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Gingivitis gravidarum
Oral GINGIVITIS
Pathology GRAVIDARUM”
Studies on Clinic and on Etiology With Special Reference to the Influence of Vitamin C FRODE HILMING,
DR. ODONT., COPENHAGEN, DENMARK
T
HERE are many unsolved problems of a clinical and etiological nature conIt has long been nected with gingivitis gravidarum (pregnancy gingivitis). a matter of discussion whether there is a specific form of gingivitis in pregnancy, or whether it occurs only occasionally among pregnant women. Three main schools of thought have prevailed in regard to its etiology: Some believe in a purely local etiology, others, in vitamin C deficiency as a primary factor, and still others, in the importance of hormonal factors. Clinical studies were made during the years 1943-1946, in order to find out whether the gingivitis occurring among pregnant women is of a sufficiently characteristic type to be considered specific to pregnancy, and whether a relat,ive vitamin C deficiency can cause gingivitis graviclarum.
Material and Methods The material consists of 203 pregnant women between the ages of 16 and 44. The patients were examined for the first time as early as possible, during the second, third, or fourth month of pregnancy, the second time usually a All the month later, and subsequently every other month until parturition. patients were examined at least once after delivery, usually during puerperium (twelve to fourteen days following parturition). A total of 1,092 clinical examinations were made by the author personally and under identical light conditions. The stomatological examination was recorded on charts in accordance with ARPA’s system (Fig. 1). As will be seen, each gingival papilla was examined separately, abbreviations for slightly hyperemic, 1. hae., greatly hypertrophic, st. ht., etc., having been employed. The figures in the crowns indicate the distance in millimeters from the deepest point of the incisal edge to the papillary tip or the gingival border; the object is to obtain an exact measure for possible growth of hypertrophic formations. The measurements were readily made with a graduated probe. The occurrences of gingivitis are here classified into five different degrees, as follows : 1. Gingivitis levi gradu (1. g.): Slight edema, and, possibly, slight cyanosis, not extended to the entire gingiva, and at the most a few spots may be slightly hyperemic or slightly hypertrophic. *This is a concentration of a book submitted for the acquirement of the Danish Doctor for ReOdontologiae degree. The studies were performed for the Danish ARPA (Association search upon Paradentopathy) in the Obstetric Department (Chief, Erik Rydberg, Prof. Dr. Med.) of the Danish State Hospital and in the Zoophysiological Institute (Chief P. Brandt Rehberg, Prof. Dr. Phil.) of the University of Copenhagen.
734
GINGIVITIS
GRAVIDARUM
: :1,-i
2. Gingivitis Zevi-me&o gradu (l-mea. .(I.): More edema, and more cxlt.nOtherwise the gingivitis is of a mild character. 3. Gingivitis me&o grudu (med. g.): Pronounced edema, distinct hyperemia or cyanosis, in large parts of the gingiva, frequently excessive h,Ip~U?riliil sive.
Fig.
I.
(Ziskin and assoeiates,l”~ ‘I “raspberry red gums”) in small areas, and mcbrc pronounced hypertrophy. 4. Gingivitis me&o-magno gradu (med.-m. g.): A severe gingivit.is with all symptoms pronounced, and extended to the entire gingiva. However, provided
736
FRODE
HILMING
severe hyperemia and hypertrophy are present, the condition is not necessarily found in the entire gingiva, but may involve large areas. 5. Gingivitis magno gradu (nz. g.): A very severe gingivitis, highly developed hyperemia or cyanosis, marked hypertrophy, and extended to the entire gingiva. In the literature, we have little definite knowledge of the relationship between pregnancy and the associated gingivitis. It is therefore. impossible to have accurate criteria for a pregnancy gingivitis beforehand. As controls on nonpregnant women are lacking, in order to study the material at hand it is necessary to find the best possible criteria. It is repeatedly stressed in the literature that a pregnancy gingivitis disappears or is ameliorated after parturition. It is logical to expect that a gingivitis which is causally connected with pregnancy would be ameliorated after delivery. The studies revealed that the above assumption applied to one group of patients; the other group, however, showed no improvement after parturition. It appears reasonable to divide the patients studied into two groups according to the previously mentioned criteria, so that the cases of gingivitis in the group showing improvement from the final examination in pregnancy to the examination after parturition are called syecific, while the remainder, which displayed no improvement, are called nonspecific pregnancy gingivitis.
