Journal of Dental Research

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The Aymara of Western Bolivia: III. Occlusion, Pathology, and Characteristics of the
Dentition
Hernan Palomino
J DENT RES 1978 57: 459
DOI: 10.1177/00220345780570030901

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The Aymara of Western Bolivia:
III. Occlusion, Pathology, and Characteristics of the Dentition
HERNAN PALOMINO
Departamento de Biologia Celular y Genetica, Facultad de Medicina, Universidad de Chile,
Casilla 6556, Santiago 7, Chile, and Center for Demographic and Population Genetics, The
University of Texas Health Science Center, Houston, Texas 77025, USA
With the objective of contributing to the under-
standing of factors influencing the character-
istics of dentition, dental observations from 429
children and adult highland people of western
Bolivia are described. Various age, sex, ethnic,
and village differences are observed in maloc-
clusion, dental caries, periodontal disease, den-
tal morphology, and anomalies. The findings
revealed a population with relatively good oc-
clusion, low frequency of dental pathology, and
dental characteristics in part consistent with
those of other similar Amerindian populations.
J Dent Res 57(3):459-467, March 1978.
The normal and pathological characteristics of
dentition have been the object of wide study
from both a clinical and an anthropological
point of view. The prevalence of malocclu-
sionl-5 and dental anomalies6-8 differ between
populations as greatly as do patterns of dental
morphology.9-'4 Substantial variation also ex-
ists between populations in the frequencies of
caries and periodontal disease.15-'6 The expres-
sion of the hereditary and biological compon-
ents for both the normal and pathological char-
acteristics have been described but with dif-
ferent intensity and importance. Thus, dental
morphological patterns and dental anomalies
appear to have a clear genetic component in
their determination;6'8'16 in caries and perio-
dontal disease, the role appears to be dimin-
ished.2"15"17 The etiology of malocclusion is
variable and complex; however, various auth-
ors2,4"l7,'8 have discussed the genetic contribu-
tion from population admixture and inbreed-
ing. In addition, other authors demonstrated
Received for publication July 6, 1977.
Accepted for publication October 6, 1977.
This research was supported in part by the National
Institutes of Health, Fogarty International Fellowship
No. IFO 5TW 021-1 1-01 and the National Heart and
Lung Institute, Grant HL-15614.
Vol. 57 No. 3
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that different environmental factors contribute
to malocclusion as is true in the maxillofacial
complex (see Graber'9 for references) and gen-
erally in the growth and development of the
human body.20
The inhabitants of the Bolivian altiplano
live under extreme environmental conditions
and have little Spanish-Amerindian (Aymara)
admixture; they therefore are a good model for
observing the impact of environmental and
ethnic influences over the different normal or
pathological characteristics of dentition, in-
cluding malocclusion, dental caries, periodontal
disease, dental morphology, and dental anom-
alities.
Materials and Methods
Subjects of this study are 429 residents of
Turco and Toledo, two of the numerous Aym-
ara communities of the altiplano of western
Bolivia, descendants of the formidable Tiahua-
nacan civilization. Murillo et al2l characterize
the land and the people, and Schull and Roth-
hammer22 describe the project background and
interview and examination process in depth.
The population was subdivided into ethnic
groups: Aymara (Amerindian), mestizo (mix-
ed Indian and Spanish) and non-Aymara
(Spanish) using the cultural tradition of pa-
ternal and maternal surnames. Diaz et a123 and
Schull and Rothhammer22 explain the algo-
rithm for these group distinctions.
Oral and dental examinations were under-
taken on all individuals 6 years of age or older;
the results are grouped into two classes: chil-
dren (less than 15 years of age) and adults (15
years of age or older). (Refer to Palomino et
a124 for an account of the dental morphology
and facial and dental arch morphology.) The
original dental data were obtained by one ob-
server (H.P.) using direct intraoral examina-
459
460 PALOMINO
tions with a plain dental mirror (No. 5) and
explorers. Deciduous teeth were excluded from
consideration.
A large percentage of the population did
not have dental attention before this study.
Dental caries was assessed using the conven-
tional DMF index (decayed, missing, and filled
teeth). Care was taken to exclude congenital
missing teeth from the index. Periodontal dis-
sease was ascertained using Russell's25 perio-
dontal index (PI) and oral hygiene by using
Greene and Vermillion's26 simplified oral hy-
giene index (OHI-S). Dental anomalies
were scored as supernumery teeth, fused, hypo-
plasia, congenital missing lateral, peg- and
barrel-shaped lateral teeth, and molar pattern
asymmetry. Malocclusion is any disharmonic
variation from the accepted or theoretical nor-
mal arrangement of the teeth as described by
Grainger,27 who recognized in nature individ-
ual variation is always present and established
a degree of tolerated disharmony not consti-
tuting malocclusion. We have employed Grain-
ger's arguments and Niswander'sl criteria used
when studying another group of South Amer-
ican Indians. Therefore, for the Bolivian study,
the harmonic or normal occlusion was defined
as neutral occlusion with normal or bis a bis
anterior incisor relationships without crowding
or rotation other than mesial-palatal version of
the central upper incisors (winged) and a very
slight crowding of the lower incisors. Maloc-
clusion was coded using Angle's28 classification
of neutral, distal, and mesial occlusion. Also the
anterior maxillary-mandible incisor relation-
ship and tooth displacement were recorded.
Upper central incisor mesial-palatal version
(winging) was scored as present (winging more
than 900) or absent.
Presence or absence of shovel shape in the
maxillary central incisors was determined using
Dahlberg's9 categories which consider all de-
grees of shoveling. Carabelli's cusp was scored
on the upper first molar following Kraus's29 def-
inition of cusps but combining categories 0
and 1 as "absent" and 2 to 5 as "present," as
Brewer-Carias et a130 have employed. Molar
1 and 2 occlusal morphology cusps and groove
pattern were examined and coded according
to Dahlberg's9,31 standard categories: 4, 4-,
3 +, and 3 for upper and + 4, y 4, + 5, and
y 5 for lower molars. In addition, the less fre-
quent sixth cusp pattem was noted. The y 6
pattern was coded for molars exhibiting the
typical Y groove pattern with a sixth cusp and
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J Dent Res March 1978
the + 6 pattern coded when the + or X groove
shape was seen with a sixth cusp. The seventh
cusp pattern was not observed. The trait was
not scored if the groove pattern or cusps of the
molar teeth were uncertain because of caries or
attrition.
Categories for some of the morphologi-
cal traits were collapsed because classification
of continuous traits is mixed with bias and sub-
jectivity which provides an opportunity for
misclassification and exaggeration of differences
between scorings within observer, as is applica-
ble to this study, and between observers when
there is more than one examiner as Sofaer
et al"3 described. Chi square or analysis of
variance tests were performed to check for sig-
nificant sex and ethnic effects. Where necessary,
categories were collapsed, e.g., upper MI, 4-,
3 +, and 3 were grouped into one category
and lower Ml and M2 grouped according to
the number of cusps.
Findings and Discussion
OCCLUSION.-Table 1 provides the occlu-
sal status of the individuals examined by age,
sex and ethnic group. Normal occlusion was
encountered in 53.4% of the total Bolivian
sample and in 54.4% of those persons over 15
years of age. Of the individuals whose occlusion
was not normal, 30.3% exhibited malocclusion
Class I, 12.9% distal occlusion, and 3.4% me-
sial occlusion. No significant differences be-
tween ethnic groups or sexes were observed,
although there is a slightly greater frequency of
Class II in females than in males and a higher
frequency of Class III in males than in females.
Among the Aymara, 56.6% have normal occlu-
sion compared to 50.3% of the mestizos. Much
of the difference between these ethnic groups is
expressed in Class III malocclusion.
There is a significant (0.05 < P < 0.025,
4 d.f.) age effect, possibly due to the changing
and adjusting dentition, but with increasing
age normality of occlusion also increases. Class
I and III malocclusions are more frequent in
children and Class II in adults. Anterior incisor
relationships also exhibit significant (P <
0.0005, 6 d.f.) age differences. With increasing
age, a higher frequency of overbite and overjet
is present and conversely, openbite, crowding
and underjet decrease with advancing age. Also
apparent is a significant (0.01 < P < 0.005, 6
d.f.) sex difference for anterior incisor rela-
tionships (normal and bis a bis are considered
Vol.57 No. 3 DENTITION OF THE BOLIVIAN AYMARA 461

