- Email: [email protected]
Vitamins as an Adjunct in the Treatment of Periodontal Disease
V ITAM IN S AS AN ADJUNCT IN THE TREATM ENT OF PERIODONTAL DISEASE H arry R oth
* B.S., D.D.S., N e w Y ork, N . Y .
HE mere absence o f disease does not im ply buoyant health. Health has m any gradations, extending from buoyant or m axim um health all the way d ow n to the borderline o f disease. O ptim u m nutrition can assure buoyant health if no anatom ic or fu n c tional limitations are present. Com m enting on the im portance of nutrition, Russell M . W ilder, chairman o f the Com m ittee on F ood and Nutrition o f the National Research Council, w rites:
T
When the story of the control of malnutri tion can finally be told it may not be quite so dramatic a tale as that of the eradication of cholera and typhoid, but the advantages to the public health from such control will, in my opinion, match in importance what has been accomplished in sanitation. Typhoid either kills or ultimately relaxes its hold. Nutritional deficiency saps vitality in so in sidious a way that the victim may be una ware that enough is wrong to call a doctor. . . . The milder degrees of nutritional defi ciency, although they are neither fatal nor completely incapacitating, constitute the nub of the problem of malnutrition. They inter fere with sleep, so that rest is disturbed. They wreck courage. They undermine the will to do. They seriously depress resistance to other diseases, and, in women, contribute to the occurrence of complications during pregnancy. The prevalence of milder de grees of malnutrition, in the opinion of those who are best informed, accounts for . . . a considerable part of the relief rolls. The undernourished are unable to hold jobs if they find them; they become unemployable. •Assistant professor in periodontia, New York University College of Dentistry. Jour. A.D.A., Vol. 32, January 1, 1945
A person may be apparently well. H e may g o to business, d o a hard day’s work, and yet not have buoyant health. Fatigue m ay be part o f his daily life. H e accepts manifestations of atrophic changes because he has adapted himself to such com m on complaints as headache, backache, pain in the arms and legs, poor appetite, toothache and bleeding o f the gingivae. T rue, these conditions exist in a majority o f the population, and yet they cannot be accepted as norm al. T hey are the complaints o f average people existing on a subsistence level maintained by an average diet. A verage diets have been shown to be deficient in essential minerals and vita mins, with too high an intake o f refined carbohydrates (sugars, candy, cakes and pastries). H ealth to the nutritionist today means buoyant h e a lth : better eyesight; better h ea rin g ; freedom from aches and p a in s; greater resistance to infections, such as the co m m o n c o ld ; reduction in the rate of a troph ic changes sueh as arteriosclero sis, an d an increased life span, with extra years added in the prim e o f life. Dentistry has up to the present failed to fulfil its full obligation as a health service. T here are many reasons and logical explanations fo r this fact. O ne of the most im portant is that 70,000 den tists can not adequately correct the den tal diseases o f even 25 to 30 p er cent o f the people. It is also a known fact that only a small portion o f the 30 per cent receiving adequate dental care are en joy in g the benefits o f m odern dentistry. H o w can we cope with this problem ? 60
R o t h — V i t a m i n s a n d P e r i o d o n t a l D is e a s e
61
T h e best answer by fa r was given by the S can din avian countries before the N azi cloud engulfed them . T h e y learned that even m inim um rem edial op erative p ro cedures w ould be a colossal, if not an impossible, undertaking. T h e problem was approached by ed u catin g parents on dietary principles. T h e “ O slo breakfast” was instituted in order to insure a daily intake o f optim um m inerals and vitam ins in the diet. A lon g w ith this diet, the den tal defects o f all school children w ere corrected. T h e im provem ents produced in general and oral health are indisputable, as m ust be recog nized by the dentist. T h e discovery of nutritional deficiencies b y m eans o f rou tine oral exam ination and the institution of vitam in therapy and im provem ent of
or corrected by alterations in the daily diet. Such changes can be accom plished readily by elim inatin g the non-detergent, acid -prod u cing foods, such as candies, cakes, pastries and w h ite bread, w h ich lack essential vitam ins and m inerals, and replacin g them w ith detergent, alkalip rod u cin g foods contain ing essential v ita m ins and m inerals, such as raw salads, w hole grain breads and cereals, m ilk, fruit, eggs, organ m eats, potatoes and raw and steam ed vegetables in the daily diet. T h e systemic conditions m ay be influ enced by all the conditions that affect the teeth and supporting structures, in addition to the local physical effects o f food on both the h ard and the soft structures o f the den tal apparatus.
Fig. i.— Condition before vitamin therapy. Hypertrophy, edema and congestion are pres ent (severe chronic scurvy). .
