with accompanying coca leaf-filled textile
bags in the coastal Chiribaya region (Aufderheide et
al., 1991); 3) Moche ceramic paintings depicting coca
chewing on the north coast of Peru (AD 100 – 800)
© 2001 WILEY-LISS, INC.
compared with results of a test for coca use derived from
hair samples from the same individuals. The hair and
dental studies exhibited an 85.7% agreement. Thus, we
have demonstrated the validity of a hard-tissue technique
for identifying the presence of habitual coca-leaf chewing
in ancient human remains, which is useful in archaeolog-
ical contexts where hair is not preserved. These data can
be used to explore the distribution of coca chewing in
prehistoric times. Simultaneously, we document the den-
tal health associated with this traditional Andean cultural
practice. Am J Phys Anthropol 114:242–257, 2001.
© 2001 Wiley-Liss, Inc.
(Moseley, 1992); 4) Moche ceramic portraiture illus-
trating a spatula being used to remove lime from a
gourd container, in preparation for coca chewing in
the north coast of Peru (Lumbreras, 1974); 5) burial
inclusions showing dried coca leaves and lime held
in gourd bottles and bone spatulas from the Late
Preceramic culture in coastal Peru (2500 BC–AD
1800) (Lanning, 1967); and 6) a stone sculpture de-
picting coca chewing in highland Tiwanaku Bolivia
(Kolata, 1993). There are many reports on the ar-
chaeological evidence of coca chewing on the coast,
but few for the highlands.
In addition to the discovery of extensive coastal
artifacts and coca paraphernalia, a prehistoric site
from the Zaña Valley in northern Peru has been
reported to contain evidence of lime production
(Dillehay, 1992; Dillehay et al., 1991). The authors
report that lime or cal was produced from travertine
and calcite deposited at the headwaters of local
creeks. They suggest that the lime extracted from
Grant sponsor: Bioanthropological Foundation; Grant sponsor: Uni-
versity of Chicago; Grant sponsor: National Science Foundation.
*Correspondence to: Etty Indriati, Laboratory Bioantropologi dan
Paleoantropologi, PO Box 23/YKBS, Yogyakarta 55002, Indonesia.
E-mail: indriati@idola.net.id
Received 26 October 1998; accepted 23 October 2000.
 COCA CHEWING IN PREHISTORIC COASTAL PERU
this early preceramic site was probably specifically
produced for use with coca.
In addition to artifacts and prehistoric lime pro-
duction, botanical remains of coca leaves have also
been found more frequently in the coastal lowlands
in comparison to the highlands. Botanical findings
suggest that coca was already under cultivation in
the Peruvian coastal valleys by 1900 –1750 BC
(Patterson, 1971) or 2500 –1800 BC (Plowman,
1984). Plowman (1984) concludes that a coca variety
which had adapted to the dry coastal environment,
namely Trujillo coca, was cultivated and chewed on
the Peruvian coast by 2000 BC and possibly earlier.
The expected conclusion from these studies, i.e., a
theory of coastal dominance of coca chewing in ar-
chaeological and botanical findings, however, is not
consistent with the conclusions of Leigh (1937).
Leigh (1937) argued, based on dental evidence, that
coca-leaf chewing was more common in highland
populations, a finding consistent with the modern-
day distribution of coca leaf consumption. Most mod-
ern reports indicate that coca chewers are predom-
inately residents of highland areas (Hanna, 1974;
Allen, 1986, 1988). Buck et al. (1968) indicate that
the percentage of traditional Andean Indians who
chew coca decreases substantially from the high-
lands to the lowlands. At about 11,500 feet, coca
chewers make up about 72% of the population; at
5,600 feet, about 28%; at 3,500 feet, about 29%; and
at sea level, about 3%. The relatively low frequency
of chewing among modern coastal populations dif-
fers from the prehistoric coastal evidence of coca
chewing. This difference may be explained in vari-
ous ways. It is probable that coastal peoples today
have been substantially influenced by modern urban
practices and have moved away from traditional
lifestyles. In addition, highlanders have gradually
gained access to coca over time, have faced less
cultural and governmental interference, and have
found coca chewing helpful in reducing altitude sick-
ness.
The conflict between the conclusions of Leigh
(1937) and the findings of others is a focal point for
our study. Specifically, we develop a new method for
identifying coca usage in the prehistoric skeletal
record which may help clarify the contradictory find-
ings of previous research.
USE OF BIOLOGICAL EVIDENCE IN
IDENTIFYING COCA CHEWERS
One method for investigating the distribution of
coca chewing among ancient Andean peoples is
through studying the effects of coca-leaf chewing on
teeth, thereby allowing the identification of coca
chewers from skeletal remains alone. Unfortu-
nately, there has been no systematic attempt to
accomplish this. The presumed oral pathological ef-
fects of coca-leaf chewing are numerous and include:
heavy calculus formation (Klepinger et al., 1977);
dark brown tooth crowns (Elzay et al., 1977); brown
or green-colored accretions on teeth (Thompson,
243
1903); calcareous accretions (Leigh, 1937); buccal
alveolar bone erosion (Turner, 1993); and antemor-
tem posterior tooth loss (Langsjoen, 1996). Unfortu-
nately, systematic evaluation of these factors as coca
indicators is lacking.
In biology, efforts to detect coca use in prehistoric
populations have primarily relied on the presence of
preserved hair from mummies. Two primary efforts
have been undertaken in the field of biology: testing
hair and researching dental evidence. In an innova-
tive study, Cartmell et al. (1991) and Aufderheide et
al. (1991) detected the presence of traces of coca, as
a cocaine metabolite benzoylecgonine (BZE), in the
hair of ancient mummies from the coastal Andes via
a radioimmunoassay technique. Hair follicles easily
capture the metabolite and provide an accurate
method of testing for coca consumption, either
through chewing or by drinking coca tea. While hair
analysis (Cartmell et al., 1991; Aufderheide et al.,
1991) provides convincing biological evidence for
coca use in prehistoric populations, research on the
association between various dental signatures and
coca-leaf chewing (Klepinger et al. 1977; Elzay et al.,
1977; Thompson, 1903; Leigh, 1937; Turner, 1993;
Langsjoen, 1996) has been speculative at best. Thus,
there is a clear need for a more systematic evalua-
tion of the dental evidence.
EFFECTS OF COCA CHEWING ON THE ORAL
ENVIRONMENT
Coca leaves are the primary materials used in
coca chewing, even though lime is commonly added.
Coca contains alkaloids such as cocaine, cis- and
trans-cinnamoylcocaine, ecgonine methyl ester, ben-
zoylecgonine, tropacocaine, pseudococaine, methyl-
egnonine, hygrine, cuscohygrine, and nicotine (Car-
roll, 1977, p. 43). Among these, cocaine has the
strongest anesthetic and narcotic effect in the oral
cavity, such as the blocking of the parasympathetic
nerves, thus increasing blood pressure and creating
a feeling of euphoria (Weil, 1981). Coca chewing also
suppresses salivary glandular activity, decreasing
the secretion of saliva and slowing salivary flow, a
condition termed xerostomia (dryness of the mouth,
caused by the halting of normal salivary release,
Mosby Medical Encyclopedia, 1992, p. 837).
The positive relationship between decreased sali-
vary flow, xerostomia, narcotic use, and caries is
reported in various studies. For example, Johnson
and Brown (1993) state that cocaine dries the
mouth, and Holbrook (1993) reports that low sali-
vary flow rate is significantly associated with high
caries prevalence. Holbrook (1993), however, did not
provide information on the location of the individual
caries. Kerr (1986) also suggests that xerostomia
predisposes caries formation. Kerr (1986) notes that
drugs or irradiation treatments may cause cervical
caries, also known as rampant caries. Another ex-
ample of xerostomic relation to cervical caries is
discussed by Hecht and Friedman (1949), who re-
ported a high incidence of cervical caries in narcotic
244 E. INDRIATI AND J.E. BUIKSTRA
TABLE 1. Number of observed individuals from all sites1
Number of Age range
Sites individuals (years)
Chiribaya Alta 26 20–55
Algodonal 5 20–40
Yaral 9 20–50
Chen-Chen 46 20–45
Total 86
1
Each individual has an assigned case number (see Tables 6 –9).
Fig. 1.
addicts (76%; 115/151). These findings suggest that
the cervical segment of teeth is more susceptible to
caries formation than other areas in the oral cavity.
This is perhaps because cementum is less dense
than enamel, and therefore the cementum at the
root is more prone to caries compared to the enamel
at the crown of the teeth.
FOCAL POINT OF THIS STUDY
The current study attempts to utilize dental evi-
dence to help resolve some of the contentious issues
regarding the biological effects of coca use. Previous
research suggested that coca chewing induces xero-
stomia, thus causing cervical-root caries on the mo-
lar area where the coca quid is typically positioned
during chewing. The availability of research sub-
jects (prehistoric individuals established as coca
chewers through evidence of positive traces of coca
substance; Aufderheide et al., 1991) provided an
opportunity to study the dental lesions of these in-
dividuals. This in turn enabled us to develop a sys-
tematic method for identifying coca chewing in skel-
etal populations and thereby aid in research on the
distribution of coca chewing in prehistoric Andean
populations.
We hypothesize, based on previous archaeological
findings, that coca chewing was pervasive in prehis-
toric Andean populations. We define a systematic
dental method for identifying coca chewing that has
Average age
(years) Male Female
34.46 10 16
32.00 3 2
33.33 6 3
32.26 18 28
33.01 37 (43%) 49 (57%)
Map of area of study.
previously been ignored in distributional studies.
This method, we feel, provides an important contri-
bution to this anthropological question.
In conducting this research, we examined the den-
tal health of prehistoric individuals who had previ-