Results. Clinic of Pregnancy Gingivitis Among the 203 pregnant women examined the following main diagnoses were arrived at: Gingivitis gravidarum specifica Gingivitis gravidarum non specifica
95 = 47% 108 = 53%
Thus no completely healthy gingivae whatever were found in any of the patients during the entire period of study. We shall now inquire whether the two groups deviate from one another in other respects than the selected criteria. By following the clinical course of the material in Table I we find the greatest number of aggravations among the specific cases (84 per cent) in the eighth month of pregnancy, while in the ninth month there is a marked decrease in the number of aggravations. This month, with 43 per cent, shows the lowest number. In contrast, we find that in the groups of ameliorations the ninth month shows 41 per cent ameliorations, a figure which is three times as large as in any of the other months. In the nonspecific group we find in particular no increase in the number of aggravations toward the eighth month, and no culmination of ameliorations in the ninth month. The reason why, despite the criterion (no amelioration after delivery), there is 1 per cent amelioration following parturition is that this single patient displayed a progressive improvement throughout the period of study, an improvement which also continued after delivery, so that it was deemed advisable to classify this instance as nonspecific. Table II shows how the gingivitis diagnoses are divided into three stages of the study, i.e., the first examination, the point of culmination of the gingivitis,
GINGIVITIS
::ry
GRAVID.iRL’.\I
and condition after parturition. It should first be pointed out, however, that in the entire material there was but one patient who had completely healthy gingivae at the first examination, and subsrqurntl~ none. In a complctrlp heaIthy gingiva the gums should clin p fir~nl,~ ant! tightly to the twth in flw -----~~..--..-~~--.-
-__MONTH
AMELIORATION
AGGRAVATION
Gingivitis
III IV V VI VII VlII IX Post partum
100%
0% Gingivitis
III IV V VI VII VIII
ALTERATIONS
graridarum-~~cificn-----~-.‘ 277c 6% 16% 13% 23yr 7% 52 p/c8 0% 14% 9% 12% 41%
67% 71% 70% 48% 77% 84% 43%
SO
--.OF
-.--.-. -_-. NIJMBEK EXAMINATIONS
15 38 44 44 43
= 100% z.z 100% =
1ooa
Y.z loa; ZE 100%
95 = lno;l,
graaida u7c 147c 95% "97"
36% 47%
76% 36%
IX
Post partum
108
1 CT
=
.1noq
entire mouth, without any kind of epithelial damage or pocket formatiotls, the surface should be stippled, the color a palo pink, a.nd there must nomhcl~c 1~ any indications of edema or hypertrophy. TABLE
II.
DIWKG
DIAGNOSIS
--.-___
--__.-~-
__
__
AT FIRST EXAMINATION
Gingivitis
Gingiva Gingivit.. Gingivit. Gingivit. Gingivit. Ging-ivit. Total
sana I. g. I.-med. g. med. g. med.-m. g. m. g.
Gingiva sana Gingivit. 1. g. Gingivit. I.-med. g. Gingivit. med. g, Gingivit. med.-m. g. Gingivit. m. g. Total .--_-
1= 26 .zz 29 I.= 35 = 3=
1=
I%-
1%
95 = 1ooyo Gingivitis gkmidarum o= 070 37% 40 = 35 z.z 32%
20%
9= 3=
3%
108 =
a%
10070
PERIOD OF EXAMINATIOK ~---~-__-___--~~ AT TIME OP CTTLMINATION
uraritl~~~~~*-------~----~
28% 30% 37% 3%
21 zr
THE
0-z.
0%
o= 11 rz 45 Lz 29 rz
w 12%
IO =
10%
95 ~011 0 I8
48% 30%
z.z 100oJo sp&&--0% = zz 17%
32 =
29%
40 zzx
37%
13
12%
___~__~__.-_-.j
zr
=
108 zz
5% 100%
~-~..-~~ POST
;
__PARTITnr~.._
o= 17 rz
0% 5ooJ,
37 zz I1 = o=
3970 11% 0%
o=
05%
95 =
low%,
o= 30 zz
27%
0%
38 zzz 35yp 31 zx Ma/, 5% 6~ 3 70 3= 308 zzr 100%
Table II further indicates that among the specific cases there is not OXIC-that is wholly slight (Z. g.) during the culmination, while there are 17 per cent among the nonspecific ones. It is also typical in the specific group that 40 per’ cent of the two severest degrees decrease as far as zero after delivery. The difterence between the two groups in the three stages of study is otherwise readily seen in Fig. 2, where the three severest forms of gingivitis from Table II (“more severe gingivitis”) are combined. Here we notice the larq~
738
FRODE
HILMING
difference in the number of more severe cases at the time of culmination and after parturition in the specific group (77 per cent), compared with the slight difference (16 per cent) in the nonspecific group. We further observe that among the specific group there are far fewer such cases after delivery than at the first examination. On the contrary, among the nonspecific group there are a far greater number of severe cases after parturition. Table II and Fig. 2 do not, however, show the development of the individual cases. On the other hand, this can be seen from Tables III and IV. The latter unquestionably gives the best impression of the possible significance of the pregnancy factor to the gravity of the individual cases. While we have no way of knowing whether the changes which may have been caused by the pregnancy had not already begun prior to the first examination, there is considerable certainty that the effect of the pregnancy must have ceased after delivery. The difference in the gingival condition after delivery and at the time of culmination will, therefore, provide as reliable a picture of the changes in the gingiva, assumed to have been caused by the pregnancy, as we can obtain at present. Ging.
grnv.
spec.
