J. Pertodonmt Ra.

13: 563-572, 1978

The natural history of periodontal

disease in man
Tooth mortality rates before 40 years of age

HARALD LOE, AGE ANERUD, HANS BOYSEN AND MARTYN SMITH

School of Dental Medicine, University of Connecticut, Farmington, Connecticut, U.S.A.

The material presented in. this report was derived from a longitudinal study of the development and progress of periodontal disease and resultant tooth loss. The first population
group was established in Oslo, Norway in 1969 and consisted of 565 male, non-dental
students and academicians between 17 and 30-1- years. A second group was established in
Sri Lanka in 1970 and consisted of 480 male tea laborers between 15 and 30+ years. Both
populations were examined 4 times and the time span between the first and fourth examinations was in Oslo 6 years and 3 months, in Sri Lanka 7 years and 6 months. Each
participant was scored for various disease parameters and the number of permanent teeth
(third molars excluded) was recorded at each examination. The results show that in these
randomly sampled groups no one was edentulous. The 17 year old Norwegian had 27.4
teeth present out of 28 possible and no major loss of teeth occurred during the twenties
and thirties. As the participants approached 40 years of age, the mean number of teeth
present was 27.1 and the mean mortality rate was 0.01 teeth per year. The Sri Lankan 15
year old had 27 teeth present and the 40 year old had 25.6 teeth. The mean mortality
rate ranged between 0.1 and 0.3 teeth per year. Teeth with deep periodontal lesions started
to exfoliate in Sri Lankans as they approached 40 years of age,
(Accepted for publication April 13, 1978}

Introduction
it is generally accepted that the number of
teeth decreases with age and that caries and
periodontal disease are the main causes of
tooth loss, although the relative impact of
these two disease entities may vary in different population groups and geographic
areas. Most of our knowledge of tooth
mortality stems from cross-sectional studies
of populations of different age and socioeconomic circumstances, and longitudinal
studies in which tooth loss can be assessed

in the same individuals over a lifetime or

^^^-^^^ ^^^^^ portions of man's life are
non-existent.
This paper, which reports on tooth mortality during the first forty years of life, is
based on material from a longitudinal investigation, the purpose of which was to
describe the natural development and progress of periodontal disease in man and the
resultant tooth loss. The two population
groups involved in tbe study were chosen in
anticipation of big differences in the rate of
periodontal destruction and in loss of teeth

564

L D E , ANERUD,

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

due to periodontal disease. Published reports on baseline data (Loe, Anerud, Boysen
& Smith 1978a) and on the rate of periodontal destruction (Loe. Anerud, Boysen &
Smith 1978b) have substantiated this notion.

Materials and Methods

The first group was established in Oslo,
Norway in 1969 and consisted of 565
healthy male students and academicians between 17 and 30-|- years of age. The older
age groups were drawn at random from the
census filed with the Central Bureau of Statistics and the younger age groups were recruited from three high schools in Oslo selected by the City Board of Education. The
principal reason for doing the study in Oslo
was that this city has had a dentai program
offering systematic preventative, restorative,
endodontic, orthodontic and surgical therapy on an annual recall basis for ali children
and adolescents (3-16 years) and a documented attendance record of 90 per cent
for the last 40 years. It is also a matter of
record that the remaining 10 per cent make
use of the personal dental services provided
by the private practitioners in the area. In
addition, the City of Oslo offers a reimbursement pian for expenses incurred for
dental services between 18 and 21 years of
age and the University, through its health
services, provides a dental program for
students. It is, therefore, fair to state that
the chosen population represents a group of
individuals that has had maximum exposure
to conventional dentai care throughout its
iife.
A second group was established in Sri
Lanka in 1970 and consisted of 480 maie
tea iaborers between 15 and 30-1- years of
age. The participants were all tamils and
descendants of groups who 2-3 generations
ago emigrated from Southern India. They
were healthy and well-built by local standards and their nutritional condition was