ously been tested for coca use through hair analysis
(Aufderheide et al., 1991). From these data, we de-
veloped a quantitative dental technique for identi-
fying coca chewing, which in turn enabled us to plot
the prehistoric distribution of coca chewing based on
the percentage of identified coca chewers in our
south-central coastal Andean populations.
MATERIALS AND METHODS
One of us (E.I.) examined the dental health of 86
individuals from four prehistoric sites in southern
coastal Peru (AD 800 –1350): Chiribaya Alta, Alg-
odonal, Yaral, and Chen-Chen (Table 1, Fig. 1). The
inhabitants of these sites were primarily maize ag-
riculturalists who supplemented their diets with a
variety of other domesticated and wild resources
(Dendy, 1991). The first three samples have been
examined for coca use via radioimmunoassay by
Aufderheide et al. (1991), using preserved hair
samples. Aufderheide et al. (1991) applied radio-
immunoassay (RIA) to test for the presence of co-
caine metabolite remnants, namely benzoylecgnonie
(BZE). They took 30 mg of hair from each individual
studied, rinsed the hair with 100 ml sterile water,
 COCA CHEWING IN PREHISTORIC COASTAL PERU 245
and centrifuged it. The rinsed water was used for
analysis of the presence of BZE. This analysis was
done with an antibody reactive with cocaine and
cocaine metabolite. RIA was monitored by a gas
chromatography-mass spectrometry method (GCMS).
Aufderheide et al. (1991) found an excellent correla-
tion in samples tested by RIA and GCMS. They set
the “cutoff” value differentiating reactive (positive)
from nonreactive (negative) at 5 ng of BZE/10 mg of
hair.
One of us (J.E.B.) randomly selected samples aged
20 –50 years (average age about 33 years, Table 1)
from Chiribaya Alta, Algodonal, and Yaral popula-
tions. Sex was determined through pelvic and cra-
nial morphology (Buikstra and Mielke, 1985); age
was determined by pubic symphysis morphology
(Suchey et al., 1986) and lateral anterior cranial
suture closure (Lovejoy et al., 1985). E.I. scored the
dental remains without knowledge of the results of
the radioimmunoassay tests.
We scored the following variables: tooth presence,
antemortem and postmortem tooth loss (Turner et
al., 1991), stage of dental wear (Scott, 1979; Smith,
1984), direction of attrition, slope of the teeth and
wear angle of occlusal surface (Smith, 1984), and
caries location and extent of calculus formation
(Dobney and Brothwell, 1986). Root exposure was
measured from the cemento-enamel junction to the
alveolar bone, and coded as 1– 4: 1, if the distance
was 1–ⱕ3 mm; 2, for ⬎3–ⱕ4 mm; 3, for ⬎4 –ⱕ5 mm;
and 4, for ⬎5 mm. If abscesses were present, the
location was recorded as either buccal or lingual. Fig. 2. a: Mandible, left view. On lower first and second
molars, note triangular root caries with severe root exposure but
Careful observation of dental pathological condi- intact crowns. This is an example of a strong indicator for coca
tions revealed a repeated pattern of buccal caries on chewing. b: Close-up of described area.
the cervix of molar teeth, frequently extending api-
cally and accompanied by severe root exposure (Figs.
2a,b, 3). We subsequently hypothesized that this
pattern could be the primary indicator of coca leaf ence of molar roots loosing crowns, and antemortem
chewing (CLC) resulting from the quid (chewed coca loss of molars) because they are obvious and do not
leaves with the addition of lime) being placed di- require a visual demonstration. However, Figure 4
rectly on the area. Other dental features considered represents the drawing of these weak indicators.
as secondary indicators included buccal crown car- As indicated in Table 2, strong indicators are at-
ies, interproximal caries, presence of only molar tributed only to lower molars. If all lower molars
roots being exposed, and antemortem loss of molars. were present, the maximum possible number of
These dental variables are listed and quantified in strong indicators in one individual is 6, with one
Table 2; together they form the dental technique indicator corresponding to each lower molar. In
used to identify coca chewers. On both lower and many examples, however, molars were lost before
upper molars we divided these parameters into death. Antemortem loss could be due to caries, pul-
three categories: strong, mild, and weak expres- pitis, or periodontitis, which may or may not be
sions, as detailed in Table 2, and illustrated in Fig- associated with coca chewing. We therefore included
ure 4. We used these indicators to place each indi- antemortem molar loss as a weak indicator of coca
vidual into categories of either a definite, probable, chewing. In addition to antemortem molar loss, post-
or possible coca chewer, or nonchewer, as indicated mortem tooth loss also occurred in the archaeologi-
in Table 2. Photographs of strong indicators are cal remains. To cope with the problem of antemor-
presented in Figures 2 and 3 in the form of cervical- tem loss of molars, we determined that the presence
root caries with irregular alveolar resorption on the of 2 strong indicators and accompanying mild or
buccal surface of lower molar teeth. An example of a weak indicators was sufficient to place an individual
mild indicator in the form of root caries on the in- in the “definite coca chewer” category (⫹CLC). We
terproximal surface of an upper molar tooth is seen describe the identification categories of coca chewers
in Figure 5 (MI-2604). We do not present a photo- in Table 2, as part of the dental technique. Results of
graph of weak indicators (interproximal caries, pres- coca-chewer determinations were compared to the
246 E. INDRIATI AND J.E. BUIKSTRA
Fig. 3. Mandible, right view. On lower first molar tooth, note
deep triangular root caries following root outline on buccal sur-
face, with occlusal surface and buccal crown caries-free. We de-
fine this as an example of a strong dental indicator for coca
chewing.
results of hair analyses (Aufderheide et al., 1991) for
the same individuals.
Statistical analysis
We use the chi-square statistical test to compare
the frequency of coca chewing between males and
females. Specificity and sensitivity tests establish
the significant concordance between dental tech-
nique and hair analysis. Sensitivity and specificity
are two means of describing test accuracy (Ingelfin-
ger et al., 1983) that are commonly used in clinical
medicine. “If all persons with the disease have ‘pos-
itive’ tests, we say that the test is sensitive to the
presence of the disease. If all persons without the
disease test ‘negative,’ we say that the test is specific
to the absence of the disease,” according to Ingelfin-
ger et al. (1983). Ingelfinger et al. (1983) also state
that if a test is sensitive and specific, no ambiguous
interpretation occurs, but this condition rarely hap-
pens. We therefore define a threshold of 75% concor-
dance between two tests as significant. The applica-
tion of specificity and sensitivity tests in our study is
useful to establish the probable positive rates of true
coca chewers and probable negative rates of true
nonchewers. We tested the dental test (CLC) against
a hair assay (BZE) by applying sensitivity and spec-
TABLE 2. Dental techniques developed to identify coca chewers
Categories of variables on molar teeth used to identify
coca-chewers
1. Strong
Lower molars with deep and wide cervical-root caries on the
buccal surface, with severe root exposure equal or more
than 3 mm from the cemento-enamel junction.
2. Mild
A: Upper molars with deep and wide cervical-root caries on
the buccal surface, with severe root exposure less than 3
mm from the cemento-enamel junction.
B: Cervical-root caries on the mesial, distal, and lingual
surfaces of upper and lower molars;
C: Cervical-root caries on the buccal surface of premolars,
when their adjacent molars were lost antemortem;
D: Buccal-pit caries and caries on the buccal crown.
3. Weak
A: Interproximal caries;
B: Presence of molar roots only;1 Antemortem loss of
molars1
Identification categories of coca chewers
1. Definite coca-leaf chewer (⫹CLC): two strong indicators
present, along with accompanying mild or weak indicators.
2. Possible coca-leaf chewer (⫹?CLC): one strong indicator and
at least one mild indicator present.
3. Possible coca-leaf chewer (⫹??CLC): at least one mild
indicator present, or the percentage of mild indicators
relative to number of molars observed is at least 33%.
4. Noncoca-leaf chewer (⫺CLC): may or may not display mild
indicators. If displaying mild indicators, the percentage of
mild indicators relative to number of molars observed is
below 33%.
1
In our later study (Indriati, 1998), the presence of molar roots
only and antemortem loss of molars are in fact strong dental
variables for coca chewers.
ificity tests (Dawson-Sanders and Trapp, 1990, p.
231).
RESULTS
General findings
Because tooth wear, abscess presence or absence,
and calculus are not the focus of our study, we do not
present these data by specific categories such as
tooth type or age cohort. Instead, these observations
merely provide a general background of the oral
health of the Andean populations we are studying.
The teeth generally exhibit slight to moderate wear
(Scott, 1979 for anterior teeth; Smith, 1984 for pos-
terior teeth). Abscesses are uncommon and, when
present, are usually on the buccal surface. Calculus
is slight to moderate (Dobney and Brothwell, 1986),
suggesting normal pH in the oral environment. Root
exposure varies in severity. Overall dental structure
is therefore sound and should not, by itself, lead to
irregular caries patterns. However, in cases where
severe root exposure is observed, it is usually accom-
panied by root caries that developed first at the
cemento-enamel junction and then extended api-
cally on the buccal surface. This condition primarily
affected molars, which is consistent with our hy-
pothesis concerning the quid position in the cheek
region during coca chewing.
Caries rates
In measuring caries rates, we calculated the total
adult tooth count in total mouths, which can include
 COCA CHEWING IN PREHISTORIC COASTAL PERU 247