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462 PALOMINO
as one class); females have a lower frequency
than do males for all altered incisor relation-
ships except overjet and openbite.
As soon as some degree of variation is ex-
pressed among individuals, there is also vari-
ation among populations. The Aymara har-
monic occlusion occurs in broader and shorter
arches, with the incisors almost in line. The
anterior incisor relationships present slightly
less overjet than described for the normal Cau-
casian patterns and a certain tendency for a bis
a bis relationship. Dempster et al32 described
the normal axial inclination from the vertical
line perpendicular to the occlusal table to be
near 290 for upper and central incisors and
220 for the lower central incisors forming a
130° angle between the two axes. The Aymara
lower and upper teeth are more parallel and
exhibit almost vertical axes with a greater angle
between upper and lower incisors than the Cau-
casian population. Abrasion and attrition were
observed in the majority of the adults examined
in Bolivia.
MORPHOLOGY.--Table 2a presents the
morphological traits from which it can be seen
that there are no apparent sex or ethnic differ-
ences for shovel shape, Carabelli's cusp, or
mesial-palatal version traits. Both ethnically de.
fined groups, Aymara and mestizo, exhibit a
high prevalence of the Amerindian traits-
shovel shape incisors and mesial-palatal version
--and a low frequency of the Caucasian trait,
Carabelli's cusp. The similarity of the frequen-
cies expressed in both ethnic groups for these
traits supports the belief that the Aymara and
mestizo groups are strongly ethnically influenced
Aymara. This dental finding and data of Palo-
J Dent Res March 1978
mino et a124 support previous statements (see
Murillo et al21) concerning the high contribu-
tion of Aymara genes in the mestizo.
Occlusal patterns for the maxillary and
mandibular Ml and M2 are seen in Table 2b.
The upper first molars have a high frequency
of the 4 cusp pattern with only 1.1% of the
sample presenting the 3 or 3+ occlusal pattern.
There are no sex or ethnic differences, although
the Aymara exhibit the 4 occlusal pattern more
often than do the mestizos, 85.9% and 74.4%,
respectively. The reduced pattern is exhibited
more frequently by the upper second molar
than the first (54.4% have the 3 or 3+ occlu-
sal pattern) without significant sex or ethnic
differences. However, the male and Aymara
groups more frequently have the larger pattern
than do the females and mestizos, respectively.
The mandibular molars are more variable
than the maxillary molars in the number of dif-
ferent patterns and in the frequency of these
patterns. The typical y5 pattern is seen in
62.1% of the total population; however 28.1%
exhibit the y6 pattern, that is, the Y groove
shape with a sixth cusp. The frequency of +5
and +6 is relatively low and only 0.6% exhibit
the 4 cusp pattern. No ethnic differences were
found, but there is a significant (0.005 < P <
0.0005, 1 d.f.) sex effect principally because
males exhibit the 6 cusp pattern more frequent-
ly. Lower molar 2 also exhibits the reduced
pattern more often than the lower molar 1;
the 6 cusp pattern occurs among 14.3% and the
4 cusp pattern increases to 38.1%, without sex
differences. Significant (0.025 < P < 0.01, 2
d.f.) ethnic differences reflect the more fre-
quent occurrence of 6 cusps among the mestizo