clinically fair. The workers had never been

exposed to any programs or incidents relative to prevention or treatment of dental
diseases. Toothbmshing was unknown. Betel
chewing was common.
The Norwegian group was first examined
in 1969. Subsequent examinations took
p,^^^ -^ j ^ ^ ^ ^ -,9^3 ^^^ .^ ^^^5 ^^^ ^^.
Lankan group was examined initially in
1970, in 1971, 1973 and in 1977. 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
eare and habits. Clinical examinations ineluded inspection of the orai cavity at large
as well as measurements and scoring of indices relative to the periodontal status (Loe
et al. 1978a). All examinations throughout
the study were performed by the same two
examiners who were both well-trained and
experienced periodontists. The number of
teeth present, excluding third molars, was
recorded by the same investigator at all examinations. All scores were dictated to the
ehairside assistant who recorded the scores
on a special scoring chart. The examinations
of the Norwegians took place at a facility
provided by the Oslo University Faculty of
Dentistry equipped with modern dental
chairs, scialitic lamps, compressed air and
saiiva ejectors. The plantation groups in Sri
Lanka were examined in an outdoor facility
comprising portabie dental chairs and supporting equipment, but no compressed air
or saiiva ejectors. No preventive or therapeutic measures were undertaken during the
examinations.
The data from each examination were
computerized and updated on an ongoing
basis and are being subjected to detailed
analysis. Each population was divided into
two-year age cohorts to facilitate the analysis. A certain number of individuals dropped out and eould not be followed up.

T H E

N A T U R A L

H I S T O R Y

O F

Table 1
Cumulative number of observations in each
age category for all participants and for those
who appeared in all four surveys
(in parenthesis)
Age

1969-1975
and academicians

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

81
127
150
216
232
232
174
147
75
33
14

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

P E R I O D O N T A L

77
127
162
196
203
199
170
145
85
57
19
19

(34)
(58)
(72)
(95)
(96)
(104)
(91)
(85)
(59)
(38)
(18)
(16)

However, in both populations the Ioss to

follow-up individijals appeared to be independent of age (Loe et al. 1978a). In the
analysis, the most interesting groups were
those who were present in all surveys
(IAS). Analyses were also perfortned on all
valid observation groups (AVO). The IAS
group was compared to the total AVO
group to determine if those lost to followup were significantly different from those
that remained in the study. Tbe cumulative
tooth mortality rate was calculated on the
basis of all individuals who appeared at
both the first and fourth surveys. When insignificant changes in the estimates of the
parameters occurred over time, the birth
cohorts were collapsed into age cohorts to
give a picture of eaeh population over 25

565

years (Table ]). For further details on the

design of the study and the baseline data,
see Loe et al. 1978a.

Results

1970-1977
tea laborers

D I S E A S E

The 565 Norwegians who participated in

the first examination in 1969 showed a total
of 441 missing teeth, excluding third molars
(Table 2). None of the participants were
edentulous. The average number of leeth
standing per person was 27.22 (range 26.927.5) (Table 3) or an average of 0.78 missing teeth per person. There were more missing bicuspids than all other teeth put together (Table 2). In 1969 the 17 year olds
averaged 27.4 teeth present and the 30-1year olds had 27.2, indicating that in this
population there had been no significant
tooth loss in 15 years of adult life (Table
3). It is also seen that those who were 17,
19, 21 etc. in 1969 and appeared at some
(Table 3) or all reexaminations (Table 4)
continued to have the same number of teeth
present and that no major loss of teeth had
occurred between 30 and 40 years in this
population. The 245 participants of all age
groups who participated in the first (1969)
and the last (1975) examinations had lost a
total of 27 teeth (17 molars and 10 bicuspids. Table 5), averaging 0.11 tooth per individual over the six year period (Table 6).
Actually, the vast majority of the participants (229 out of 245) had lost no teeth at
all, and only 16 individuals accounted for
the 27 teeth lost (Table 7).
Thirty-one of the students who were 17

Table 2
Number and types of teeth missing in both study populations at baseline in 1969 and 1970
Populatio ns
Norwegiain students aind a'c ademician s
Sri Lankai

individuals

Number
teeth lost

565
480

441
415

Mol
Max
Mand
59
59

86
212

Biciispids
Max
Mand
15B
39

51

Max

Mand

27
28

13
26

566

L O E .

A N E R U D .

