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Apples and Teeth
753
Apples
and Teeth
THE merits of" an apple a day " have perhaps not been subjected to the vigorous testing and objective experiment which such an assertion deserves; but, in preventive dentistry at least, the apple’s claim has long been taken seriously. Dr. SIM WALLACE, in the early 1900s, was a strong supporter of the fermentable carbohydrate theory of dental caries, and he campaigned vigorously for more fibrous foods in the diet-not the first nor the last to protest against the apparently irreversible march towards manufactured foods. Among the measures he suggested was fresh fruit at the end of each meal, to remove carbohydrate debris. The efficacy of this advice remained unproven until 1958, when SLACK and MARTINcarried out a small pilot study on children, with controls and statistical analysis but, for obvious reasons, no placebos. The eating of apple slices after meals over a period of two years produced a significant improvement in gum condition and a reduction in caries, though the improvement in teeth was significant only at some ages and for certain teeth. This benefit comes not only from the mechanical scouring of the tooth surface by the fibrous content of the apple, but also from the increased stimulation of saliva to wash away food debris. Salivation is promoted both by the low pH of the apple juice and by mastication of the fibrous fragments. CLARK et al. believed that the salivary flow was the more important factor in removing the substrate for acidforming bacteria, and they devised a hard unchewable tablet, with non-fermentable components, to stimulate salivation. The tablet contained sorbitol and malic acid and was buffered to minimise erosion of the teeth. In a laboratory experiment the tablet was found to be as efficient in cleansing as tooth-brushing with water alone, more efficient than rinsing with water, but less efficient than apple slices. The tablets were made available commercially, and now SLACK et al.have studied their use by schoolchildren during a two-year investigation. The difficulties of such a clinical trial are obviously considerable. It was not found possible to manufacture a suitable control tablet, presumably because of the difficulty of producing one which was apparently stimulating but did not evoke a flow of saliva. Moreover, control groups could not be organised in the same school, because the experiment would almost certainly be sabotaged by sharing of tablets, especially if that was forbidden. The mere act of giving tooth-cleaning tablets must make the child more conscious of oral hygiene; and to counter this objection all families in both groups were sent regular free supplies of toothbrushes and dentrifrice. Nevertheless, as SLACK et al. point out, the tablets may still have reduced tooth-brushing to an unknown extent. In the event a small but significant benefit in the control of caries was attributable to the use of tablets. The benefit was mainly confined to the first year ofthe study, probably because much of the interest among the tablet group evaporated during the second year. At the end of &: trial, 157 of the original 231 children were inter1 Sack G. L., Martin, W. J. Brit. dent.J. 1958, 105, 366. 2 Gark, R., Hay, D. I., Schram, C. J., Wagg, B. J. ibid. 1961, 111, 244. 3 Sack, G. L., Millward, E., Martin, W. J. ibid. 1964, 116, 105.