Fig. 4. Illustration of variable categories. Location and shape of caries for strong, mild, and weak indicators of coca chewing, as
described in Table 2. Dark areas indicate caries. Superscripts refer to upper teeth and subscripts refer to lower teeth. M, molar teeth;
P, premolar teeth. A, B, C, and D refer to the text in Table 2.

one or more caries per tooth. Each of the four popu-
lations is characterized by a high total caries rate,
ranging from 30.1–54.5% (Table 3). This is signifi-
cantly higher than the caries rates for most agricul-
tural peoples reported by Turner (1979) (see Table
2), ranging from 2.3–26.9 %. This frequency also far
surpasses caries rates in mixed subsistence econo-
mies (0.44 –10.3%) and among hunter-gatherers (0 –
5.3%). The high caries rate and high incidence of
root caries in our study prompted the examination of
248 E. INDRIATI AND J.E. BUIKSTRA

study, Kelley et al. (1991) report 23.9% cervical car-

ies, 42.9% occlusal caries, 25.1% interproximal car-
ies, and 8.4% smooth caries. Langsjoen (1996) exam-
ined the same population and concluded that a high
caries frequency, particularly at the cemento-
enamel junction, along with high posterior tooth
loss, implicated the cultural practice of coca leaf
chewing among the Maitas Chiribaya.
In addition, cervical-root caries most commonly
attack the posterior teeth. Therefore, we further
limited our observations to molar teeth and found
that both lower and upper molars suffered root car-
ies exceeding other caries types. Lower molars dis-
played 39.8% of caries on the cervical-roots, includ-
ing 25.2% located on the buccal surface and 14.7%
on the mesial, distal, or lingual surfaces. This was
followed by occlusal pit caries (25.6%), pit caries on
the buccal surface and caries on the buccal crowns
(18%), occlusal caries (8.6%), and proximal caries
(7.9%) (Table 5). On upper molars, root caries sur-
passed other caries types: 40.5% (15.8% on the buc-
cal surface and 24.7% on mesial, distal, and lingual
surfaces). The occlusal pit rate was 25.3%, followed
by proximal, occlusal, and buccal crown caries
(15.2%, 10.1%, and 8.9%), respectively. We did not
analyze the caries percentage by age cohort in this
study, as we focus on caries location. We suggest
that the prevalence of caries on the buccal root of
molar teeth further strengthens our hypothesis re-
garding the probable relationship between quid
placement and caries development.
Fig. 5. Maxilla, distobuccal view. On upper molar tooth, note
severe root exposure accompanied by root caries on distal surface.
We define this as an example of a mild indicator for coca chewing. Coca chewing results
Based on the number and type of indicators rela-
TABLE 3. Caries frequency for all sites1 tive to the number of molars present, each individ-
Number of Number of % teeth ual was defined as a definite, probable, or possible
Sites teeth caries with caries coca chewer, or as a nonchewer (Table 2). Of 86
Chiribaya Alta 366 166 45.3
individuals from four sites, 35 individuals (40.7%)
Algodonal 123 67 54.5 were identified dentally as coca chewers. Of these 35
Yaral 189 57 30.1 individuals, we identified 16 (45.7%) as definite coca
Chen Chen 695 293 42.1 chewers (Table 6); 3 (8.6%) probable coca chewers
Total 1,373 428 31.2
(Table 7); and 16 (45.7%) possible coca chewers (Ta-
1
Adult tooth count in total mouths, one or more caries per tooth. ble 8). Nonchewers (⫺CLC) comprised 59.3% of the
sample (Table 9). Considering all sites collectively,
there is no evidence of sex difference in our sample
the distribution of caries locations in order to use it
in regard to coca chewing practice (Table 10; 46.9%
as an indicator of coca chewing.
vs. 32.4%; ␹2 ⫽ 1.84, P ⫽ 0.17).
The most common type of caries occurred in the
cervical area or in the cervical area extending to-
Comparisons with BZE test
ward the root (26.2% on the buccal surface and
15.9% on the mesial, distal, or lingual surfaces). After conducting the blind test, the results for
This was followed by small pit caries on the occlusal each individual designated dentally as a coca chewer
surface (23.3%), proximal caries (13.0%), pit caries or nonchewer were compared to the hair analysis by
on the buccal surface and caries on the buccal Aufderheide et al. (1991). The results indicate an
crowns (11.5%), occlusal caries (6.3%), and root-only 85.7% concordance (Table 11) between the two
caries (3.6%) (Table 4). The high frequency of cervi- methods of identification. Only 5 (14.3%) of 35 cases
cal-root caries in this study is unusual and requires (the total number of three samples) were inconsis-
further explanation, particularly since a similar dis- tent with the results of Aufderheide et al. (1991). In
tribution was identified among Chiribaya people two cases, possible (??CLC) coca chewers had nega-
from a coastal site at nearby Arica, Chile, about 120 tive BZE results (cases 16 and 34, Table 8). These
km south of Ilo, Peru (Kelley et al., 1991). In their two discordant cases might have resulted from indi-
 COCA CHEWING IN PREHISTORIC COASTAL PERU 249
TABLE 4. Frequency of caries location in total mouths