B O Y S E N

A N D

S M I T H

Table 3
Average number of teeth present in Norwegian students and aoademicians that participated in
ali vaiid observation groups. 1969-1975
Years
of age

17

18

19

27,41

1969

21

20

22

23

24

25

26

27

28

29

30

31

32

34

33

36

35

37

38

26.90

27,28

27,50

27.29

27-13

26.95

27,17

27,45

26.91

27.43

27.58

27.35

27,13

27.18

26.83

27.33

27.09

27.20

27-61

27.28

26,89

27.19

27.42

27.42

26.60

27,32

27.59

27,52

26.78

27.22

26.86

27.63
216

27,16
232

27,37
232

27.27
174

27.29
147

26.93
75

27.32
33

26.86
14

1970

1971

1973

1975

Crossnctiona
Means

27.41
81

27-17
127

27.17
150

Average number of teeth present in Norwegian students and academicians that participated in
all four surveys. 1969-1975
Years
of age

17

1B

20

19

21

22

23

24

25

26

27

28

29

30

31

32

33

35

34

36

1969

27.38

26.92

27.50

27,68

26.46

26.00

27.23

26.78

1970

21

13

26

37

26

22

13

27.38

27-00

27.54

27.68

27,46

26.77

27-38

26.78

21

13

26

37

26

22

13

27,24

26,85

27.50

27,62

27.35

26.64

27.38

21

13

26

37

26

22

13

27.24

26.92

27.58

27.68

27.38

26.64

27.31

21

13

26

37

1971

\
\

1973

38

\
\
26.78 \

\
1975

37

\
27.11

26

22

13

27.07

26,89

27.09

27.11

70

44

22

\
Crosssectional
Means

27.38

27,20

21

34

60

97

102

111

98

The number and types of teeth lost in Norway during 1969-1975 and in Sri Lanka during 19701977 for those participating in the first and fourth survey
Populations

Norwegian students sind academicians

Sri Lankan tea labore rs

Number
individuals

Number
teeth lost

Molars

245
228

27
169

17
121

10
16

32

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

567

Table 6

Table 7

Number of teeth lost and tooth mortaiity rates

by birth cohorts for 245 Norwegian students
and academicians. 1969-1975

Frequency distribution of teeth lost in 245

Norwegian students and academicians in six
years. 1969-1975

Birth-

Number o.

",""'1'"

;.,H;..;^...,I.,

'

Six y.a,

' " ^ ' t6in

,..,1;....

teeth lost

._

individuals

1934-39
T94O

1946
1948
1950

17 to 37-i- were extracted or lost due to

periodontal disease.
The 480 Sri Lankan tea laborers showed
a total ot" 415 missing teeth at the first examination in 1970 (Table 2). The average
number of teeth present (Table 8) per individual was 27.05 (range 27.7-25.8) or an
average of 0.95 missing teeth per person.
There were considerably more missing molars, especially mandibular molars, than
other types of teelh (Table 2). The 15 year

years old in 1969 (born in 1952) and reported back six years later had lost a total
of 3 teeth or an average of 0.09 tooth per
person over the six year period and 20 who
were 19 years old in 1969 (born in 1950)
had lost no teeth in the six years (Table 6).
None of the teeth lost between the age of

Average number of teeth present in Sri Lankan tea laborers that participated in all valid
observation groups. 1970-1977
Yean
of ge
1970

1971

14

15

16

17

18

19

20

21

22

23

27.00

27.70

27.67

27.34

27.16

40

47

69

62

77

24
26

26

27

2B

29

30

31

27.31

25 81

26.71

61

36

34

54

32

33

34

27.65

27,47

27.43

27.22

26.97

26.55

27.06

26.78

26.39

34

40

63

54

65

5T

52

32

31

26.74

26.09

26.70

24.44

29

3d

54

51

68

43

46

27

27

26.66

25.93

26.60

1973

1977

Cron.
tections
Means

25

35

36

37

38

26.11

26.63

26.91

26.88

27.00

24.63

25.63

19

22

33

27

32

27

30

19

19

25.62

26.37

24.63

26.63

85

57

19

19

27.50

27.54

27.44

27.14

27.00

26.80

26.72

26.38

77.5

127

162.5

196.5

203.5

199.5

170.5

145

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

SMITH

Average number of teeth present in Sri Lankan tea laborers that partioipated in ail four surveys.
1970-1977
Yean
of age
1970