viewed, and 35% were found to dislike the tablets, while only 27% had brought them to school. This combination of a therapeutic agent with a pleasurable habit is more likely to be successful than the denial of sweetmeat delights-only here the delight in the tablet was far from universal, perhaps because of a basic aversion to the taste, or an acquired dislike, accentuated by any persuasion used. A dentally harmless sweet in a variety of tastes seems desirable, not only for children but also for adults who need a compensating distraction when they give up smoking. Indulgence in peppermints can produce a disastrous increase in caries activity. What about chewing-gum as a preventive measure? The investigations4 that have been made indicate that ordinary chewing-gum neither increases nor reduces the caries attack-rate, although the increased salivary flow and cleaning action removes debris. These benefits may be offset by the increased concentration of carbohydrate in’ the mouth. Contrary to expectation, however, chewing-gum with a non-fermentable base has been found to produce an insignificant improvement in the caries attack-rate compared with a non-chewing group. On the other hand, incorporation of enzyme and bacteriostatic compounds in special gums is reported to be of benefit. 56 But all these " oral sweetmeat " approaches are mere nibbling at what is a vast and costly national problem. Fluoridation of water-supplies is known to bring considerable benefit, but it cannot give, and does not claim to give, complete protection; and there is still very strong opposition to its use. Indeed, the goal of really effective caries prevention seems to be as far off as ever: so much is known, but a comprehensive answer is elusive. A determined attack by a caries-prevention research unit, with adequate staff and resources, might produce valuable results. The cost could hardly compare with the millions spent in this country alone on the palliative patchwork which is our therapy for this disease. "... It would be naive to declare that our difficulties in science and medicine are directly attributable to our creation of specialties and to the logical amplification of study and research. Our peril lies in our tendency to turn aside from those simple issues that determine health or disease for the great majority of mankind. For one reason or another some of the finest intellects in the biological sciences are concentrating on the bizarre or on refining the techniques of established practice and drug therapy; and so in the midst of one of the most brilliant epochs of scientific discovery there are things we see in the human situation that cause us disquiet and even feelings of guilt. We hear of untold millions who lack health for want of food, want of elementary instruction in hygiene, want of prophylaxis against infection and infestation. Let there be no mistake, there are circumstances in which the discriminating use of the materia medica can promote the wellbeing of the sick man. But the health of mankind is a concept infinitely greater than this: it must be visualised in terms of conservation of a goodly heritage and awareness of the simple truth-thatwhere there is no vision the people perish’."Prof. STANLEY ALSTEAD in a sermon preached in Glasgow University on Oct. 28, 1962, and published in the London Quarterly and Holborn Review, January, 1964, p. 65. 4. 5. 6.
Volker, J. F. J. Amer. dent. Ass. 1948, 36, 23. Burrill, D. Y., Calandra, J. C., Tilden, E. B., Fosdick, L. S.J. dent. Res. 1945, 24, 273. Dreizen, S., Spies, T. D. J. Amer. dent. Ass. 1951, 43, 147.
Apples
and Teeth
THE merits of" an apple a day " have perhaps not been subjected to the vigorous testing and objective experiment which such an assertion deserves; but, in preventive dentistry at least, the apple’s claim has long been taken seriously. Dr. SIM WALLACE, in the early 1900s, was a strong supporter of the fermentable carbohydrate theory of dental caries, and he campaigned vigorously for more fibrous foods in the diet-not the first nor the last to protest against the apparently irreversible march towards manufactured foods. Among the measures he suggested was fresh fruit at the end of each meal, to remove carbohydrate debris. The efficacy of this advice remained unproven until 1958, when SLACK and MARTINcarried out a small pilot study on children, with controls and statistical analysis but, for obvious reasons, no placebos. The eating of apple slices after meals over a period of two years produced a significant improvement in gum condition and a reduction in caries, though the improvement in teeth was significant only at some ages and for certain teeth. This benefit comes not only from the mechanical scouring of the tooth surface by the fibrous content of the apple, but also from the increased stimulation of saliva to wash away food debris. Salivation is promoted both by the low pH of the apple juice and by mastication of the fibrous fragments. CLARK et al. believed that the salivary flow was the more important factor in removing the substrate for acidforming bacteria, and they devised a hard unchewable tablet, with non-fermentable components, to stimulate salivation. The tablet contained sorbitol and malic acid and was buffered to minimise erosion of the teeth. In a laboratory experiment the tablet was found to be as efficient in cleansing as tooth-brushing with water alone, more efficient than rinsing with water, but less efficient than apple slices. The tablets were made available commercially, and now SLACK et al.have studied their use by schoolchildren during a two-year investigation. The difficulties of such a clinical trial are obviously considerable. It was not found possible to manufacture a suitable control tablet, presumably because of the difficulty of producing one which was apparently stimulating but did not evoke a flow of saliva. Moreover, control groups could not be organised in the same school, because the experiment would almost certainly be sabotaged by sharing of tablets, especially if that was forbidden. The mere act of giving tooth-cleaning tablets must make the child more conscious of oral hygiene; and to counter this objection all families in both groups were sent regular free supplies of toothbrushes and dentrifrice. Nevertheless, as SLACK et al. point out, the tablets may still have reduced tooth-brushing to an unknown extent. In the event a small but significant benefit in the control of caries was attributable to the use of tablets. The benefit was mainly confined to the first year ofthe study, probably because much of the interest among the tablet group evaporated during the second year. At the end of &: trial, 157 of the original 231 children were inter1 Sack G. L., Martin, W. J. Brit. dent.J. 1958, 105, 366. 2 Gark, R., Hay, D. I., Schram, C. J., Wagg, B. J. ibid. 1961, 111, 244. 3 Sack, G. L., Millward, E., Martin, W. J. ibid. 1964, 116, 105.