Fig. a.— Condition one month later. (Com pare Fig. r.) Ascorbic acid, 300 mg. daily, was given. There is reduction in hypertrophy, with a tendency of the tissue to return to normal. Vitamin therapy is to be continued for at least a year, along with local treatment for gingival disease.
dietary intakes are im portant responsi bilities o f the dentist. Physicians and research w orkers con sider the tongue, teeth and gin givae the m irror o f physiologic activities. Dentists are m uch better equipped to interpret aberrations o f the gin givae and thus recognize systemic disturbances reflected therein. A cco rd in g to M iller,1 the dietary causes o f caries and periodontal diseases can be divided into tw o general classes: ( i ) local, or extrinsic and (2) systemic, or intrinsic. T h e local conditions m ay be influenced
D eficien cy states m ay be caused also by the follow in g conditions (m odified from J o lliffe )2 : 1. In d igen cy or low incomes. 2. Erroneous d ietary habits and food idiosyncrasies ; e.g., excessive use o f re fined sugar, candy, pastries, cakes, ch o c olate flavors and soft drinks. 3. E xcessive consum ption o f alcohol, refined starches or m ineral oil. 4. Diseases alterin g nutritional re quirem ents :
62
1'h e J o u r n a l o f t h e A m e r i c a n D e n t a l A s s o c i a t i o n
(a ) Hyperthyroidism. (b ) Fever, especially o f long dura tion. (c ) Gastrointestinal disturbances, colitis, achlorhydria, vagotonic spasms. (d ) Pregnancy. (e ) R apid growth. i(f) Increased excretion; diarrhea; p oly u ria ; lactation. ,(g) Nervous states. 5. F ood fads. 6. A n edentulous state or wearing o f inefficient dentures. I t is because o f these conditions, in addition to inadequate consum ption, soil depletion and unsatisfactory transporta tion, marketing and cooking, that most o f the population is in a state o f malnu-
it should include not only a deficiency but also any metabolic disturbances of the essen tial in the tissues. The causes may be com plex. T hey may be conveniently classified as external and internal. Dietary deficiency is the most common external cause. Any bodily condition interfering with digestion, transport or utilization, prompting destruc tion or excessive excretion, or raising the requirements of the dietary essential is for example an internal cause. Almost every non-nutritional disease affects nutrition. A cause comes about through a combination of circumstances. For example, assuming a sat isfactory internal mechanism, a deficiency disease from insufficient intake relative to age, activity, exposure to light, storage, state of tissue and probably other factors.
Fig. 3.— Condition before treatment; cheilo sis, or perleche. The patient came in for perio dontal treatment, with a “sore” in the corner of the mouth, present for a year. There is a urea-like frosting of the lower lip at the mucocutaneous junction. The cracking, or Assuring, at the angles of the mouth is an advanced ariboflavinosis.
Fig. 4.— Condition after vitamin therapy. (Compare Fig. 3.) Riboflavin, 5 mg., plus two yeast tablets three times a day was given after meals from September 25 to October 16, approximately three weeks. The Assuring at the angle of the mouth and the urea frost ing of the lower lip have disappeared. A pain in the right forearm disappeared at the same time.
trition. A problem presents itself when virtually all our patients (three-fourths o f the population have some form of “ hidden hunger” or m alnutrition) fall into one o f the foregoing categories. Kruse aptly says: More properly, the term “ deficiency dis ease” should connote a deficiency in the bodily tissues rather than in the diet. In deed, its meaning should be even broader:
Kruse has shown that apparently well
persons manifest some form o f deficiency state. M ost o f the significant changes were observed with the aid o f a biom icro scope. T h e changes brought about in the gingivae and the tongue with the aid o f vitamin therapy were reported by him in two excellent papers .3’ 4 T on g u e changes were effected by giv ing 200 mg. o f niacinam ide daily for
R o t h — V i t a m i n s a n d P e r i o d o n t a l D is e a s k
T a b le
1.—
V i t a m i n T h e r a p y E m p lo y e d i n P e r i o d o n t i a D e p a r t m e n t , N e w Y o r k U n i v e r s i t y C
Deficiency Vitamin
Niacin (nicotinic acid)
Thiamine B
Riboflavin (B2)
Vitamin C (ascorbic acid)
Mild polyvitamin and mineral deficiencies
Subclinical
63
ollege of
D
e n t is t r y * !
Oral Signs as Seen by DentistJ Keratinization and hypertrophy of gingivae
Scarlet tongue; smooth atrophy of the lateral borders and tip of the tongue; painful, sore, fis sured and corrugated tongue; may influence red ness of gingivae along with avitaminosis C; stages from mildly acute to severe chronic may be seen Neuralgic pains in and about the mouth; dry socket; aphthae
Prescription (Refilled as Necessary) Vitamin A (25,000 I.U. tabs) No. 100, 6 tablets a day after meals for six months to a year. Niacinamide (100 mg. tablets) No. 100, 1 tablet 3 times a day after meals.