1971

14

15

17

16

19

18

21

22

23

24

25

29

30

31

27.14

26 60

27.18

26.00

26.87

17

18

28

24

28

25

22

18

16

32

33

34

35

36

37

38

26.81

27.47

27-50

27.50

27.25

27.00

26.52

27,00

25.89

17

18

26

24

28

25

22

18

16

27.24

27.44

27.29

27.12

26.86

26.08

26.91

25.56

26.50

17

18

28

24

28

25

22

18

16

26.65

27.22

26 71

27.08

26.68

26.08

27.09

24.89

26.12

17

18

28

24

28

25

22

18

16

34.5

58

72

95

96 5

Number of teeth and tooth mortality rates by

birth cohorts for 228 Sri Lankan tea laborers.
1970-1977

1950
' 1952
1954

28

27-33

olds had an average of 27.0 teetb and the

3 0 + year olds had 26.7 (Table 8).
The cross-sectional means for the cumulative observations of the different age
groups showed that there was a decrease in
the number of teeth per individual from
the age of 15 (27.5) to 3 0 + (25.6) of ap-

1942
1944

27

27 75

1977

Birthyear

26

27.78

1973

Crosssect iona
Meant

20

27-00

Nu mbEirof
ind ivid uals

Nur nbe
in se'

SGve n yea
morta hty rate

1.32
1.05

104.5

91

85

59

38

18

16

proximately 2 teeth (Tables 8). When only

those who participated in ali four surveys
were considered (Table 9), It is seen that a
similar decrease has taken place.
An examination of the 228 individuals
who participated in the first and last examinations (Table 5) showed that they had lost
a total of 169 teeth (121 molars, 16 bicus-

Frequency distribution of teeth lost in 228 Sri

Lankan tea laborers in seven years. 1970-1977
Number ot
teeth lost

.,^^ , ,. ,
(169 teeth)

Number of
individuals

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

pids, 32 anteriors) averaging 0.72 over the

seven years (Table 10). As can be seen from
Table 11, 77 individuals accounted for the
loss of these 169 teeth and 151 had !ost
none.
Out of the 196 individuals who participated in all surveys 7 showed 10 teeth v/Uh
loss of attachment equal to or greater than
10 mm in 1970. In the course of the subsequent seven years, 6 of these teeth were
lost. This gives a mortality rate of 0.6 as
compared with over 5,000 teeth which were
scored with less than 10 mm and out of
which 141 teeth were lost over the s&me
period, or a mortality rate oi 0.03. This will
be explored further in subsequent reports.

Discussion
AH eross-seetional studies of tooth mortahty
demonstrate that with increasing age there
is a decrease in rhe number of leelh preseni
(Brekhus 1929, Klein 1943, Belting, Massler
& Schour 1953, Krogh 1958, Sandier &
Stahl 1960, Johnson, Kelly & Van Kirk
I9f>5. KoUchke 1%5, Bay & Oati A%7.
Ltindquist 1967, Sheiham, hiobdeU & Cowell
1969, Johansen 1970, Grey et a). 1970,
Jackson & Murray 1972, Axelson et al.
1975,
Edmuttds &. Crahb 1975). 0T^ the
basis of these reports it appears that in
general the 20 year old western patient has
lost between 3 and 5 teeth; 30 year olds
have on an average lost between 5 and 7
teeth, and at 40 years of age the average
patient has lost approximately 10 teeth. It is
also apparent from this literature that at
approximately 40 years of age some S to 1 fl
per cent of the teetb have been losf due to
periodontal disease. At or before 30 years
less ihan 1 per cent of moat western populations are edentulous (Johnson et al. 1^65,
Grey et al. 1970, Axelson et al. J975, Roder
1975). However, after this age, although
varying greatly for specific populations, the
frequency of edentulousness increases sig-

D I S E A S E

nificantly. and at 40 years of age generally

ranges between 10 and 30 per cent.
In the present study populations, both of
which were chosen at random, no one participant in Norway nor in Sri JLanfca w^as
edentulous at the first examination in 1969^
70 and none were seen 6-7 years later.
At the baseline scoring in 1969, the 17
year old Norwegian student had an average
of 27.4 of possible 28 teeth present (third
molars eJtcluded) and the 3 0 + year olds
had 27.2, indicating that virtually no tooth
loss had occurred between 17 and 30 +
years of age.
The speciat design of the present study
permitted the comparing of the initiaJ crosssectional data of groups of different ages
with individual reaching the same age
levels in the course of the study. Such an
analysis along with a study of those who
reported for ail four surveys or of those of
each age group who parlicipated in tbe fiisi
and last survey, demonstrated that the number of teeth present in individuals of the
same age at different time periods was es?.eviViaUy th^ same. This shows that in Norwegian students and academicians below 40
years of age, the frequency of tooth extraction has been consistently low during
ttie last 30 years. (Vs a matter of fact, tooth
mortality in this population is much lower
than in any other age-comparable group reAnother feature of this particular population is that more teeth had been extracted before 17 years of age than between
17 and 40 years. 3udged by the type of
teeth missing in the 17 year olds at the
1969 examinations, there Js reason to believe that the majority of the teeth were extracted oTi orthodotitic indications (bicuspids and incisors). This conclusion is confirmed by recent reports from the management of the Oslo City School Denial Program (Engh 1978) that from 1971 through
1977 the ratio of tooth extractions on or-

570

L O E .