Sites Number of Caries location1

studied carious teeth OP O PMD CRB CRMLD PCB Only root Total
CHA 115 46.0 6.0 18 28.0 39.0 24.0 5.0 166
ALG 48 24.0 10.0 8 5.0 3.0 11.0 6.0 67
YAR 54 30.0 0.0 10 5.0 6.0 6.0 0.0 57
CHEN 214 36.0 21.0 40 55.0 105.0 26.0 10.0 293
Total 431 136.0 37.0 76 93.0 153.0 67.0 21.0 583
%3 23.3 6.3 13 15.9 26.2 11.5 3.6 100
1
OP, pit caries on occlusal surface; O, occlusal caries; PML, proximal caries on medial and distal surfaces; CRB, cervical-root caries
on the buccal surface; CRMLD, cervical-root caries on the mesial, lingual, and or distal surfaces; PCB, pit and or caries on buccal
crown.
2
CHA, Chiribaya Alta; ALG, Algodonal; YAR, Yaral; CHEN, Chen-Chen.
3
Number of caries location per total number of surfaces affected.

TABLE 5. Caries type for molar teeth1

Number of Location of caries

Sites studied carious surfaces RCB (%) RCMDL (%) PCB (%) P (%) OP (%) O (%)
Lower molar
CHA 84 17.8 10.7 25.0 5.9 34.5 5.9
ALG 33 12.1 3.0 24.2 17.8 30.3 15.1
YAR 24 16.7 8.3 16.7 8.3 45.8 4.2
CHEN 125 35.2 21.6 12.0 7.2 14.4 9.6
Total 266 25.2 14.7 18.0 7.9 25.6 8.6
Upper molar
CHA 55 16.4 18.6 9.1 20.0 16.4 14.5
ALG 19 0 10.5 21.0 15.8 36.8 15.8
YAR 18 16.7 5.5 5.5 22.2 50.0 0
CHEN 66 19.7 34.8 6.1 9.1 22.8 7.6
Total 158 15.8 24.7 8.9 15.2 25.3 10.1
1
RCB, root caries on the buccal surface; RCMDL, root caries on the mesial, distal, and/or lingual; P, caries on proximal surface; PCB,
pit and/or caries on buccal crown; OP, pit caries on occlusal surface; O, caries on occlusal surface; CHA, Chiribaya Alta; ALG,
Algodonal; YAR, Yaral; CHEN, Chen-Chen.

TABLE 6. Identification of definite coca-leaf chewer (⫹CLC)1

Number of BZE CLC Number of Indicator4

individuals Case tests2 test3 molars Strong Mild Weak
1 2 ⫹ ⫹ 11 2S 7M 3W
2 3 ⫹ ⫹ 5 3S 2M 4W
3 65 ⫹ ⫹ 10 4S 9M 1W
4 14 ⫹ ⫹ 5 2S 3M 4W
5 21 ⫹ ⫹ 7 4S 3M 2W
6 27 ⫹ ⫹ 10 2S 3M 2W
7 29 ⫹ ⫹ 12 2S 6W
8 40 ⫹ ⫹ 4 3S 4W
9 57 No test ⫹ 10 3S 3W
10 60 No test ⫹ 6 2S 7W
11 64 No test ⫹ 7 2S 5M 2W
12 66 No test ⫹ 5 3S 1M 1W
13 73 No test ⫹ 4 2S 4M 8W
14 82 No test ⫹ 4 2S 2M 6W
15 84 No test ⫹ 3 2S 4M 10W
16 86 No test ⫹ 4 3S 2M 7W
1
At least two strong indicators and two other indicators, either mild or weak, must be present.
2
BZE test, benzoylecgonine test-hair analysis (Aufderheide et al., 1991).
3
CLC test, coca-leaf chewer identified based on dental method developed in this study.
4
For indicators, we attach abbreviations of S, M, and W to the number of indicators present for strong, mild, and weak, respectively,
to emphasize the presence of each type of indicator in each individual.
5
See Figure 2.

viduals chewing coca occasionally but ceasing to
chew coca sometime (from 2–3 months to 2 years)
before death, rendering cocaine undetectable in
their hair (⫺BZE). Coca metabolite products remain
stable from 2 months up to 2 years in the human
body; thus, using coca at those times prior to death
facilitates coca detection. Ceasing coca use more
than 2 years prior to death would not leave detect-
able chemical signals in hair (Aufderheide et al.,
1991; Cartmell et al., 1991), even though dental
250 E. INDRIATI AND J.E. BUIKSTRA
TABLE 7. Identification of probable coca-leaf chewer (⫹?clc)1

Number of BZE CLC No. of Indicator4

individuals Case test2 test3 molar Strong Mild Weak
1 46 ⫹ ⫹? 7 1S 4M 4W
2 65 ⫹ ⫹? 3 1S 2M 10W
3 83 ⫹ ⫹? 2 1S 1M 9W
1
At least one strong and one mild indicators must be present.
2
BZE test, benzoylecgonine test-hair analysis (Aufderheide et al., 1991).
3
CLC test, coca-leaf chewer identified based on dental method developed in this study.
4
S, strong; M, mild; W, weak.