Thiamine hydrochloride (10 mg. tabs) No. 100, 1 tablet with 1 yeast tablet and 100 mg. of as corbic acid 3 times a day after meals; usually used in conjunc tion with riboflavin, niacinamide and ascorbic acid. Purplish red or magenta tongue; cheilosis; crack Riboflavin (5 mg. tabs) No. 100, ing at corners of mouth ' * 1 tablet and 1 compressed yeast tablet 3 times a day after meals. Gingivitis; easy bleeding of gingivae; edema of Ascorbic acid (100 mg. tabs) No. 100, 2 tablets after each meal 3 gingivae; slow healing; may also be used preoperatively and postoperatively to hasten healing times a day for six months to one and one-half years. and in treatment of necrotic gingivitis In adults, red marginal gingivitis (S. C. Miller); 2 tablespoons of cod liver oil every day; 3 glasses of milk in children, as result of deficiency in infancy, poor tooth formation (tooth structure cannot be taken at mealtime for at least a improved by vitamin therapy; for gingivae signs year .for adults (vitamin D po and alveoloclasia and to preserve ridges under tency of product should be prosthetic appliances, use in conjunction with checked on label). high calcium diet) Poor oral health in general, tissue bloated and 6 brewers yeast tablets and 1 teaspoonful of cod liver oil daily; coated: alveoloclasia active in general balanced diet with minerals and vitamins in abundance (for maintenance dose, commercial vitamin products may be used). Any of the foregoingsymptomsinmoderationor Ascorbic acid 75 mg., riboflavin as voted by capillary microscopy or slit-lamp (B2) 5 mg., thiamine HCL (BL;, technic; vague, confused, indefinite complaints or 10 mg.; niacinamide 50 mg. ft., complaints of unknown etiology in and about capsule or tablet, 1 tablet or capsule 3 times a day after meals mouth for ten days, thereafter once a day until all symptoms disap pear
*Miller, S. C.: Oral Diagnosis and Treatment Planning, Ed. 2. Philadelphia: P. Blakiston’s Son and Co., Inc., 1944. fCaution: Specific vitamins are to be used for definite clinical conditions, only U.S.P. and C.P. products accepted by the Council on Therapeutics of the A.D.A. being used. Vitamins are best taken immediately after or with meals. It is safe to use the foregoing doses unless the patient complains of unusual symptoms or the prescription indicated is contrary to the advice of the physician. {Local causes in addition to the systemic conditions are usually present even though not mentioned in this outline.
64
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
from one to one and a half years. T he changes in the pattern o f the tongue were recorded by kodachrom e p h oto graphs. T h e N ew Y ork University Periodontia Research G roup m ade tests on the gingi vae. M any im provem ents could be achieved only by giving 500 mg. o f vita min C daily to patients fo r from one to one and a half years. Som e changes can be seen only with the aid o f the biom icro scope. H ow ever, many o f the m acroscopic changes in the gingivae can be seen by dentists. In acute cases, quicker reactions may be expected. These changes are demonstrated in the accom panying il lustrations. Patients in the Periodontia D epart m ent o f N ew Y ork University .College o f Dentistry w ho apparently had gingi val disease were given 500 mg. o f vita min G daily. Photographs were taken before and after administration. M arked changes were noted in tone, color and consistency. A purplish red, bloated, edematous, swollen condition o f the gin givae was converted to a pink, firm even tone w ithout edema. Gingival hem or rhage also was reduced, in most cases. (Figs. 1 and 2.) T h e same procedure was follow ed in the treatment o f cheilosis and cracking or Assuring o f the com ers o f the mouth. Patients were given 5 m g. o f riboflavin (B 2) with tw o tablets o f compressed yeast three times a day after meals. Definite healing resulted. (Figs. 3 and 4.) Figures 5 and 6 show the results o f treatment with 100,000 units daily o f vitamin A. Figures 7 and 8 show the effects o f administration o f 1500 m g. o f vitamins C daily for tw o days in a cáse o f acute necrotic gingivitis superimposed on hy pertrophy (resulting from dilantin ther a p y ). V itam in therapy was instituted after failure to respond to three weeks o f routine treatment fo r necrotic gingi vitis.
T able
2.—
V it a m in V a l u e s
v it a m in
a
The international unit of vitamin A is de fined as the vitamin A activity of 0.6 micro gram of pure beta-carotene. The U.S.P. unit is equal, in growth-promoting and antiophthalmic activities for the rat, to one international unit. The U.S.P. reference cod liver oil contains at least 850 U.S.P. units of vitamin A per gram. THIAMIN HYDROCHLORIDE (VITAMIN B i )
The U.S.P. Unit of vitamin B is defined as the vitamin Bi activity of 3 micrograms of the U.S.P. reference standard thiamine hydrochloride, and is equal in value to one international unit of vitamin Bi. One U.S.P. or international unit of vitamin Bi is ap proximately equivalent to two Chase-Sherman units; 0.5 Smith-curative unit; 20 Cowgill mg. equivalents. One milligram of vitamin Bi contains 333 U.S.P. or international units. RIBOFLAVIN ( VITAMIN B2)
The Bourquin-Sherman unit is equal to that amount of source material which, when fed daily to a standard test animal, will sup port a growth rate of 3 gm. per week. In vestigators have reported that 2.5 micrograms of pure riboflavin will support this growth rate. There is no international unit for ribo flavin. Pure riboflavin may be used as the reference standard and, according to assays, 1 mg. contains approximately 400 BourquinSherman units. ASCORBIC ACID ( VITAMIN c) The U.S.P. unit of vitamin G is defined as the vitamin C activity of 0.05 mg. of the U.S.P. reference standard ascorbic acid, and is equal in value to one international unit of vitamin G. One milligram of vitamin C equals 20 U.S.P. or international units. One cubic centimeter of fresh lemon or orange juice has a potency of approximately 10 U.S.P. or international units of vitamin C. VITAMIN D
The international unit of vitamin D is de fined as the vitamin D activity of 1 mg. of the international standard solution of irradiated ergosterol, which is equal to that of 0.025 mi crogram of crystalline vitamin D, or. calciferol. The U.S.P. unit of vitamin D is defined as equal, in antirachitic potency for the rat, to one international unit of vitamin D. The U.S.P. reference standard cod liver oil con tains 95 U.S.P. units of vitamin D per gram. U.S.P. cod liver oil contains at least 85 U.S.P. units of vitamin D per gram. Viosterol is fre quently labeled 250 or 150 D, which means that it contains 250 or 150 times the vitamin D content of U.S.P. cod liver oil. Activated ergosterol in oil U.S.P. (viosterol) contains not less than 10,000 U.S.P. units vitaminD per gram.