viewed, and 35% were found to dislike the tablets, while only 27% had brought them to school. This combination of a therapeutic agent with a pleasurable habit is more likely to be successful than the denial of sweetmeat delights-only here the delight in the tablet was far from universal, perhaps because of a basic aversion to the taste, or an acquired dislike, accentuated by any persuasion used. A dentally harmless sweet in a variety of tastes seems desirable, not only for children but also for adults who need a compensating distraction when they give up smoking. Indulgence in peppermints can produce a disastrous increase in caries activity. What about chewing-gum as a preventive measure? The investigations4 that have been made indicate that ordinary chewing-gum neither increases nor reduces the caries attack-rate, although the increased salivary flow and cleaning action removes debris. These benefits may be offset by the increased concentration of carbohydrate in’ the mouth. Contrary to expectation, however, chewing-gum with a non-fermentable base has been found to produce an insignificant improvement in the caries attack-rate compared with a non-chewing group. On the other hand, incorporation of enzyme and bacteriostatic compounds in special gums is reported to be of benefit. 56 But all these " oral sweetmeat " approaches are mere nibbling at what is a vast and costly national problem. Fluoridation of water-supplies is known to bring considerable benefit, but it cannot give, and does not claim to give, complete protection; and there is still very strong opposition to its use. Indeed, the goal of really effective caries prevention seems to be as far off as ever: so much is known, but a comprehensive answer is elusive. A determined attack by a caries-prevention research unit, with adequate staff and resources, might produce valuable results. The cost could hardly compare with the millions spent in this country alone on the palliative patchwork which is our therapy for this disease. "... It would be naive to declare that our difficulties in science and medicine are directly attributable to our creation of specialties and to the logical amplification of study and research. Our peril lies in our tendency to turn aside from those simple issues that determine health or disease for the great majority of mankind. For one reason or another some of the finest intellects in the biological sciences are concentrating on the bizarre or on refining the techniques of established practice and drug therapy; and so in the midst of one of the most brilliant epochs of scientific discovery there are things we see in the human situation that cause us disquiet and even feelings of guilt. We hear of untold millions who lack health for want of food, want of elementary instruction in hygiene, want of prophylaxis against infection and infestation. Let there be no mistake, there are circumstances in which the discriminating use of the materia medica can promote the wellbeing of the sick man. But the health of mankind is a concept infinitely greater than this: it must be visualised in terms of conservation of a goodly heritage and awareness of the simple truth-thatwhere there is no vision the people perish’."Prof. STANLEY ALSTEAD in a sermon preached in Glasgow University on Oct. 28, 1962, and published in the London Quarterly and Holborn Review, January, 1964, p. 65. 4. 5. 6.
Volker, J. F. J. Amer. dent. Ass. 1948, 36, 23. Burrill, D. Y., Calandra, J. C., Tilden, E. B., Fosdick, L. S.J. dent. Res. 1945, 24, 273. Dreizen, S., Spies, T. D. J. Amer. dent. Ass. 1951, 43, 147.