TABLE 8. Identification of possible coca-leaf chewer (⫹??CLC)1

Number of BZE CLC Number of Indicators4

individuals Case test2 test3 molars Strong Mild Weak % (mild/NM)5
1 1 ⫹ ⫹?? 1 2M 6W 200
2 4 ⫹ ⫹?? 9 5M 55.55
3 11 ⫹ ⫹?? 7 3M 2W 42.85
4 12 ⫹ ⫹?? 7 4M 1W 57.14
5 16 ⫺ ⫹?? 10 5M 50.00, discordant
6 25 ⫹ ⫹?? 9 5M 55.55
7 28 ⫹ ⫹?? 10 7M 1W 70.00
8 31 ⫹ ⫹?? 12 4M 33.33
9 34 ⫺ ⫹?? 10 4M 40.00, discordant
10 39 ⫹ ⫹?? 4 3M 2W 75.00
11 47 No test ⫹?? 5 4M 1W 80.00
12 50 ⫹ ⫹?? 7 6M 5W 85.71
13 58 ⫹ ⫹?? 1 1M 11W 100
14 68 ⫹ ⫹?? 0 4M 12W 400
15 71 ⫹ ⫹?? 3 3M 4W 100
16 81 ⫹ ⫹?? 6 4M 3W 66.66
1
(Number of mild indicators/number of molars) ⫻ 100% ⫽ or ⬎33%.
2
BZE test, benzoylecgonine test-hair analysis (Aufderheide et al., 1991).
3
CLC test, Coca-leaf chewer identified based on dental method developed in this study.
4
M, mild; W, weak.
5
NM, number of molar teeth.

health might retain earlier signatures. In these Validity of dental test

cases, dental health may be the preferred indica-
tor.
The other three discordant cases were designated
as nonchewers by the dental tests but had a positive
hair test (⫺CLC/⫹BZE) (cases 13, 26, and 30; Table
9). In two cases (13 and 26), the small number of
observable molars probably explains the disagree-
ment between the dental test and the hair analysis:
only 2 and 5 molars were present, respectively. How-
ever, case 30 had 10 observable molars, with only 1
mild and 3 weak markers, leading to a negative CLC
designation. In this example, coca may have been
ingested in some manner other than through coca
leaf chewing (e.g., drinking tea), or this individual
may have been especially caries-resistant.
As would be expected given the overall concor-
dance, the sex distribution of coca chewing deter-
mined by hair analysis paralleled that of the dental
study. The hair analysis results indicate that female
chewers are slightly more common than males, al-
though the difference is not large (Table 12; 55.6%
vs. 35.3%, ␹2 ⫽ 1.72, P ⫽ 0.19). We therefore identify
no significant sex differences for the Chiribaya sam-
ple.
The presence of strong dental indicators always
agrees with positive BZE findings (cases 2, 3, 6, 14,
27, 29, and 40; Table 6). Mild indicators, especially
buccal pit caries and buccal crown caries, represent
less reliable markers for identifying coca chewers, as
they may or may not show an agreement with the
BZE test: 3 cases match, whereas 2 are discordant
(Table 8). These 5 cases had mild indicators such as
small cervical-root caries on the mesial, distal, or
lingual surfaces and buccal pits. The weak indica-
tors alone cannot be used to assess coca chewing, as
they disagree with the BZE test (case 13; Table 9).
The sensitivity and specificity tests (Ingelfinger et
al., 1983; Dawson-Sanders and Trapp, 1990) mea-
sure the reliability of the CLC test against BZE
(Table 13). Dawson-Sanders and Trapp (1990) de-
fine sensitivity as “the probability of a positive test
result in patients who have the conditions,” whereas
specificity is defined as “how well the test correctly
identifies those patients who do not have the condi-
tion.” Applying these definitions of sensitivity and
specificity to our study, sensitivity measures how
reliable the ⫹CLC test is, when tested against as-
sumed known coca users based on ⫹BZE tests: 15/
 COCA CHEWING IN PREHISTORIC COASTAL PERU 251
1
TABLE 9. Identification of noncoca-leaf chewer (⫺CLC)

Number of BZE CLC Indicator4 Number

individuals Case test2 test3 Strong Mild Weak of molars % (mild/NM)5
1 5 ⫺ ⫺ ⫺ ⫺ 2W 0 ⫺
2 7 ⫺ ⫺ ⫺ ⫺ 5W 0 ⫺
3 8 No test ⫺ ⫺ 1M 2W 10 10%
4 9 ⫺ ⫺ ⫺ ⫺ 4W 8 ⫺
5 10 ⫺ ⫺ ⫺ ⫺ 6W 4 ⫺
6 13 ⫹ ⫺ ⫺ 1W 2 ⫺, discordant
7 15 ⫺ ⫺ ⫺ ⫺ 3W 4 ⫺
8 17 ⫺ ⫺ ⫺ 1M 1W 11 9%
9 18 ⫺ ⫺ ⫺ ⫺ 6W 2 ⫺
10 19 ⫺ ⫺ ⫺ ⫺ ⫺ 12 ⫺
11 20 ⫺ ⫺ ⫺ 2M 2W 8 25%
12 22 No test ⫺ ⫺ ⫺ 6W 0 ⫺
13 23 No test ⫺ ⫺ ⫺ 4W 0 ⫺
14 24 No test ⫺ ⫺ ⫺ 1W 5 ⫺
15 26 ⫹ ⫺ ⫺ 1M 1W 5 20%, discordant
16 30 ⫹ ⫺ ⫺ 1M 3W 10 10%, discordant
17 32 ⫺ ⫺ ⫺ ⫺ ⫺ 10 ⫺
18 33 ⫺ ⫺ ⫺ 1M 4W 12 8%
19 35 ⫺ ⫺ ⫺ ⫺ 4W 10 ⫺
20 36 ⫺ ⫺ ⫺ ⫺ 1W 11 ⫺
21 37 ⫺ ⫺ ⫺ ⫺ 1W 11 ⫺
22 38 ⫺ ⫺ ⫺ 1M 6W 4 25%
23 41 No test ⫺ ⫺ 1M 6W 5 20%
24 42 No test ⫺ ⫺ ⫺ 6W 2 ⫺
25 43 No test ⫺ ⫺ ⫺ 3W 11 ⫺
26 44 No test ⫺ ⫺ ⫺ ⫺ 10 ⫺
27 45 No test ⫺ ⫺ ⫺ 4W 9 ⫺
28 48 No test ⫺ ⫺ 2M 2W 7 28%
29 49 No test ⫺ ⫺ ⫺ 3W 6 ⫺
30 51 No test ⫺ ⫺ 1M ⫺ 10 10%
31 52 No test ⫺ ⫺ ⫺ 1W 10 ⫺
32 53 No test ⫺ ⫺ 3M ⫺ 10 30%
33 54 No test ⫺ ⫺ 1M 6W 6 16%
34 55 No test ⫺ ⫺ ⫺ 3W 2 ⫺
35 56 No test ⫺ ⫺ 1M 4W 8 12.5%
36 59 No test ⫺ ⫺ ⫺ ⫺ 11 ⫺
37 61 No test ⫺ ⫺ ⫺ 2W 9 ⫺
38 62 No test ⫺ ⫺ ⫺ 1W 3 ⫺
39 63 No test ⫺ ⫺ 1M 1W 6 16%
40 67 No test ⫺ ⫺ ⫺ 4W 4 ⫺
41 69 No test ⫺ ⫺ 1M 8W 4 25%
42 70 No test ⫺ ⫺ ⫺ 10W 0 ⫺
43 72 No test ⫺ ⫺ ⫺ 6W 6 ⫺
44 74 No test ⫺ ⫺ 1M 2W 9 11.1%
45 75 No test ⫺ ⫺ 1M 4W 3 30.3%
46 76 No test ⫺ ⫺ 2M 4W 6 30%
47 77 No test ⫺ ⫺ 1M 2W 5 20%
48 78 No test ⫺ ⫺ 1M 5W 7 14%
49 79 No test ⫺ ⫺ 1M 3W 9 11.1%
50 80 No test ⫺ ⫺ 1M 7W 3 33.3%
51 85 No test ⫺ ⫺ ⫺ 3W 10 ⫺
1
(Number of mild indicators/number of molars) ⫻ 100% ⬍33%.
2
BZE test, benzoylecgonine test-hair analysis (Aufderheide et al., 1991).
3
CLC test, coca-leaf chewer identified based on dental method developed in this study.
4
M, mild; W, weak.
5
NM, number of molar teeth.