Gins. grav. non
spec.
-
9a
80 70 60 50 1
40
30 20 10 a& !
[
I
1 Fig.
Z.-Percentage
of total tion;
1 2
3
number of patients with more severe gingivitis. 2, culmination of gingivitis; 3, post partum.
1,
First
examina-
The most important thing to be observed in Table IV is that the majority of the patients in the specific group who had severe gingivitis (degrees 4 and 5) at the time of culmination had, in contrast to the corresponding cases in the nonspecific group, improved so much after parturition that they now belong in the slight degrees 1 and 2. This means that pregnancy had made them correspondingly worse. While a further 61 cases in the specific group improved two degrees and more post partum, this was observed in.only eight nonspecific cases. Therefore, we can assume that in the majority of cases the specific pregnancy gingivitis is a rather severe gingivitis during its culmination.
Fig. 3 charts the culmination of the cases of gingivitis at various t,irileq The majority of the specific cases culminate in the eight11 during pregnancy. month of pregnancy, whiIe a somewhat smaller number cubninate in the nirrt h month. A much smaller number culminate at an car-lit-r stage. The rising t1umher of culminations toward the end of pregnancy is not to he found among 1hc nonspecific cases. They seem to culminate irregularly, extending over t11c cut irth period of study. TltktrIE
III.
DEGREES OF DIAGN~SIR
.tT FHWI~ ExnhrrziA7w~ --.~-..-_------. NUMBER OF PATIENTS
1 ::
ANI) ('r-r3
17 1
JNATIOS .~
5 .,
i
The question at what point in pregnancy gravidity begins to affect, ihe gingiva is an interesting one. In the literature it has been fixed from the second to as far as the seventh month. In order to arrive at a safe solution of this problem it would be necessary to keep track of the patients from shortly, prior to conception. Since this cannot be done in pract,ice, we shall have to be content with finding out how early in the period of examination the sperific wscs TABLE
IV.
DEGREES OF DIAGNOSIS NUMBER
AT CIZBIINATION
AKD POST PARTIW
OF PATIEh-TR
can be traced. For this purpose we used those patients who were examined for the first time in the second month, and compared the condition of the gingiva at t,his point with the same individual’s condition after delivery. As we know, t,he specific cases improve spontaneously post partum, and since there have been no treatments which could have brought about this improvement, and since we
740
FRODE HILMING
cannot assume, either, that the parturition itself can have any curative effect on gingivitis, we must assume that the improvement takes place because the causative factors connected with the pregnancy cease at parturition. Among those patients in whom the condition post partum was better than at the first examination in the second month, the gingivitis must have commenced prior to the first examination. The same thing presumably applies to those patients in whom the gingival condition was the same following delivery as at the first examination, when the next pregnancy examination showed aggravation. These criteria proved to be existent among two-thirds of the patients, and so there seems good reason to believe that the specific pregnancy gingivitis most frequently commences at about the second month. Although we dare not form firm conclusions from the relatively small number of patients who were examined several times after parturition (during puerperium, eight, after puerperium, fourteen), there is much to indicate that the specific pregnancy gingivitis improves as soon as the first few days after delivery, while further amelioration thereafter is rare. So%
Ging. grav. spec.
Cling. grav. non spec.
44% 30%
d-l
40% /O%
Fig. 3.-Commencement
of culmination
of gingivitis.
It is a question of great practical interest whether the specific pregnancy gingivitis results in any permanent damage to the gingiva despite its spontaneous amelioration after delivery, or whether it can be regarded as completely harmless owing to its disappearing entirely and leaving the gingiva in the same condiIt has been observed that 71 per cent of the patients tion as prior to pregnancy. with specific gingivitis suffered no permanent damage, whereas 16 per cent developed a lasting aggravation, and 13 per cent perhaps did so. Thus, twenty-nine per cent may have suffered lasting damage from their specific pregnancy gingivitis, a fact which should warn against taking pregnancy gingivitis too lightly from a therapeutic point of view on the basis of the common belief that it probably disappears automatically after parturition.