TABLE 2a
DENTAL MORPHOLOGICAL TRAITS IN A BOLIVIAN AYMARA POPULATION
Males Females Aymara Mestizo Total
Trait N % N % N % N % N %
Shovel Shape
Present 105 95.5 114 91.9 101 93.5 114 93.4 219 93.6
Absent 5 4.5 10 8.1 7 6.5 8 6.6 15 5.4
Total 110 124 108 122 234
Mesial Palatal Version
Present 57 53.3 65 53.7 54 50.9 65 55.1 122 53.5
Absent 50 46.7 56 46.3 52 49.1 53 44.9 106 46.5
Total 109 121 106 118 228
Carabelli's Cusp
Present 15 12.3 9 6.9 7 5.9 17 13.1 24 9.5
Absent 107 87.7 122 93.1 112 94.1 113 86.9 229 90.5
Total 122 131 119 130 253

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 Vrol. 57- No. 3 DENTITION OF THE BOLIVIAN AYMARA 463

TABLE 2b
DENTAL MORPHOLOGICAL TRAITS IN A BOLIVIAN AYMARA POPULATION
Males Females Aymara Mestizo Total
Trait N % N % N % N % N %
Upper molar 1
4 175 80.3 180 78.6 177 85.9 174 74.7 355 79.4
4- 40 18.3 47 20.5 27 13.1 56 24.0 87 19.5
3+ 2 0.9 0 0.0 2 1.0 0 0.0 2 0.4
3 1 0.5 2 0.9 0 0.0 3 1.3 3 0.7
Total 218 229 206 233 447
Upper molar 2
4 9 5.7 4 2.6 7 4.7 6 3.8 13 4.1
4- 67 42.4 63 40.4 62 41.9 66 41.3 130 41.4
3+ 44 27.8 45 28.8 47 31.8 39 24.4 89 28.3
3 38 24.1 44 28.2 32 21.6 49 30.6 82 26.1
Total 158 156 148 160 314
Lower molar 1
+5 6 3.4 19 10.4 10 6.2 14 7.3 25 7.0
y5 101 57.1 129 67.0 101 62.7 119 62.0 223 62.1
+4 2 1.1 0 0.0 2 1.2 0 0.0 2 0.6
y6 64 36.2 37 20.3 46 28.6 53 27.6 101 28.1
+6 4 2.3 4 2.2 2 1.2 6 3.1 8 2.2
Total 177 182 161 192 359
Lower molar 2
+5 41 41.0 64 48.9 40 40.4 65 50.8 105 45.5
y5 4 4.0 1 0.8 4 4.0 1 0.8 5 2.2
+4 41 41.0 47 35.9 47 47.5 39 30.5 88 38.1
+6 13 14.0 19 14.5 8 8.1 23 18.0 33 14.3
Total 100 131 99 128 231
Note: x2 for lower molar 1 between sexes significant at 0.005 < P < 0.0005 and lower molar 2 between
ethnic groups significant at 0.025 < P < 0.01.