TABLE 10. Dental method (CLC test) by sex in each site1

Sites Males CLC⫹ %⫹ Females CLC⫹ %⫹
Chiribaya Alta 10 2 20.0 16 9 56.2
Algodonal 3 2 66.7 2 2 100.0
Yaral 6 2 33.3 3 1 33.3
Chen-Chen 18 6 33.3 28 11 39.0
Total 37 12 32.4 49 23 46.9
1
CLC test, coca-leaf chewer identified based on dental method developed in this study.
252 E. INDRIATI AND J.E. BUIKSTRA
TABLE 11. Dental method and hair-test agreement ings of Aufderheide et al. (1991), with 85.7% concor-
Number of Number showing % dance. This strong agreement indicates that the
Sites individuals agreement agreement dental technique is a reliable method for identifying
Chiribaya Alta 21 18 85.7 prehistoric coca chewers in the absence of hair tis-
Algodonal 5 4 80.0 sue.
Yaral 9 8 88.9 The finding of cervical-root caries with alveolar
Total 35 30 85.7 bone resorption in the lower molar region in our
study is consistent with reports of high caries inci-
TABLE 12. Hair analysis in identifying coca user by sex in
dence (Langsjoen, 1996) and alveolar resorption in
combined sites1 the buccal region (Turner, 1979), which these schol-
ars associate with coca chewing. Meanwhile, our
n BZE⫹2 %⫹
results cast doubt on several other theories on the
Males 17 6 35.3 effects of coca chewing on teeth, including heavy
Females 27 15 55.6 calculus formation (Klepinger et al., 1977); dark
1
Analysis by Aufderheide et al., 1991. brown tooth crowns (Elzay et al., 1977); brown or
2
BZE⫹, benzoylecgonine test or hair analysis (Aufderheide et al., green-colored accretions on teeth (Thompson, 1903);
1991) results in the presence of coca metabolite in hair of mum- and calcareous accretions (Leigh, 1937). While pos-
mies studied. terior tooth discoloration was occasionally observed,
neither staining nor calculus formation was found to
TABLE 13. Comparison of dental method and hair test in be a reliable indicator of coca usage.
identifying coca user1 The successful identification of coca chewing in
BZE test2 skeletal remains enables us to comment on the pre-
⫹ ⫺ Total historic distribution of coca chewing. This percent-
age reached 40.7% in this study, which indicates
CLC test 3
⫹ 15 2 17
⫺ 3 15 18 that coca chewing was common in south-central
coastal Peru. This percentage, however, could have
1
Predictive value of negative test: 15/(3 ⫹ 15) ⫽ 83.3% (sensitiv- been higher if we had included molar roots and
ity). Predictive value of positive test: 15/(2 ⫹ 15) ⫽ 88.2% (spec-
ificity).
molar loss as strong indicators, as the clinical study
2
BZE test⫹, benzoylecgonine test (Aufderheide et al., 1991) of Indriati (1998) suggested. Indriati (1998) studied
showed the presence of coca metabolite substance in hair of the oral health of contemporary coca chewers and
mummies, suggesting coca user. BZE test⫺, benzoylecgonine test identified the dental variables significantly associ-
(Aufderheide et al., 1991) showed the absence of coca metabolite ated with coca chewing; these included molar tooth
substance in hair of mummies, suggesting noncoca user.
3
CLC test ⫹, coca-leaf chewer identified based on dental method loss, molar radices, cervical-root caries, and peri-
developed in this study. CLC test⫺, noncoca-leaf chewer identi- odontal damage. In addition, Langsjoen (1996) also
fied based on dental method developed in this study. associated antemortem posterior tooth loss with
coca chewing. Our inclusion of molar loss and molar
radices as weak rather than strong indicators, how-
18 ⫽ 83.3% (Table 13). Specificity, on the other ever, was based on the fact that both lesions could
hand, measures how reliable the ⫺CLC test is, i.e., have been caused by factors other than coca chew-
as an indicator of ⫺BZE: 15/17 ⫽ 88.2% (Table 13). ing, such as pulpitis, periodontitis, and progressive
This sensitivity figure suggests that if people did occlusal caries. Despite this exclusion of molar loss
chew coca, there was an 83.3% chance that the den- and molar radices as strong indicators for coca chew-
tal features would yield a positive identification of ing, our study still provides significant results, as
this cultural practice. The specificity results suggest shown by the 85.7% agreement between the dental
that if people did not chew coca, there is an 88.2% technique and the hair test. This level of agreement
chance that the dental evidence would also be neg- between the two biological techniques is considered
ative. The high sensitivity and specificity figures at high in medical science statistical testing (Dawson-
a threshold of 75% concordance underscore the reli- Sanders and Trapp, 1990).
ability and the validity of the dental test CLC.
Triangular root caries differences
DISCUSSION
Our findings of cervical-root caries on the buccal
We have demonstrated that specific dental lesions surfaces of lower molars corresponding with quid
among ancient Andean skeletal remains were posi- position (Figs. 2, 3) are consistent with the report of
tively correlated with coca usage as identified Rowe (1993) that caries attacks smooth surfaces of
through hair tests. Thus our method holds promise teeth where the synthesis of an adherent protein-
for clarifying existing inconsistencies in current the- aceous matrix occurred. In contrast, on rough oc-
ories about the effect of coca chewing on teeth and cusal surfaces, caries is associated with the physical
the prehistoric distribution of coca chewing. Our impaction of food particles without an adherent ma-
study shows that cervical-root caries accompanied trix. Our study indicates a high incidence of caries,
by irregular alveolar resorption is a strong indicator ranging from 30.1–54.5% in the four populations.
of coca usage. These results closely match the find- This elevated incidence is probably related to carbo-
 COCA CHEWING IN PREHISTORIC COASTAL PERU
hydrate-rich diets, despite the xerostomic effects of
coca substance. We support this argument with find-
ings from multiple studies noting the positive rela-
tionship between a carbohydrate-rich diet and caries
formation (e.g., Turner, 1979; Powell, 1985), and
note that the populations in our study also con-
sumed such diets.
The carbohydrate-rich diet associated with our
populations is associated with the cultivation of ba-
sic starchy crops such as manioc, maize, sweet po-
tatoes, and achira, as well as guava, lucuma, beans,
squash, and bottle gourds (Dendy, 1991). This
starchy diet contributes to caries incidence through
decreasing oral pH and fermentation into glucose. A
study by Lingstrom et al. (1993) found that most
starch products ferment in the oral cavity and cause
a decrease in pH level in dental plaque. This low
salivary pH is found to be significantly associated
with high caries scores (Holbrook, 1993). Normal pH
levels of 7 must drop to between 4 –5 for caries to
develop (Hardwick, 1965).
Another study emphasizing the interaction be-
tween microorganisms and carbohydrates in pro-
moting caries was carried out by Loesche (1986).
Loesche (1986) maintains that Streptococcus mu-
tans alone does not lead to caries because the pro-
cess of caries formation requires a combination of
plaque exposure to fermentable carbohydrate, acid-
uric microorganisms in plaque, and the presence of
Streptococcus mutans. Thus, both acidic microbacte-
ria and carbohydrates are major factors triggering
caries development. While a heavy carbohydrate
diet leads to increasing general caries rates, coca
chewing leads to specific types of caries on the root
surfaces of lower molar teeth where quids are typi-
cally positioned.
Cervical root caries (CRC) with irregular alveolar
resorption on the buccal surfaces of lower molars is
the result of chronic irritation from coca quids being
held in the cheek. The prolonged accumulation of