R o t h — V i t a m i n s a n d P e r i o d o n t a l D is e a s e
T h e fo llo w in g replies are m ade to com m only asked questions : 1. Can high vitamin doses in any way harm the p atien t? T h e re is no evidence th at doses even 100,000 times greater than those ad vo cated in this p a p er w ill in any w ay harm the patient. 2. A re parenteral injections better than administration o f vitamins by m ou th ? T h ere is n othin g in the literature to indicate th a t the parenteral route is bet ter than the oral route. O n ly in rare cases, such as intestinal disorders (e.g., colitis), is the parenteral m ethod in d i cated. G iv in g vitam ins by m outh m ay
Fig. 5.— Condition before vitamin therapy; showing edema, congestion and hypertrophy (possible avitaminosis A ). Calculus was not removed nor was toothbrushing taught.
65
((b) A large m ajo rity of the p o p u la tion h a ve some form o f m alnutrition. ,(c) Patients com ing to the dentist are apparently w ell and usually are not u n der the care o f a physician. A large m ajo rity o f these patients need some form o f d ietary advice. M a n y m ay need vitam in therapy. (d ) W hen prescription by the dentist interferes w ith m ed ical prescription for specific diseases, the physician should be consulted and his recom m endations al low ed to take precedence. 4. W hat are the reasons fo r failure in vitamin therapy? (a ) F ailu re to give sufficient dosage o f vitam ins fo r a lon g enough period of
Fig. 6.— Condition after treatment. (Com pare Fig. 5.) Vitamin A, 100,000 international units, was given daily from July 21 to No vember 2, with reduction in edema, hyper trophy and congestion. The acne on the pa tient’s face disappeared in two weeks.
even enhance the absorption o f certain tim e; e.g., 500 m g. daily of vitam in G vitam ins because o f the phosphorylization th at takes place in the alim entary fo r a year. canal. (b) A ttem pts to treat long-standing vitam in deficiency diseases by ordinary 3. Should a dentist prescribe vitamins? dietary means. F o r the follo w in g reasons, it is ob (c) F ailu re to take into consideration ligatory fo r dentists to be prepared to conditions th at m ay interfere w ith the advise dietary changes and prescribe absorption o f vitam ins by the tissues; vitam ins. (a ) T h e m ed ical profession sees in such, as colitis, alcoholism and excessive ingestion o f m ineral oil. the m outh signs o f nutritional deficien (d ) A dm inistration o f vitam ins before cie s; e.g., p ellagra, tongue and m ucous meals. V itam in s a ct best in an acid m em brane changes ; scurvy, gin gival changes, and tongue and lip changes m edium and should be taken after (riboflavin d efic ien cy ). meals.
66
T h e J o u r n a l o f t h e A m e r i c a n D e n t a l A s s o c i a t io n
CONCLUSIONS BASED ON CLINICAL EXPERIENCE
1. T h e m ajo rity o f patients h a ve some form o f avitam inosis, usually o f a m ulti ple nature. 2. V ita m in C should b e given in suffi cien t dosage to reach th e gin givae as w ell as other tissues o f the body. 3. V ita m in C , 500 m g. daily, w ill im prove and m ain tain th e health o f the gin givae to a better degree than local
Fig. 7.— Condition before vitamin therapy; acute necrotic gingivitis superimposed on dilantin hypertrophy. All the classical symp toms were present and failed to respond after three weeks of the usual treatment for necrotic gingivitis.
treatm ent w ith out vitam in therapy. A d m inistration over a lon g period, e.g., a year o r a year and a h alf, is beneficial and w ill do no harm . 4. B ecause o f the m an y conditions present, 500 m g. o f ascorbic acid (vita m in C ) w as foun d to be the dose re quired to alter the condition o f the m a jo rity o f the chronically affected tissues. 5. T h ere is a possibility th a t vitam ins h ave a special affinity fo r certain tissues, such as vitam in C fo r the g in g iv a e ; n ia cin fo r the tongue, and riboflavin (B 2) fo r the lips.
6. T re a tin g gin gival conditions by d i etary m eans alone is not adequate, if one is seeking the optim um nutrition and health o f tissues. 7. R em oval o f calculus subgingivally and su p ragin givally as w ell as elim ina tion o f pockets, equilibration o f occlusion and stim ulation o f the gin givae by cor rect m assage can n o t be replaced by vita m in therapy. A ll etiologic factors must be elim inated if success in the treat-
Fig. 8.— Condition forty-eight hours later. (Compare Fig. 7.) Administration of Vitamin C, 1,500 mg. daily, dissipated the subjective symptoms. Reduction in hypertrophy, con gestion and edema is evident.
m ent o f periodontal disorders is to be achieved. BIBLIOGRAPHY
1 . M i l l e r , S. C .: Textbook of Periodontia. Ed. 2. Philadelphia: Blakiston Co., 1943. 2. Id em : Textbook of Periodontia. Ed. 2. Philadelphia: Blakiston Co., 1943. 3. K r u se , H. D.: Gingival Manifestations of Avitaminosis C with Especial Considera tion of Detection of Early Change. M ilbank M em . Fund Q uart., 20:290, July 1942. 4. Id em . Lingual Manifestations of Aniacinosis, with Especial Consideration of Detection of Early Changes by Biomicroscopy. M ilbank M em . Fund Q uart., 20:262, July 1942. 156 East Fifty-Second Street.