No clinical symptoms have been found in this material which are not observable in nonpregnant women as well, a finding which is in agreement with the newer literature on this subject (Ziskin and associates”‘~ I1 and Maier and Orba+ “). However, in order to see to what extent the clinical symptoms
GINGIVITIS
ml-41
GRAVIDARUM
may be charact,eristic of the specific pregnancy gingivitis, each symptom has been compared to the conditions of the nonspecific group. -4 few illustrations of this will be given. Table V shows how the cases of sperific gingivitis are of a more compliesled character and of a more severe type than the nonspecific cases. The frt~quc~nc~) of hyperemia escessiva (raspberry red gums) is far greater in the spetritk group than in the nonspecific one. TABLE
V.
FREQUENCY
AND EXTEKT
OF VAIUOUS
BmPTom IN eaterPATIE~~TS
.--
_-
HYPEREMIA 95 =
I Gingivitis
100%
Slight cases (1-3 papillae, generally only in fev examinations) 15 out of 95 = 16”+?z Gingivitis
104 Yz 96% Slight cases ( I-3 papillae, generally only in few examinations) --___-.-_31 of 104 = 3noJc
FXCESSIVA gravidar2lm 46 zz 48%
Slight
1iYYERTROYllY spetifica (!k5 patknts) 80 zz 849%
Slight
cases
Slight
cases
9 of 13 =
69%
EXVESSIVA -.-. 9 =
9%
rases
25 of 46 ~54% 16 of 80 = gravidarzlm non specifica (308 13 rz 11% 71 = 66~
Slight
I i-__--
20% patients) --
-----~_ ,37 =
--34%
cases
36 of 71 =
._~ ~-..---.
.jlCz .--.
______
Fig. 4 indicates the intense frequency of hyperemia in the last months in the specific group, and the very great decrease in the frequency after part IIrition, in contrast to the nonspecific group. Fig. 5 shows that in the majority of the spccifie caasesthe hyperemia culn~inates in the last two months, in marked contrast t,o t,hc conditions in t,he notispecific group. Fig. 6 indicates the specific course of the symptom hyperemia c.rces.siw. The great frequency in the eighth month in the specific group is notahle. In Fig. 7 we find that the frequency of hypertrophy rises considerably between the fourth and fifth months, and culminates in the eighth and ninth months. Then it decreases by about one-half following parturit.ion. It is interesting to note that t.he average number of hypertrophies among the nonspecific group is about equal to the specific cases in t,he first rnont,h and after deliver>-, despite the fairly large number. This indicates that among the gingivitis cases in this material about 45 per cent have hypertrophy without, the influence ot pregnancy, a thing which cannot be discovered unless one keeps track of tile It is likely that the general stressing in tile patients throughout pregnancy. literature of hypertrophy as a characteristic symptom of pregnancy gingivitis is somewhat overemphasized. Fig. 8 shows the specific hypertrophic cases culminating in the last, tu,o months, and a few after delivery, while in the nonspecific group the times of culmination are evenly spread throughout the entire period of examination. Table VI indicates the development of hypertrophp among t)he individual Thus we see that cases from the first examination to the point of culmination.
742
FRODE HILhlING
scarcely half of the specific cases and somewhat more than half of the nonspecific cases displayed no aggravation at that point when the gingivitis was worse with respect to the other symptoms. This corresponds to what we found out from Fig. 7. We further observe that greater aggravations of the hypertrophies (two to four degrees of diagnosis aggravated) are to be found among Ging.
av. spec.
Ging. grav. non spec.
i i Fig. I.-Percentage
of the total
40%
number
in each month where
hyperemia.
was
Ging. grav. non spec.
Ging. grav. spec. r
20%
1
20%
23~. 5.-Percentage
of examinations present.
of
cases
in
which
hyperemia culminaFes aPter partutItIon.
in each month
of pregnancy
Or
scarcely one-fourth of the specific cases, and a really violent development (from one to five) is to be found in one patient only. On the background of the Iiterature it again seems startling that a larger number did not deveIop severe hypertrophies, particularly since in the nonspecific group there were but five
GINGIVITIS
GRAVIDARI*?J
Cling. grav. non spec.
Ging. grav. spec.
Fig.
(i.-Percentage
of
the
total
number of examinations excrssiva was present.
Chg. grav. spec.
in
enrh
month
where
hypm~wiw
Ging. gray. 11011 spec.
80% 10% LO% 50% 40% 30% 20% 10% 0% Fig.
i.-Percentage
! of
40%
i the
total
number
of was
Ging. grav. spec.
examinations present.
in
each
month
!vhrre
hypertrmphy
Ging. grav. non spec.
30% LoI/, IO% 0% Fig.