quid in the cheek during chewing is evident from
various reports on the technique of coca chewing.
Allen (1986, 1988) reports that coca is chewed for
about 45– 60 min, and the coca quids are used re-
peatedly and then discharged. The effects from the
duration of chewing are enhanced by the frequency
of chewing, which often reaches 3–5 times a day, 3
times after daily meals and 2 times between meals
in mid-morning and mid-afternoon (Allen, 1986,
1988). The duration and frequency of coca chewing
induce cervical-root caries with alveolar damage.
The process of pathological change probably took
place in several stages, which might have been gin-
gival recession, root exposure, cervical-root caries,
and finally alveolar resorption.
Gingival recession may be manifested in the grad-
ual loss of gingival structure initiated by the loss of
interdental papillae, marginal gingivae, and at-
tached gingivae, leading to exposure of the roots.
While increased exposure of the root is generally
age-progressive, we believe our focus upon relatively
253
young adults (average age of 33 years) renders our
interpretation robust. The exposed roots can become
carious, either beginning at the cemento-enamel
junction or at the root itself. There is no overwhelm-
ing agreement among researchers about the etiology
of root caries, but it is generally accepted that root
caries increases with advancing age (Manji et al.,
1989; Hillson, 1996) and is associated with general
periodontal health (Vehkalahti and Pauino, 1994).
Banting and Courtwright (1975) conclude that root
caries are more prevalent in ancient societies than
enamel caries, while the opposite holds true for mod-
ern societies. Hillson (1996, Fig. 12.11) notes that
the typical root caries found among many British
archaeological samples are band-like in outline.
Other studies, however, show a higher prevalence of
root caries in modern societies of middle to advanced
age (Vehkalahti et al., 1993; Manji et al., 1989; Peric
and Vrbic, 1990; Retief et al., 1990).
While we conclude that the smooth triangular root
caries found on lower molars in our study is caused
by coca chewing, questions arise whether other
causes could lead to similar lesions. A literature
review shows that no other causes are associated
with the specific erosive triangular root caries found
in this study. Although CRC is also found among
narcotic addicts (Lowenthal, 1967; Hecht and Fried-
man, 1949), very heavy consumers of soft drinks
(Kerr, 1986), and cancer patients undergoing irradi-
ation therapy (Kerr, 1986), the caries outline in
these activities is not triangular. Banting and
Courtwright (1975) categorized root caries into
round, elliptical, and band-like, which often occur
among the elderly and those with negligent oral
hygiene. In contrast, the outline of CRC in drug
addicts and patients who undertake drug and irra-
diation treatment is horizontal, and mostly affects
the buccal surfaces of all teeth (Hecht and Fried-
man, 1949; Kerr, 1986; Rowe, 1993). The CRC in our
findings, on the other hand, were typically triangu-
lar, affecting the buccal surface and often limited to
lower molars (Figs. 2, 3). The CRC on lower molars
are often accompanied by irregular alveolar resorp-
tion, matching (Fig. 2 of Turner, 1993) findings
among the prehistoric Chicama in northern Peru,
which Turner (1993) associates with coca chewing.
The telltale triangular pattern of the CRC is due to
the nearly constant presence of the coca quids,
which causes the caries to follow the pattern of the
root shape, leading to a triangular shape. The
smooth-erosive triangular root caries in our study is
dissimilar with that of rough root caries from pre-
historic Hungary (Molnar and Molnar, 1985, their
Figs. 1, 2).
In a study of oral soft tissue among living coca
chewers, Hamner and Villegas (1969) found leukoe-
dema (a whitish hyperkeratinization on the buccal
mucosa) in many of the Aymaran and Quechuan
coca chewers in Bolivia. This whitish hyperkeratini-
zation on the buccal mucosa may have been caused
by the irritation of an alkaline substance such as
254 E. INDRIATI AND J.E. BUIKSTRA
lime, which is added to coca leaves to create a ball of
coca quid during chewing. The lime transforms al-
kaloids from the leaves into free bases (Rivier, 1981)
and thus adds flavor to the coca (Allen, 1986). The
substances included in the coca quid vary from veg-
etable ash, burned shells, ash of quinoa and cani-
hua, or plantain roots of cacao pods (Rivier, 1981).
Therefore, long-term usage could chronically irritate
gingivae and buccal mucosa where the quids are
typically positioned. The location of buccal mucosal
lesions among living coca chewers (Hamner and Vil-
legas, 1969) confirms the location of CRC with buc-
cal alveolar resorption in our skeletal samples, with
independent archaeological evidence of coca chew-
ing.
Lesions associated with other nonmasticatory
chewing habits
Other nonmasticatory habits exist in various so-
cieties, such as betel-nut chewing and tobacco chew-
ing. These two chewing habits have much in com-
mon with coca chewing, as the users form quids and
keep them in their cheeks for a sustained period of
time. Do these chewing habits produce the same
lesions as with coca chewing? Just as coca quids
induce both mechanical and chemical irritation
within the oral cavity, so do betel quids and tobacco
quids. However, the ultimate effects produced by
other forms of chewing differ substantially. While
coca quids induce xerostomia and therefore cause
caries on the exposed roots, the substances of betel
quids and tobacco quids do not induce xerostomia. In
fact, betel leaves have been found to have an anti-
septic effect due to their ethanol-based content, and
betel solutions have proven to be useful in cleaning
root canals during root canal treatment in dentistry
as a substitute for hydrogen peroxide (Indriati,
1997). Betel-nut chewing, however, causes an abnor-
mal lining of the oral mucosa (Chin and Lee, 1970)
and tooth discoloration (Rooney, 1993).
Clinical studies show that tobacco chewers exhibit
gingival recession (Robertson et al., 1990; Greene et
al., 1992). Professional baseball players who habit-
ually chew tobacco or use snuff show a loss of gingi-
val attachment and a line of oral mucosa and gingi-
val recession at the site where the tobacco quid is
most commonly placed. However, they typically lack
caries. In the study by Robertson et al. (1990) of 423
tobacco users, 46% had mucosal lesions following
this pattern. The gingival tissue adjacent to mucosal
lesions showed greater recession and loss of attach-
ment. Mandibular gingivae were much more fre-
quently affected (94%) than maxillary gingivae (4%).
The higher frequency of mandibular gingival reces-
sion was due to quids being placed relatively low
across the mandibular gingivae. Unlike coca-chew-
ers who suffer root caries, tobacco chewers did not
suffer such caries. Thus while tobacco chewing may
cause oral cancer and mucosal keratinization (Pind-
borg et al., 1980), it does not lead to caries (Gibbs,
1952; Van Reenen, 1954). We therefore conclude
that quids of various substances cause gingival re-
cession and lead to root exposure in nondietary mas-
ticatory habits. However, the extent to which the
exposed roots lead to caries in each case depends on
the quid’s chemical properties.
Implications for the prehistoric distribution of
coca chewing
Several important studies of coca chewing among
modern populations (e.g., Allen, 1986, 1988;
Bastien, 1985; Buck et al., 1968) indicate a high
degree of consistency with regard to the percentage
of coca chewers in ancient and contemporary groups
(Aufderheide et al., 1991; Cartmell et al., 1991).
