A Mouthful of Evidence

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Who among us has not heard the time-honored adage, "Those who cannot remember the past are condemned to repeat it?" The saga of scurvy in stomatology is a superlative case.

You will recall the earlier stories concerning sea voyages. The point was made even back then of a trinity of symptomatology, namely inordinate weakness, the hemorragic diathesis, and spongy (and clearly bleeding) gums. So we have long known of the connection between vitamin C state and the oral tissues.

What is the number one twentieth-century chronic problem in Western culture? No question ... 95 percent of the public suffers with dental caries and/or periodontal disease.

There is also another, and very exciting, uniqueness to symptomatology. Disease is the result of the interplay of nine constellation of environmental challenges as it relates to the internal milieu. The oral cavity is one of than few areas where experiments can be performed delineating the relative importance of the environment and host state.

For example, it is possible to clean and polish only half the teeth (e.g., the right or left side). This then allows a comparison of the effect of modifying the local environment versus letting it remain unchanged. On the other hand, you can give a group of subjects vitamin C versus a placebo. (We tried but failed to give half a person ascorbate!) By these experimental designs, one can derive the relative contributions of these four different ecologic possibilities. There is also the converse. Banding half the teeth makes it possible to compare the added irritation (of bands versus no bands) in the light of vitamin C and placebo supplementation. Such experiments have been described in the literature with various nutrients, including ascorbic acid.

The Current Official Dental Opinion
Russell in 1963 summarized the results of the studies conducted under the auspices of the Interdepartmental Committee for Nutrition in National Defense (ICNND). He recorded the dietary and oral health status of selected samples. The evaluation of nutritional deficiencies was based on clinical examinations and on biochemical tests of blood and urine in a small subsample. Serum levels of ascorbic acid were used in the ICNND studies to assess deficiency levels. The ICNND played a big role in the original standards for blood AA concentrations. Russell concluded from these well-publicized epidemiologic data that age and oral hygiene contributed most to the variance in Periodontal Index (PI) scores. Also, he further saw no correlation between ascorbic acid deficiency and increased PI scores (then the most popular measure of periodontal health). In another study, the Ten State Nutrition Survey, only a "weak" correlation was reported between hypoascorbemia and the presence of gum disease.

These observations in the 1960's dominated and continue to color the thinking of dentistry. They even serve today as a basis for the relative unimportance of the ascorbates in oral health and sickness.

On the other hand, there have been, and still are, clinicians who feel, from their limited but presumably cause-and-effect observations, that vitamin C seems to play a role in oral health. For these reasons, plus the fact that a large governmental study had been completed, it became possible to reexamine the epidemiologic data.

This project investigated the association (again in an epidemiologic way) between the reported levels of dietary ascorbic acid intake and the presence of periodontal disease. A representative segment of the U.S. population provided by the first National Health and Nutrition Examination Survey (NHANES 1), from 1971 to 1974, was reviewed. The NHANES I survey was a comprehensive accounting of health and nutrition in more than 20,000 individuals, aged 1 to 74, in the continental United States. Data were collected from 8,609 dentulous persons (those with teeth), aged 25 to 74 years, who received a dental examination during NHANES I and with whom a 24-hour dietary recall interview was conducted. The purpose of this analysis was to investigate the possible correlation between periodontal disease and reported dietary intake of vitamin C. A corollary aim was to determine whether a more-than-recommended daily intake of ascorbic acid was associated with better periodontal health.

Periodontal disease status (PI) and oral hygiene state (Simplified Oral Hygiene Index, OHI-S), in addition to other oral and dental health assessments, were collected by 10 trained dentists at 65 locations during the four years of the NHANES I survey.

Ascorbic acid intake was calculated from the foods consumed by each individual during the preceding 24 hours. To ensure the greatest possible accuracy, the interviews were conducted by people trained in gathering dietary data. In this report, the term "dietary ascorbic acid" refers to ascorbate reportedly consumed in the 24-hour dietary recall, without considering vitamin supplements.

The conclusions are complex and convoluted. They can be summarized by two large statements splashed in appropriate places in the original report.

Among those who reported taking vitamin supplements,
there is nothing to support any association between levels
of ascorbic acid ingestion and periodontal health.... Dental
practitioners are better advised to concentrate on
plaque control rather than vitamin C supplements to
prevent and control periodontal disease in their patients.
This conclusion is, in part, the basis for the current recommendation of the Council on Dental Therapeutics of the American Dental Association.

Is this the whole story?

By not including edentulous patients (those without teeth), did they not actually omit those with probably the worst periodontal disease? Would their findings have been different had they incorporated those with vitamin supplementation? What would have been the results had they included one or more of the biochemical measures of vitamin C? Might there have been significant relationships between oral hygiene and the dietary conditions?

Copyright by the estate of Emanuel Cheraskin, M.D., D.M.D. Adapted with permission from Vitamin C: Who Needs It? by Emanuel Cheraskin, M.D., D.M.D. Published by Arlington Press.

CARTOON

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By Emanuel Cheraskin, M.D., D.M.D.

You Are What You Eat
Nearly 65 percent of periodontists believe that nutrition plays a major role in the status of their patients' periodontal health, according to a poll conducted recently by the American Academy of Periodontology (AAP). About 75 percent of the periodontists recommended more vitamin C for improved oral health.

More than half of the 135 periodontists polled reported that they or their staffs had talked to patients on a regular basis about the role of good nutrition in maintaining good oral health.

"I tell them that a well-balanced diet is important for the body and, subsequently, the mouth's health," said one responding periodontist. "I inform my patients that vitamin C is important for tissue health and calcium is important for bone health."

Most periodontists recommend calcium supplements and multivitamins for patients who are not getting adequate amounts from their diet.

"Research has proved that people who consume inadequate amounts of calcium and vitamin C have higher rate of periodontal disease," said Michael McGuire, D.D.S., president of the AAR "However, many other nutrients likely play a role in maintaining good periodontal health too."

Conversely, some foods are best avoided to maintain good periodontal health. The top culprit chosen by periodontists was popcorn, because the husks can get caught in between the teeth and gums and may cause abscesses.

Untitled
More than 400,000 adults in the United States develop oral complications each year as a result of cancer treatment.(Source: U.S. Department of Health and Human Services. 2000. Oral Health in America.)

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