R.-Percentage
of cases
in which
hypertrophy culminates post pa&urn.
in each
month
of pregnancy
or
744
FRODE HILMING
cases displaying an only fairly significant development from the first examination to the point of culmination (i.e., here from one degree to three). Pregnancy tumors in the generally current interpretation of large, isolated intumescences of the gingiva were not found in this material. However, if it is so desired, each one of the tremendously hypertrophied papillae in the one severe case of generalized hypertrophy (development from degree of hypertrophy one to five degrees in Table VI) (Case 83) can very well be considered a pregnancy tumor, and this also supports Maier and Orban’+ 5 interpretation of pregnancy tumors as localized, especially highly developed inflammatory hypertrophies. The frequency of pregnancy tumors in this material would in that case be 0.5 per cent, which corresponds exactly to the frequency of this gingival manifestation in Maier and Orhan’s materiaL41 ’ 70%
II
III
IV
V
VI
VII
VIII
IS
Ging. grav. spec.
Ging. grav. non spec.
YO% 30%
bI
20% 10%
01
Fig.
9.-Gingival
bleeding
after
/ k
I01 i!
Percentual distribution provocation. the various degrees of bleeding.
Of
of the examinations
a3
in
In this study we have objectively examined for gingival bleeding by passing a blunt probe over the interdental gingival papillae with a certain pressure, and we have classified the tendency of bleeding into three degrees, according to severity.
GINGIVITIS
GRAVIDARURI
-; ,1 ,‘i
Fig. 9 accordingly shows with respect t,o the specific gingivitis cases au increase of second and third degree bleeding as pregnancy advances, with a culmination in t,he eighth month in almost 15 per cent of the severest bleedings. a,nti about 50 per cent of the medium severe ones: in the ninth month the SNYY~’ bleedings again appear to diminish, and after parturition the condition of orll~* 3 per cent of the medium severe bleedings and the remainder of light casts autl those without bleeding improved vigorousl>-. The same typical rourse c*nnnot. howwr, be ohscrved in the nonspecific group.
Some European aut,hors, particularly the older ones, were advocates of a purely local etiology, whereas in recent years nutrition factors and hormonal factors have been looked upon as the causes of pregnancy gingivitis. f’ery recently, however, Maier and Orban + 5 have again support,ed a local etiology. In the conclusions of their work Maier and Orban4 accordingly said: “Gingivitis in pregna.ncy is an inflammatory condition, most probably of local. i vritatire origin. ” One definite thing in this study is readily capable of discounting t,he importance of local factors. As we know, the specific pregnancy ging&itis frequently improves to an even very considerable extent, and in the course of but a few days after delivery, despite the fact t,hat the factors locally affecting the gingivitis remain the same, since the patients in this study received no trcatment capable of abolishing these factors from the final examination during pregnancy to the examination during puerperium. The local factors can, as in any other gingivitis, have an a.ggravating effect, so that the pathologic manifestations grow worse when local factors are present, but, they cannot, cause the specific pregnancy gingivitis. For many years, mainly as a result of the works of Stroh,8 Kutzleb,” Suter” and Schuck,’ the belief prevailed in Europe that a vitamin C factor was conIt is true that in 1945 Fredrikson,’ siderably important in pregnancy gingivitis. without documenting his assertion, maintained that he was unable to find any connection between the serum ascorbic acid values and gingivitis in his matcrial of pregnant women; however, practicing physicians and dentists in Europe
746
FRODE
HILMING
still commonly try to cure pregnancy gingivitis with vitamin C therapy, even more so as the vitamin C requirements of pregnant women are thought to be considerably increased. In this study venous blood was taken at each examination of the pregnant women, and the content of ascorbic ,acid in serum (with Rehberg’@ electrophotometric method) was determined. Furthermore, 61 patients were given a daily supplement of 50 mg. vitamin C (two tablets of “Ido-C”) from the first examination to parturition, whereas the remaining 142 pat.ients of the material received no such supplement to their diet. Fig. 10 shows how that part of the material which received the vitamin C supplement presents higher average values of serum ascorbic acid than the other part which received no supplement. Both curves show typical Scandinavian seasonal variations according to the varying supply of vegetables and fruit. Jan.
Feb. Mar.
Apr.
Maj
Jun.
Jul.
Aug.
Sep. Okt.
Nov.
Dec.
t,oo~s’o
9 9s 9 96 0.W 0.80 0.75 O,?O o.bS 0.60 45s
0.50 0.W QW 0.35 0.30 0.15
slowj% Fig. c&“,“,)mg.
IO.-Ayerage seasonal curves of 60 pregnant women who received a daily supplement ascorbx acid (+C curve) and of 142 pregnant women wthout any supplement (tC
Thus, after it has been demonstrated that among those patients who received the vitamin C supplement the organism contains more ascorbic acid than among those who received none, we shall now inquire how this difference in the vitamin C level of the two groups affects their gingivitis. From Table VII it can be seen that in the supplemental vitamin C group the majority of the patients had specific pregnanoy gingivitis, while on the other hand, the majority of the group not receiving the vitamin C supplement had nonspecific pregnancy gingivitis. Table VIII furthermore shows how the number of ascorbic acid values obtained is identical in the corresponding levels in the specific and nonspecific cases.