These findings strengthen the argument that usage
patterns have remained stable over long periods of
time, i.e., from Late Middle Horizon times to the
present day. This stability is presumably due to
strong cultural factors; many workers maintain that
coca chewing is a pervasive tradition still playing a
dominant role in Andean lives including religious,
social, medicinal, and economic life (Allen, 1986,
1988; Carter et al., 1980; Morales, 1989; Naranjo,
1981; Rostworowski, 1973; Weil, 1981, 1986). The
strong cultural factors that preserve the ancient cul-
tural traditions were also evident in the form of coca
leaves which have been found in prehistoric burials
for tomb offerings (Aufderheide et al., 1991) and are
still used as tomb offerings today (Harris, 1982;
Bastien, 1985).
Age at which coca chewing is adopted
In modern Peruvian Indians, the age at which
coca chewing begins typically ranges from 15– 24
years, but as people get older, they tend to adopt the
habit (Carter and Mamani, 1986). Hamner and Vil-
legas (1969), however, report a lower average age of
10 –16.5 years among Aymarans and Quechuans in
Bolivia. Results suggest that prehistoric Indians
might have started to chew coca within the same
time range as modern Indians, between age 10 –16.5
years.
Our results show an absence of strong indicators
but a presence of mild and weak indicators among
individuals aged 20 –25 years. Most individuals aged
about 25 years bear only mild and weak coca chew-
ing indicators, as seen in cases 11, 16, 25, 47, and 71
(Table 8). Older individuals, 30 – 45 years old, have
strong dental indicators and are identified as either
probable (case 83; Table 7) or definite (cases 2, 6, 14,
57, 60, and 73; Table 6) coca chewers. The dental
markings found among people aged about 20 –25
years suggest that our subjects might have started
to chew coca when they were 10 –16.5 years old,
similar to the Aymaran and Quechuan coca chewers
studied by Hamner and Villegas (1969). The age
range of 10 –16.5 years is likely to be the age at
which prehistoric Indians reached puberty and thus
were not considered children anymore, resulting in
both social permission to chew coca and probably
 COCA CHEWING IN PREHISTORIC COASTAL PERU
also full participation in rituals where coca chewing
was involved.
Distribution of coca chewers between males
and females
Coca chewing was found to be roughly evenly dis-
tributed between males and females in the prehis-
toric Andes. In our study, the percentage of female
chewers was slightly higher than that of male chew-
ers (46.9% vs. 32.3%), although the difference was
not significant statistically (␹2 ⫽ 1.84, P ⫽ 0.17;
Table 10). This gender difference is consistent with
the hair study by Aufderheide et al. (1991), where
the difference was 55.6% vs. 35.3% (also not statis-
tically significant; ␹2 ⫽ 1.72, P ⫽ 0.19; Table 12),
and with findings from a prehistoric coastal popula-
tion in northern Chile studied by Cartmell et al.
(1991), i.e., 60.7% vs. 53.3%. In addition, research by
Indriati (1998) on modern Aymarans in Bolivia is
consistent with that cited for prehistoric popula-
tions: more female chewers (70.4%) than male chew-
ers (67.4%). However, this difference was again not
statistically significant. The slightly higher number
of female chewers may be due to sampling error.
Overall prevalence of coca chewing
Our determination that 40.7% of three combined
populations chewed coca is consistent with the im-
plications suggested by the discovery of artifacts
depicting coca chewing in the coastal regions of the
ancient Andes (Lanning, 1967; Lumbreras, 1974;
Moseley, 1992). On the other hand, our finding con-
tradicts Leigh (1937), who relied on dental lesions of
calcareous accretion to identify coca chewing and
concluded that chewing was more dominant in the
highlands. Exclusion of prehistoric highland sam-
ples from our study does not permit us to draw
conclusions as to whether coca chewing was common
in the highlands. A study by one of us (E.I.), how-
ever, indicated that 49% of prehistoric highland peo-
ple from the Tiwanaku sites of Lukurmata,
Akapana, Marcapata, Putuni, and Mollokontu (Ti-
wanaku IV–V, dated ⬃300 –1500 AD) chewed coca
(Indriati, 1998). This suggests that coca-leaf chew-
ing was indeed common in the ancient highlands.
This, in turn, confirms archaeological evidence of
coca chewing in the highlands as suggested by stone
sculptures of Tiwanaku elites with distended cheeks
(Fierens, 1991; Kolata, 1993).
The overall prevalence of coca chewing is similar
in both the dental technique and the BZE method.
The frequency (40.7%) of coca chewers in our study
of ancient Andeans approximates that reported by
Aufderheide et al. (1991) (47.5%) and Cartmell et al.
(1991) (46.6%) in their investigations of Chiribaya
remains in late prehistoric coastal Chile. However,
several modern studies appear to suggest that usage
is higher today among high-altitude peoples. One
study of a modern population of 3,509 individuals in
Bolivia by Carter and Mamani (1986) reports a high
255
incidence of coca chewing (59.8%). Even higher us-
age rates have been found among miners of highland
Argentina (65%, 70/107; Schinder and Rider, 1989).
A third study among the Aymara in Bolivia identi-
fied 69% of the population as coca chewers (Indriati,
1998). This difference is probably correlated with
the commonly known trait of coca as reducing the
symptoms of altitude sickness. The physiological
benefits of coca use include increased stamina (Brut-
saert et al., 1995), maintained higher core body tem-
peratures (Hanna, 1974), increased blood pressure,
and temporary euphoria (Weil, 1981). These studies
support the veracity of Andean beliefs that coca
chewing helps them work long hours, and relieve
sorrow and work at high altitudes. These beneficial
functions of coca are perhaps additional strong fac-
tors for the survival of coca chewing which is also
rooted in cultural beliefs.
While these studies appear to suggest that coca
usage has, if anything, increased since ancient
times, we believe this conclusion to be premature.
Whenever there is material loss of physical evidence
in human archaeological remains, as there is here
due to postmortem tooth loss, caution should be
employed in making conclusions about percent us-
age. It is clear, however, that the studies of both
ancient and modern populations find usage rates of
approximately one half to over two thirds in a given
population. While we cannot yet draw accurate con-
clusions on relative pervasiveness, it is clear that in
both modern and ancient populations, coca-leaf
chewing was a widespread cultural and physiologi-
cal phenomenon.
ACKNOWLEDGMENTS
This study was largely funded by the Bioanthro-
pological Foundation, the University of Chicago, and
the National Science Foundation in various grants
to J.E.B. We are thankful to Dr. Aufderheide, who
provided unpublished radioimmunoassay results as
a gold standard. The late Dr. Albert Dahlberg was
generous in allowing E.I. to use his laboratory space
and contributed alginate and spoon trays for casting
the teeth upon her departure for Peru. Hu-Friedy
Chicago Dental Supply contributed three sets of di-
agnostic kits. Dr. Sonia Guillen was most helpful
when we studied the skeletal collection in Ilo, Peru.
Prof. Russell Tuttle, Dr. Deborah Blom, and Paula
Tomczak contributed critiques and comments on
earlier drafts of this paper. Michael Torbenson of the
Pritzker Medical School at the University of Chicago
shared valuable discussions on the statistical tests.
We are also thankful to Susan Antón of the Univer-
sity of Florida who commented on the final draft.
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