* B.S., D.D.S., N e w Y ork, N . Y .
HE mere absence o f disease does not im ply buoyant health. Health has m any gradations, extending from buoyant or m axim um health all the way d ow n to the borderline o f disease. O ptim u m nutrition can assure buoyant health if no anatom ic or fu n c tional limitations are present. Com m enting on the im portance of nutrition, Russell M . W ilder, chairman o f the Com m ittee on F ood and Nutrition o f the National Research Council, w rites:
T
When the story of the control of malnutri tion can finally be told it may not be quite so dramatic a tale as that of the eradication of cholera and typhoid, but the advantages to the public health from such control will, in my opinion, match in importance what has been accomplished in sanitation. Typhoid either kills or ultimately relaxes its hold. Nutritional deficiency saps vitality in so in sidious a way that the victim may be una ware that enough is wrong to call a doctor. . . . The milder degrees of nutritional defi ciency, although they are neither fatal nor completely incapacitating, constitute the nub of the problem of malnutrition. They inter fere with sleep, so that rest is disturbed. They wreck courage. They undermine the will to do. They seriously depress resistance to other diseases, and, in women, contribute to the occurrence of complications during pregnancy. The prevalence of milder de grees of malnutrition, in the opinion of those who are best informed, accounts for . . . a considerable part of the relief rolls. The undernourished are unable to hold jobs if they find them; they become unemployable. •Assistant professor in periodontia, New York University College of Dentistry. Jour. A.D.A., Vol. 32, January 1, 1945
A person may be apparently well. H e may g o to business, d o a hard day’s work, and yet not have buoyant health. Fatigue m ay be part o f his daily life. H e accepts manifestations of atrophic changes because he has adapted himself to such com m on complaints as headache, backache, pain in the arms and legs, poor appetite, toothache and bleeding o f the gingivae. T rue, these conditions exist in a majority o f the population, and yet they cannot be accepted as norm al. T hey are the complaints o f average people existing on a subsistence level maintained by an average diet. A verage diets have been shown to be deficient in essential minerals and vita mins, with too high an intake o f refined carbohydrates (sugars, candy, cakes and pastries). H ealth to the nutritionist today means buoyant h e a lth : better eyesight; better h ea rin g ; freedom from aches and p a in s; greater resistance to infections, such as the co m m o n c o ld ; reduction in the rate of a troph ic changes sueh as arteriosclero sis, an d an increased life span, with extra years added in the prim e o f life. Dentistry has up to the present failed to fulfil its full obligation as a health service. T here are many reasons and logical explanations fo r this fact. O ne of the most im portant is that 70,000 den tists can not adequately correct the den tal diseases o f even 25 to 30 p er cent o f the people. It is also a known fact that only a small portion o f the 30 per cent receiving adequate dental care are en joy in g the benefits o f m odern dentistry. H o w can we cope with this problem ? 60
R o t h — V i t a m i n s a n d P e r i o d o n t a l D is e a s e
61
T h e best answer by fa r was given by the S can din avian countries before the N azi cloud engulfed them . T h e y learned that even m inim um rem edial op erative p ro cedures w ould be a colossal, if not an impossible, undertaking. T h e problem was approached by ed u catin g parents on dietary principles. T h e “ O slo breakfast” was instituted in order to insure a daily intake o f optim um m inerals and vitam ins in the diet. A lon g w ith this diet, the den tal defects o f all school children w ere corrected. T h e im provem ents produced in general and oral health are indisputable, as m ust be recog nized by the dentist. T h e discovery of nutritional deficiencies b y m eans o f rou tine oral exam ination and the institution of vitam in therapy and im provem ent of
or corrected by alterations in the daily diet. Such changes can be accom plished readily by elim inatin g the non-detergent, acid -prod u cing foods, such as candies, cakes, pastries and w h ite bread, w h ich lack essential vitam ins and m inerals, and replacin g them w ith detergent, alkalip rod u cin g foods contain ing essential v ita m ins and m inerals, such as raw salads, w hole grain breads and cereals, m ilk, fruit, eggs, organ m eats, potatoes and raw and steam ed vegetables in the daily diet. T h e systemic conditions m ay be influ enced by all the conditions that affect the teeth and supporting structures, in addition to the local physical effects o f food on both the h ard and the soft structures o f the den tal apparatus.
Fig. i.— Condition before vitamin therapy. Hypertrophy, edema and congestion are pres ent (severe chronic scurvy). .
Fig. a.— Condition one month later. (Com pare Fig. r.) Ascorbic acid, 300 mg. daily, was given. There is reduction in hypertrophy, with a tendency of the tissue to return to normal. Vitamin therapy is to be continued for at least a year, along with local treatment for gingival disease.