GINGIVITIS
747
GRAVIDARUM
Tables VII and VIII have shown that a daily supplement of 50 mg. viiamin C has not been capable of reducing the frequency of gingivitis grucidmrunt specifica, and that the specific pregnancy gingivitis cannot be caused hy a tieficiency of vitamin C, as the values of se1’um ascorbic acid are placzecl OII I hc TABLE
VII _________---.. -____.___~--
-Gingivit. - Gingivit. Total
gravid. gravid.
spec. non spec.
WITHOUT SUPPLEMENTAL VITAMI?: ~--___~~_ C
60 pat. = 82 pat. = 142 pat. =
42% 58% 100%
WITH
SI:PPLEB~ENTAl, VITAMIN (!
35 pat. = 26 pat. = -I____ 61 pat. =
- --
.
,XCr,, 43% lOilCr,
same level as in the nonspecific cases, i.e., equally distributed over a higher and a lower level, only a few of both kinds of gingivitis having particularly low values. TABLE VIII. ACCORDING -
PERCEPITTUAL DISTRIBUTION OF DETERMINATIONS OF SERUM ASCORBIC Awl TO LEVEL (b1~./100 ML.) DURING MONTHS OF PREGNANCY III-VIII, IN<‘. .--~ -~__- ___-__ --__-_... NUMBER 01; 0.20-0.49 O-0.19 EXAIZIINATK&~~-~~ O.%)---1.10 1
Gingirit. gravid. SPW. Gingivit. gravid. non spec.
f ) i )
-Vit. +Vit. -Vit. +Vit.
C C C C
11.9%
4K4%
-Il.‘i%
294
11.8%
44.6%
43.6%
330 =
rzz l(W’i;~ l!W’,;
TABLE IX. N~JMBER OF PATIENTS WITH AND WITHOIJT C SUPPLEJIENT IN THE YA~;I(II.~ DEGREES OF DIAGNOSIS AT FIRST EXAMINATION AND CULMINATION. FURTHER AVEXA(;~:S OF THE CORRESPONDING SERUM ASCORBIC ACID VALUES IN MG./IOO ML. OF &,I, EXAMINATIONS FROM FIRST EXAMINATIOK TO GINGIVITIS CULMINATION =_-~______-__.~._
___-o -k c -C I+C -c
2tc __---c 3fC --- -c 4+C -c 5+c-C
0
-
‘-
1
Culmination.-____ 3 2 1 (0.44)
4 (0.64) 5 (0.46) 1 (0.77)
--___ 7 7 -5) 8 T@q 9
(0.61) (0.37) (0.48) (0.44)
748
FRODE HILMING
Now the natural thing to do is to find out whether the C supplement to the diet and the relatively high vitamin C content in the blood could have any mitigating effect upon the degree of gravity of gingivitis, The ascorbic acid values shown in Table IX are average figures of the individual averages for TABLE X.
EXTRACTS F~oar
CASE REPORTS
Diagn. Diaan. <, Diagn. Diagn.
Mens. III. Mens. V. Mens. VII. Mens. IX. Post partum
Diagn. Diagn. Diagn. Diagn. Diagn.
Mens. II. Mens. IV. Mens. VI. Mens. VIII. Post partum
Diagn. Diagn. Diagn. Diagn. Diagn.
Mens. III. Mens. IV. Mens. VI. Mens. VIII. Mens. IX. Post partum
Diagn. Diagn. Diagn. Diagn. Diaan. Diagn.
Mens. IV. Mens. V. Mens. VI. Eens. IX. Post partum
Diagn. Diagn. Diagn. Diagn. Diagn.
Mens. II. Mens. III. M/lens. V. Mens. VII. Post partum
Diagn. Diagn. Dia&. Diagn. Diagn.
Mens. II. Mens. III. Mens. V. Mens. VIII. Post partum
Diagn. Diagn. Diagn. Diagn. Diagn.
Mens. II. Mens. IV. Mens. VI. Mens. VIII. &fens. IX. Post partum
Diagn. Diagn. Diagn. Diagn. Diagn. Diagn.
no. 24. specifica September November March March Journ. no. 104. spec. - 2. April 3. June 4. August 3. October 2. November Journ. no. 159. spec. - 4. October 4. November 5. January 5. March 3. May Journ. no. 200. snec. - 2. March ’ 3. March 4. May 4. July 5. hlmst 2. Auffust Journ. no. 38. non spec. 1. October 3. December 3. December 4. March 4. May Journ. no. .47. non snec. November 5. 5. December 5. February April 3. 3. June Journ. no. 71. non 8oec. January x 5. 5. February April 5. 5. July 5. August Journ. no. 157. non spec. 3. October 3. iSovember 3. J-anuary 2. Mar& April 2. 2. May
C. -.
Journ.