and 4 cusps among the Aymara. The lower first
molar patterns are predominantly y5 or y6,
meaning the mesial-lingual cusp is in contact
with the buccal-distal cusp, but in the lower
M2 occlusal pattern the mesial-buccal cusp is
in contact with the lingual-distal cusp thereby
forming principally the +5 or +6 configura-
tion for the 5 and 6 cusps.
In general, one tooth in each group of
teeth (incisors, premolars, molars) is consid-
ered morphologically stable in its expression
and retention of ancestral pattern and resist-
ance to abnormal change; the other teeth are
less stable.9 Furthermore, within each tooth
class the later developing teeth have been re-
duced more rapidly than their earlier develop-
ing neighbors, which is associated with greater
phenotypic variability in present populations,
apparently due to a greater environmental in-
fluence.33 The Aymara findings are consistent
with these concepts and in general upper mol-
ars are more stable than lower molars and the
first more than the second which increases the
reduced forms. Greater dental asymmetry has
been postulated due also to genetic or environ-
mental stress in man.34'35 The Bolivia study
observed that mandibular are more asymmetric
than maxillary molars and second more so than
first molars. The percentage of asymmetry of
the morphological molar occlusal pattern re-
spectively, for each antimeric pair, are upper
MI (n = 211) 0.0%; upper M2 (n = 145)
2.r1%; lower Ml (n = 162) 4.3%; and lower
M2 (n = 103) 6.8%.
CARIES AND PERIODONTAL DISEASE.-Table
3 presents the DMF, PI, and OHI-S in-
dexes as calculated from observations of the
Bolivian population. Similar to findings in other