dietary intakes are im portant responsi bilities o f the dentist. Physicians and research w orkers con sider the tongue, teeth and gin givae the m irror o f physiologic activities. Dentists are m uch better equipped to interpret aberrations o f the gin givae and thus recognize systemic disturbances reflected therein. A cco rd in g to M iller,1 the dietary causes o f caries and periodontal diseases can be divided into tw o general classes: ( i ) local, or extrinsic and (2) systemic, or intrinsic. T h e local conditions m ay be influenced
D eficien cy states m ay be caused also by the follow in g conditions (m odified from J o lliffe )2 : 1. In d igen cy or low incomes. 2. Erroneous d ietary habits and food idiosyncrasies ; e.g., excessive use o f re fined sugar, candy, pastries, cakes, ch o c olate flavors and soft drinks. 3. E xcessive consum ption o f alcohol, refined starches or m ineral oil. 4. Diseases alterin g nutritional re quirem ents :
62
1'h e J o u r n a l o f t h e A m e r i c a n D e n t a l A s s o c i a t i o n
(a ) Hyperthyroidism. (b ) Fever, especially o f long dura tion. (c ) Gastrointestinal disturbances, colitis, achlorhydria, vagotonic spasms. (d ) Pregnancy. (e ) R apid growth. i(f) Increased excretion; diarrhea; p oly u ria ; lactation. ,(g) Nervous states. 5. F ood fads. 6. A n edentulous state or wearing o f inefficient dentures. I t is because o f these conditions, in addition to inadequate consum ption, soil depletion and unsatisfactory transporta tion, marketing and cooking, that most o f the population is in a state o f malnu-
it should include not only a deficiency but also any metabolic disturbances of the essen tial in the tissues. The causes may be com plex. T hey may be conveniently classified as external and internal. Dietary deficiency is the most common external cause. Any bodily condition interfering with digestion, transport or utilization, prompting destruc tion or excessive excretion, or raising the requirements of the dietary essential is for example an internal cause. Almost every non-nutritional disease affects nutrition. A cause comes about through a combination of circumstances. For example, assuming a sat isfactory internal mechanism, a deficiency disease from insufficient intake relative to age, activity, exposure to light, storage, state of tissue and probably other factors.
Fig. 3.— Condition before treatment; cheilo sis, or perleche. The patient came in for perio dontal treatment, with a “sore” in the corner of the mouth, present for a year. There is a urea-like frosting of the lower lip at the mucocutaneous junction. The cracking, or Assuring, at the angles of the mouth is an advanced ariboflavinosis.
Fig. 4.— Condition after vitamin therapy. (Compare Fig. 3.) Riboflavin, 5 mg., plus two yeast tablets three times a day was given after meals from September 25 to October 16, approximately three weeks. The Assuring at the angle of the mouth and the urea frost ing of the lower lip have disappeared. A pain in the right forearm disappeared at the same time.
trition. A problem presents itself when virtually all our patients (three-fourths o f the population have some form of “ hidden hunger” or m alnutrition) fall into one o f the foregoing categories. Kruse aptly says: More properly, the term “ deficiency dis ease” should connote a deficiency in the bodily tissues rather than in the diet. In deed, its meaning should be even broader:
Kruse has shown that apparently well
persons manifest some form o f deficiency state. M ost o f the significant changes were observed with the aid o f a biom icro scope. T h e changes brought about in the gingivae and the tongue with the aid o f vitamin therapy were reported by him in two excellent papers .3’ 4 T on g u e changes were effected by giv ing 200 mg. o f niacinam ide daily for
R o t h — V i t a m i n s a n d P e r i o d o n t a l D is e a s k
T a b le
1.—
V i t a m i n T h e r a p y E m p lo y e d i n P e r i o d o n t i a D e p a r t m e n t , N e w Y o r k U n i v e r s i t y C
Deficiency Vitamin
Niacin (nicotinic acid)
Thiamine B
Riboflavin (B2)
Vitamin C (ascorbic acid)
Mild polyvitamin and mineral deficiencies
Subclinical
63
ollege of
D
e n t is t r y * !
Oral Signs as Seen by DentistJ Keratinization and hypertrophy of gingivae
Scarlet tongue; smooth atrophy of the lateral borders and tip of the tongue; painful, sore, fis sured and corrugated tongue; may influence red ness of gingivae along with avitaminosis C; stages from mildly acute to severe chronic may be seen Neuralgic pains in and about the mouth; dry socket; aphthae
Prescription (Refilled as Necessary) Vitamin A (25,000 I.U. tabs) No. 100, 6 tablets a day after meals for six months to a year. Niacinamide (100 mg. tablets) No. 100, 1 tablet 3 times a day after meals.
Thiamine hydrochloride (10 mg. tabs) No. 100, 1 tablet with 1 yeast tablet and 100 mg. of as corbic acid 3 times a day after meals; usually used in conjunc tion with riboflavin, niacinamide and ascorbic acid. Purplish red or magenta tongue; cheilosis; crack Riboflavin (5 mg. tabs) No. 100, ing at corners of mouth ' * 1 tablet and 1 compressed yeast tablet 3 times a day after meals. Gingivitis; easy bleeding of gingivae; edema of Ascorbic acid (100 mg. tabs) No. 100, 2 tablets after each meal 3 gingivae; slow healing; may also be used preoperatively and postoperatively to hasten healing times a day for six months to one and one-half years. and in treatment of necrotic gingivitis In adults, red marginal gingivitis (S. C. Miller); 2 tablespoons of cod liver oil every day; 3 glasses of milk in children, as result of deficiency in infancy, poor tooth formation (tooth structure cannot be taken at mealtime for at least a improved by vitamin therapy; for gingivae signs year .for adults (vitamin D po and alveoloclasia and to preserve ridges under tency of product should be prosthetic appliances, use in conjunction with checked on label). high calcium diet) Poor oral health in general, tissue bloated and 6 brewers yeast tablets and 1 teaspoonful of cod liver oil daily; coated: alveoloclasia active in general balanced diet with minerals and vitamins in abundance (for maintenance dose, commercial vitamin products may be used). Any of the foregoingsymptomsinmoderationor Ascorbic acid 75 mg., riboflavin as voted by capillary microscopy or slit-lamp (B2) 5 mg., thiamine HCL (BL;, technic; vague, confused, indefinite complaints or 10 mg.; niacinamide 50 mg. ft., complaints of unknown etiology in and about capsule or tablet, 1 tablet or capsule 3 times a day after meals mouth for ten days, thereafter once a day until all symptoms disap pear
*Miller, S. C.: Oral Diagnosis and Treatment Planning, Ed. 2. Philadelphia: P. Blakiston’s Son and Co., Inc., 1944. fCaution: Specific vitamins are to be used for definite clinical conditions, only U.S.P. and C.P. products accepted by the Council on Therapeutics of the A.D.A. being used. Vitamins are best taken immediately after or with meals. It is safe to use the foregoing doses unless the patient complains of unusual symptoms or the prescription indicated is contrary to the advice of the physician. {Local causes in addition to the systemic conditions are usually present even though not mentioned in this outline.