Mens. III. Mens. V. Mens. IX. Post partum
4. 4. 5. 2.
1
Ser. Ser. Ser. Ser.
asc. ax. asc. asc.
0.74 0.49 0.29 0.36
mg./lOO mg./lOO mg./lOO mg./lOO
ml. ml. ml. ml.
Ser. Ser. Ser. Ser. Ser.
asc. asc. asc. asc. asc.
0.34 0.28 0.98 0.84 0.73
mg./lOO mg./lOO mg./lOO mg./lOO mg./lOO
ml. ml. ml. ml. ml.
Ser. Ser. Ser. Ser. Ser.
ase. asc. asc. ax. asc.
0.35 B 0.28 0.24 0.20
mg./lOO mg.jlOO mg./lOO mg./lOO mg./lOO
ml. ml. ml. ml. ml.
c.
C.
c. ser.
asc.
Ser. Ser. Ser. Ser. Ser.
asc. ase. ax. ax. ax.
0.86 0.28 0.41 1.15 0.79 0.64
mg./loo mg./lOO mg./lOO mg./lOO mg./lOO mg./lOO
ml. ml. ml. ml. ml. ml.
Ser. Ser. Ser. Ser. Ser.
ax. asc. asc. asc. ax.
? 0.24 0.36 0.30 0.17
mg./lOO mg./lOO mg./lOO mg./lOO mg./lOO
ml. ml. ml. ml. ml.
Ser. Ser. Ser. Ser. Ser.
asc. 0.44 mg./lOO asc. 0.34 mg./lOO a8c. 0.37 mg./lOO asc. 0.32 mg./lOO ax. 0.10 mg./lOO
ml. ml. ml. ml. ml.
Ser. Ser. Ser. Ser. Ser.
ax. asc. ax. asc. ax.
0.35 0.41 0.21 0.55 0.86
mg./lOO mg./lOO mg./lOO mg./lOO mg./lOO
ml. ml. ml. ml. ml.
Ser. Ser. Ser. Ser. Ser. Ser.
asc. asc. asc. asc. ax. asc.
0.94 0.80 0.32 0.02 0.26 0.18
mg./lOO mg./lOO mg./lOO mg./lOO mg./lOO mg./lOO
ml. ml. ml. ml. ml. ml.
- c.
-
-
-
c.
c.
c.
all examinations from the first examination to the point of culmination, since it seems reasonable to assume that a relatively low vitamin C content in the blood is likely to have existed for some time, providing that it could have caused the development of gingivitis. By including all values found in the period of time under discussion &we have endeavored to obtain as reliable a
picture as possible of the organism’s vitamin (‘ standard during the l)erio(l in which the gingivitis develops. Ta.ble IX does not indicate t.hat the C supplement or the level of s(‘I’~w~ ascorbic acid has any influence upon the gravity of gingivitis. whether sgc~~fi~’ or nonspecific. Since ascorbic acid values for some patients are lacking in Table Ix. hc~ ever, the complete course among some characteristic rases from both WOI~J)~ should be shown before any final conclusions are drawn. Tables TX and X indicate that a relatively low content of vitamin (‘ itI the blood can be of no importance to the gravity either of t,he specific or iho nonspecific cases of pregnancy gingivitis, as the values of serum ascorbic? acid follow tbe seasonal variations shown in Fig. 10 without any relation to i hc, gingival condition. (see IIifmingZ), WC shall Without here going into any documentation finally remark that nothing indicates that the typical amelioration oil a IUM of the specific cases in the ninth month is due to a better vitamin (’ lev-cll. or that the characteristic amelioration after delivery in all specific cases has anything to do with this. Nor has this study brought anF evidence that the increased tendency to gingival bleedin, 0 which is an import.ant. symptom in the specific pregnancy gingivitis is caused 1,~ a relatively low content of <.it,;lmitt C in the blood.
Conclusions In the examination
of 203 pregnant, women, with the exception of tmc patient gingivit.is was found among all who had eomplet,ely healthy gingiv;le at, t,he first exa.mination, but subsequentl;v cont.racted gingivitis. The classification of the patient material into 95 = 47 per cent. gingivitis gravidururn specifica and 108 = 53 per cent. gin,gititis gral:ida,runz non $pecificu, respectively, according to the criteria : ’ ‘hmelioration from final examination during pregnancy until after delivery,” and ‘(n-0 amelioration from final esamination during pregnancy until after delivery” must, following these stuc Kes? have proved justifiable. For among t.he first group we found a characteristic clinical course which diverged markedly from the other group, which presumably justifies maintaining that there is a gingivitis which on the ba.sis it’ its clinical course alone must be considered specific to pregnancy. The majority of the cases of specific gingivitis in this material appear to The gingivitis have begun not much later than the second month of’ pregnancy. symptoms thereupon increase during pregnancy, to reach a climax toward the end. The majority culminate in the eighth month, whereas a considerable number (here about 41 per cent) improve in the ninth month, although there appears to be no rule as to when during the ninth month the amelioration Mommertees. The discovery of a clinical amelioration in the ninth month in ahout half of the specific cases may have some bearing on %&kin and 5esse’s11 demonstration of the reappearance of a slight keratinization of the epithelium in most of their cases in this month. The ameliorat,ion that takes place after t]cIivcr~ that indicates that it usnall~- sets is often very considerable, and there is ~rluch in as early as during the first few days of puerperium.