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 qON&4~-05 dz
464 PALOMINO

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Vol. 57 No. 3
primitive populations (see Ref. 1), the DMF
mean value is relatively low for the total popu-
lation, with 31.7% (102 of 322) of the indi-
viduals caries-free. Although greater DMF
values in females are generally described in the
literature, in the Bolivian populations no sig-
nificant sex differences are seen. Nevertheless,
DMF index values are larger for females than
for males less than 30 years of age and con-
versely greater for males than for females over
30 years of age. These differences can be ex-
plained because in the younger group the major
influence for the index is decayed (D) teeth
and over 30 years of age missing (M) teeth
acquire major importance; filled (F) teeth are
not considered because there was no previous
dental attention. In addition, in the older group
more abrasion and attrition is present. This is
particularly true in males who sometimes have
almost complete abrasion and radicular atro-
phy, possibly due to stronger mastication, and
consequently have more missing teeth. Chung
et al,15 in their study of Hawaiian populations,
described an inter-racial effect for dental caries.
No significant ethnic differences were found in
the Bolivian population; however, the Aymara
exhibit lower DMF index values than mestizos
for all age groups.
Although there is a low incidence of caries,
when the villages of Turco and Toledo were
compared, the frequency of caries in Toledo
was lower than in Turco for all age groups
(ANOVA F = 8.46, 0.001 < P < 0.005). In
Toledo, 85.4% (35 of 41) of the population
less than 15 years of age and 25.8% (16 of 62)
15 years and older were caries-free. However,
in Turco the caries-free percentages were
50.0% (37 of 74) and 9.7% (14 of 145), re-
spectively, for each age group. Nutritional fac-
tors are known to influence the incidence of
caries. The two populations have a similar ge-
netic constitution and live in the altiplano
(over 3,500 m) where there is apparently
homogenous nutrition due to only a few dif-
ferent kinds and qualities of foods available for
consumption but there is a noticeable difference
in the drinking water. In Toledo, the water had
an evident salty taste. No sign of fluorosis was
observed. The cause for these differences will
be the subject of further analysis.
Bolivian individuals, in general, have low
values on periodontal and oral hygiene indexes;
however, these increase with age. The impor-
tance of oral hygiene in the etiology of perio-
dontal disease is well established.1 These in-
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DENTITION OF THE BOLIVIAN AYMARA 465
dexes do not exhibit differences between sexes,
ethnic groups, or villages. The age and size of
our sample prohibits a good comparison, al-
though the Aymara appear to exhibit lower hy-
giene index and higher periodontal index rat-
ings than the Xavantes and other populations in
Niswander's report.' Contributory to the rela-
tively good hygiene of the Aymara is the fact
that these Indians live in a cold and very dry
environment, eat raw vegetables and dried
meats when herding and farming, and com-
monly chew coca leaves which have vasocon-
strictor effects. Gingivitis and periodontal dis-
ease are principally due to traumatic occlusion
and strong mastication which in adults at times
advances to complete bone and radicular
atrophy and crown abrasion.
ANOMALIES.-The frequencies of dental
anomalies recorded in the 323 persons with
complete dental examinations are supemumer-
ary teeth, 1 case; fusion of teeth, 1 case; hypo-
plasia, 3 cases; missing upper laterals, 2 cases;
peg-shaped upper laterals, 1 case; and barrel-
shaped upper laterals, 2 cases. Because of the
Bolivian sample size and low frequency of an-
omalies, these traits are presented without dis-
cussion. However, they are, in part, consistent
with the frequencies found in Amerindians or
Mongolian populations. (See Chung, et al8
presentation of inter-racial comparisons of the
prevalence of dental anomalies in Hawaiian
schoolchildren and Niswanderl for additional
references concerning these anomalies.)
Conclusions
(1) Oral examinations of the residents of
Turco and Toledo in western Bolivia revealed
a population with relatively good occlusion and
a low frequency of dental pathology, with den-
tal characteristics in part consistent with other
Amerindian and Mongolian populations.
(2) The Aymara exhibit generally broader
and shorter arches, the incisors almost in line,
slightly less overjet than is seen in normal Cau-
casians and a tendency to bis a bis occlusion.
The axes of the upper and lower incisors are
more parallel.
(3) Normal occlusion was found in 53.4%
of the total population sample, malocclusion
Class I in 30.3%, distal occlusion in 12.9%,
and Class III in 3.4% of the sample. Only
slight differences, without statistical signifi-
cance, are found between sex and ethnic groups;
greater Class II malocclusion is found in fe-
males and Class III in males. Also the mestizos
466 PALOMINO
exhibit slightly higher frequency of Class III
malocclusion than do the Aymara. The group
of individuals under 15 years of age have a sig-
nificantly greater percentage of normal occlu-
sion than do adults, possibly due to changing
dentition with age.
(4) Anterior incisors relationship also have
a greater percentage of abnormality in children
than in adults. There is an increase in overbite
and overjet and a decrease in openbite, crowd-
ing and underjet with age. Significant differ-
ences were found between sexes with a higher
percentage of normal incisor relationship in
females.
(5) A high frequency of shovel shape and
mesial-palatal version of upper central incisors
and lower frequency of Carabelli's cusp were
observed in both sex and ethnic groups.
(6) Molar occusal patterns are de-
scribed. A greater pattem reduction and vari-
ability was observed in the mandibular molars
than in the maxillary molars and in the second
molars than in the first molars. Similar findings
were registered in the percentage of asymmetry,
greater in mandibular than maxillary molars
and second than first molars.
(7) A low incidence of caries was found,
with 31.7% of the individuals caries-free, with-
out significant sex and ethnic differences. To-
ledo exhibited significantly lower DMF index
values than did Turco. This finding possibly is
related to the salty drinking water in Toledo.
(8) Periodontal and oral hygiene index
values are correlated and increase with advanc-
ing age. However, these indexes are relatively
low possibly because of environmental factors
and cultural influences.
(9) Frequencies of dental anomalies such
as supernumerary teeth, missing, peg-shaped
and barrel-shaped lateral incisors, fusion of
teeth, and hypoplasia are described. Low fre-
quencies were found and, in part, are consistent
with the frequencies reported for Amerindian
and Mongolian populations.
The author wishes to acknowledge the extreme co-
operation and organization of the project by Dr. Fed-
erico Murillo, the contributions of the Corporacion Des-
arrollo de Oruro, and the people of the villages of Turco
and Toledo which made this field work possible, as well
as the participation in the data collection by each mem-
ber of the field team. The author is grateful for the
analytical and editorial assistance of Ms. Sara A. Barton
and Dr. William J. Schull.
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