64
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
from one to one and a half years. T he changes in the pattern o f the tongue were recorded by kodachrom e p h oto graphs. T h e N ew Y ork University Periodontia Research G roup m ade tests on the gingi vae. M any im provem ents could be achieved only by giving 500 mg. o f vita min C daily to patients fo r from one to one and a half years. Som e changes can be seen only with the aid o f the biom icro scope. H ow ever, many o f the m acroscopic changes in the gingivae can be seen by dentists. In acute cases, quicker reactions may be expected. These changes are demonstrated in the accom panying il lustrations. Patients in the Periodontia D epart m ent o f N ew Y ork University .College o f Dentistry w ho apparently had gingi val disease were given 500 mg. o f vita min G daily. Photographs were taken before and after administration. M arked changes were noted in tone, color and consistency. A purplish red, bloated, edematous, swollen condition o f the gin givae was converted to a pink, firm even tone w ithout edema. Gingival hem or rhage also was reduced, in most cases. (Figs. 1 and 2.) T h e same procedure was follow ed in the treatment o f cheilosis and cracking or Assuring o f the com ers o f the mouth. Patients were given 5 m g. o f riboflavin (B 2) with tw o tablets o f compressed yeast three times a day after meals. Definite healing resulted. (Figs. 3 and 4.) Figures 5 and 6 show the results o f treatment with 100,000 units daily o f vitamin A. Figures 7 and 8 show the effects o f administration o f 1500 m g. o f vitamins C daily for tw o days in a cáse o f acute necrotic gingivitis superimposed on hy pertrophy (resulting from dilantin ther a p y ). V itam in therapy was instituted after failure to respond to three weeks o f routine treatment fo r necrotic gingi vitis.
T able
2.—
V it a m in V a l u e s
v it a m in
a
The international unit of vitamin A is de fined as the vitamin A activity of 0.6 micro gram of pure beta-carotene. The U.S.P. unit is equal, in growth-promoting and antiophthalmic activities for the rat, to one international unit. The U.S.P. reference cod liver oil contains at least 850 U.S.P. units of vitamin A per gram. THIAMIN HYDROCHLORIDE (VITAMIN B i )
The U.S.P. Unit of vitamin B is defined as the vitamin Bi activity of 3 micrograms of the U.S.P. reference standard thiamine hydrochloride, and is equal in value to one international unit of vitamin Bi. One U.S.P. or international unit of vitamin Bi is ap proximately equivalent to two Chase-Sherman units; 0.5 Smith-curative unit; 20 Cowgill mg. equivalents. One milligram of vitamin Bi contains 333 U.S.P. or international units. RIBOFLAVIN ( VITAMIN B2)
The Bourquin-Sherman unit is equal to that amount of source material which, when fed daily to a standard test animal, will sup port a growth rate of 3 gm. per week. In vestigators have reported that 2.5 micrograms of pure riboflavin will support this growth rate. There is no international unit for ribo flavin. Pure riboflavin may be used as the reference standard and, according to assays, 1 mg. contains approximately 400 BourquinSherman units. ASCORBIC ACID ( VITAMIN c) The U.S.P. unit of vitamin G is defined as the vitamin C activity of 0.05 mg. of the U.S.P. reference standard ascorbic acid, and is equal in value to one international unit of vitamin G. One milligram of vitamin C equals 20 U.S.P. or international units. One cubic centimeter of fresh lemon or orange juice has a potency of approximately 10 U.S.P. or international units of vitamin C. VITAMIN D
The international unit of vitamin D is de fined as the vitamin D activity of 1 mg. of the international standard solution of irradiated ergosterol, which is equal to that of 0.025 mi crogram of crystalline vitamin D, or. calciferol. The U.S.P. unit of vitamin D is defined as equal, in antirachitic potency for the rat, to one international unit of vitamin D. The U.S.P. reference standard cod liver oil con tains 95 U.S.P. units of vitamin D per gram. U.S.P. cod liver oil contains at least 85 U.S.P. units of vitamin D per gram. Viosterol is fre quently labeled 250 or 150 D, which means that it contains 250 or 150 times the vitamin D content of U.S.P. cod liver oil. Activated ergosterol in oil U.S.P. (viosterol) contains not less than 10,000 U.S.P. units vitaminD per gram.