A N E R U D ,

B O Y S

thodontic indications to number of teeth

extracted for other reasons ranged between
4:1 and 7:1.
The present study has also shown that the
rate of tooth loss among young and adult
academicians in Oslo, Norway is remarkably low. During the first ten years of the
permanent dentition (6-17 years) the tooth
loss averaged 0.6 teeth per person. During
the next two decades the average loss was
less than 0.2 teeth per person. This is equal
to a mortality rate of 0.01 teeth per year.
The average Norwegian academician at 40
years of age has lost less than one tooth,
and no teeth were lost due to periodontal
disease (Loe et al. 1978b). Given the fact
that from this age on most extractions
usually occur due to periodontal disease
(Brekhus 1929, Metha et al. 1958, Kotzchke
1965, Bay & Gad 1967) and that the longitudinal data have revealed a remarkahly
slow rate of progress of this disease (approximately 0.09 mm mean loss of attachment per year) in this population (Loe et al.
1978b), the likelihood exists that on the
average, these individuals will advance into
the 5O's and 6O's with insignificant changes
in the number of teeth present. As far as
can be seen from the literature (Klein 1943,
Grey et al. 1970, Jackson 1966, Jackson &
Murray 1972, Johansen 1970, Bjorn 1974,
Hansen & Johansen 1976) these rates compare favorably with most studies and hold
promise for drastic improvements in the
longevity of the dentition.
The 15 year old Sri Lankan tea laborer
has approximately 27 teeth present and exhibits a tooth mortality situation which is
much like that of the 17 year old Norwegian student. However, over the next 25
years the mortality rate increases and leaves
the 40 year old tea laborer with an average
of 25.6 teeth. This reflects a significantly
higher mortality rate than that found in
Norwegian academicians over the same
time span, hut it is still relatively low com-

EN

A N D

S M I T H

pared to other western population groups.

The cause of this low tooth mortality rate
during the early part of life is without doubt
the almost total absence of dental caries in
this population. It is equally evident however, that moderate and advanced periodontal disease is prevalent already before
twenty years of age and that it progresses
rapidly (approximately 0.3 mm loss of attachment per year, Loe et al. 1978b) to tbe
point where the teeth start to loosen and
fall out. Jn other instances, the periodontal
destruction is so advanced already between
20 and 30 years of age that, under normal
circumstances, the individual teeth would
have been extracted, hut due to the fact
that these people have no access to dental
care, such teeth will remain in place until
they fall out or can be removed by the patient himself. It is expected, therefore, that
during the next decade an increasing number of teeth will he lost due to periodontal
disease.
Extending the life span of the dentition
either by prevention or by treatment of dental diseases is a major objective of dental
care. The mean number of teeth present
per person is therefore, an important parameter in the assessment of the longevity of
the dentition of a particular population
group, and may reflect the effectiveness of
the dental care services of a country or
community (Sheiham, Hobdell & Cowell
1969). Although the complete answer lo
this argument must await further analysis.
the preliminary data suggest that the low
mortality rate of teeth in the Norwegian
group is primarily due to systematic personal dental care services from childhood,
through adolescence and adult life. On the
other hand, it is also apparent from the
study of the Sri Lankan group that in a
predominantly caries resistant and periodontal disease prone population up to 40
years of age, the number of teeth present or
tooth mortality rates as single characters-

T H E

N A T U R A L

H I S T O R Y

O FP E R I O D O N T A L

tics, reflect poorly the true quality of the

dentition and are, therefore, less valid
parameters in the characterization of these
people's dentai health status.

Acknowledgment
This study 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. Dissanayake, his colleagues, staff and students
at the University of Sri Lanka in Paradeniya, to the staff at the tea plantations and
to the many others in Colombo and 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 of this work.

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Tandl. T. 67: 656-667.
Bay, T. & Gad, T. 1967. Causes of tooth mortality in Denmark. J. Periodontal Res. 2: 246.
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D I S E A S E

571

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