R o t h — V i t a m i n s a n d P e r i o d o n t a l D is e a s e
T h e fo llo w in g replies are m ade to com m only asked questions : 1. Can high vitamin doses in any way harm the p atien t? T h e re is no evidence th at doses even 100,000 times greater than those ad vo cated in this p a p er w ill in any w ay harm the patient. 2. A re parenteral injections better than administration o f vitamins by m ou th ? T h ere is n othin g in the literature to indicate th a t the parenteral route is bet ter than the oral route. O n ly in rare cases, such as intestinal disorders (e.g., colitis), is the parenteral m ethod in d i cated. G iv in g vitam ins by m outh m ay
Fig. 5.— Condition before vitamin therapy; showing edema, congestion and hypertrophy (possible avitaminosis A ). Calculus was not removed nor was toothbrushing taught.
65
((b) A large m ajo rity of the p o p u la tion h a ve some form o f m alnutrition. ,(c) Patients com ing to the dentist are apparently w ell and usually are not u n der the care o f a physician. A large m ajo rity o f these patients need some form o f d ietary advice. M a n y m ay need vitam in therapy. (d ) W hen prescription by the dentist interferes w ith m ed ical prescription for specific diseases, the physician should be consulted and his recom m endations al low ed to take precedence. 4. W hat are the reasons fo r failure in vitamin therapy? (a ) F ailu re to give sufficient dosage o f vitam ins fo r a lon g enough period of
Fig. 6.— Condition after treatment. (Com pare Fig. 5.) Vitamin A, 100,000 international units, was given daily from July 21 to No vember 2, with reduction in edema, hyper trophy and congestion. The acne on the pa tient’s face disappeared in two weeks.
even enhance the absorption o f certain tim e; e.g., 500 m g. daily of vitam in G vitam ins because o f the phosphorylization th at takes place in the alim entary fo r a year. canal. (b) A ttem pts to treat long-standing vitam in deficiency diseases by ordinary 3. Should a dentist prescribe vitamins? dietary means. F o r the follo w in g reasons, it is ob (c) F ailu re to take into consideration ligatory fo r dentists to be prepared to conditions th at m ay interfere w ith the advise dietary changes and prescribe absorption o f vitam ins by the tissues; vitam ins. (a ) T h e m ed ical profession sees in such, as colitis, alcoholism and excessive ingestion o f m ineral oil. the m outh signs o f nutritional deficien (d ) A dm inistration o f vitam ins before cie s; e.g., p ellagra, tongue and m ucous meals. V itam in s a ct best in an acid m em brane changes ; scurvy, gin gival changes, and tongue and lip changes m edium and should be taken after (riboflavin d efic ien cy ). meals.
66
T h e J o u r n a l o f t h e A m e r i c a n D e n t a l A s s o c i a t io n
CONCLUSIONS BASED ON CLINICAL EXPERIENCE
1. T h e m ajo rity o f patients h a ve some form o f avitam inosis, usually o f a m ulti ple nature. 2. V ita m in C should b e given in suffi cien t dosage to reach th e gin givae as w ell as other tissues o f the body. 3. V ita m in C , 500 m g. daily, w ill im prove and m ain tain th e health o f the gin givae to a better degree than local
Fig. 7.— Condition before vitamin therapy; acute necrotic gingivitis superimposed on dilantin hypertrophy. All the classical symp toms were present and failed to respond after three weeks of the usual treatment for necrotic gingivitis.
treatm ent w ith out vitam in therapy. A d m inistration over a lon g period, e.g., a year o r a year and a h alf, is beneficial and w ill do no harm . 4. B ecause o f the m an y conditions present, 500 m g. o f ascorbic acid (vita m in C ) w as foun d to be the dose re quired to alter the condition o f the m a jo rity o f the chronically affected tissues. 5. T h ere is a possibility th a t vitam ins h ave a special affinity fo r certain tissues, such as vitam in C fo r the g in g iv a e ; n ia cin fo r the tongue, and riboflavin (B 2) fo r the lips.
6. T re a tin g gin gival conditions by d i etary m eans alone is not adequate, if one is seeking the optim um nutrition and health o f tissues. 7. R em oval o f calculus subgingivally and su p ragin givally as w ell as elim ina tion o f pockets, equilibration o f occlusion and stim ulation o f the gin givae by cor rect m assage can n o t be replaced by vita m in therapy. A ll etiologic factors must be elim inated if success in the treat-
Fig. 8.— Condition forty-eight hours later. (Compare Fig. 7.) Administration of Vitamin C, 1,500 mg. daily, dissipated the subjective symptoms. Reduction in hypertrophy, con gestion and edema is evident.
m ent o f periodontal disorders is to be achieved. BIBLIOGRAPHY
1 . M i l l e r , S. C .: Textbook of Periodontia. Ed. 2. Philadelphia: Blakiston Co., 1943. 2. Id em : Textbook of Periodontia. Ed. 2. Philadelphia: Blakiston Co., 1943. 3. K r u se , H. D.: Gingival Manifestations of Avitaminosis C with Especial Considera tion of Detection of Early Change. M ilbank M em . Fund Q uart., 20:290, July 1942. 4. Id em . Lingual Manifestations of Aniacinosis, with Especial Consideration of Detection of Early Changes by Biomicroscopy. M ilbank M em . Fund Q uart., 20:262, July 1942. 156 East Fifty-Second Street.