750
FRODE
HILMING
In contrast to the characteristic course described here there is no similar regularity among the nonspecific cases. With respect to the symptoms, none are to be found among the specific pregnancy gingivitis cases which cannot also be found among the nonspecific pregnancy gingivitis group, as well as in gingivitis in nonpregnant women. There are, however, certain characteristic features in the symptomatology. In by far the prevailing majority of the cases the specific pregnancy gingivitis is a subacutely occurring inflammation of the gingiva; hyperemia and a tendency toward bleeding, which presumably commence at a very early period, are characteristic symptoms, and the particular, excessive hyperemia (raspberry red gums) is perhaps the most characteristic phenomenon. Among the specific cases the pregnancy must accordingly be said to have furthered the inflammations of t.he gingiva or been a predisposing factor. Hypertrophy of the gingiva does not appear to be as characteristic a manifestation as was formerly believed, since about half of the specific cases did not develop new hypertrophic formations as a result of pregnancy. However, rather vigorous hypertrophies developed in about one-fourth of the patients. The so-called epulis gravidwuna (pregnancy tumors) in agreement with Maier and Orban,“, 5 hardly other than particularly violent hypertrophic formations which are also to be found outside of pregnancy. Such formations were found in but one case of a generalized type. The term epulis gravidarum should surely be discarded in favor of gingivitis g,ravidarum hypertrophicans m.g., or a similar term. However, in accordance with this material the tendency toward severe hypertrophic formations is found only among a minority of the specific pregnancy cases. Among the majority of the specific cases the pregnancy brings about a severe aggravation of the gingival condition existing prior to gravidity, while among a smaller number only slight aggravations develop. While we formerly tended to believe that a pregnancy gingivitis required no or only slight treatment, because it was expected to disappear spontaneously after parturition, these studies indicate that a certain (although unquestionably the smallest) part of the cases of specific pregnancy gingivitis leave behind a permanent aggravation in the condition of the gingiva, even though they improve after delivery. And since nothing other than the course of the disease, which first stops during puerperium, justifies a safe differential diagnosis between a specific and a nonspecific pregnancy gingivitis, it should immediately be emphasized that no one should take it for granted that we are doubtless which will automatically concerned with a ‘ ‘harmless ’ ’ pregnancy gingivitis disappear after delivery. On the contrary, every case of gingivitis detected during pregnancy should be treated at once, with all means at hand. Concerning the etiology, this study has shown that local irritative factors cannot be the cause of gingivitis gravidarum specifica, as the latter improves after parturition in spite of local factors being to the same extent still present. On the other hand, local factors may condition gingival reactions and have an aggravating effect, acting in connection with the primary endogenous factors.
The specific pregnancy gingivitis is not caused by a deficiency of vitamin (‘, and it does not depend on the ascorbic acid level of the organism, cilher with respect to occurrence, gravity, or clinical course. A daily supplement ot’ 50 mg. vitamin C had no effect on t,he gingiva, although it is clearly demtrnst~rnhl(~ that by means of a supplement of this kind it is possible to maintain : he vitamin C content of the blood on a considerably higher leacl during pregnarlc’)’ than would be possible without it. Sor is there any evidence that thtb II~)~Ispecific cases of pregnancy gingivitis are ~a.usetl b,v a deficiency ol’ vitamin (‘. Should it be correct that very large closes of vitamin C have had a bcnctic+l effect in a few cases of pregnancy gingivitis, as has hern reported in the lil(:1*:1ture,“, $athis cannot be decided from this study. However. such an eff’ecdtswords very unlikely, and our present knowledge of vitamin C’ cannot accol~nt for it. The characteristic clinical course of t hc specific pregnancy gingivitis which has for the first time been demonstrated in this study seems to indiv:t?r a hormonal etiology.
References I. Fredrikson, H. : The Vitamin C Balance During Pr~gnanry, Acta ohst. gynec. ticanclirrav. 25: 1, 1945. F. : Gingivitis 2. Hilming, gravidarum. Undersagelser over klinik og atiologi rued s;pt.ligt henblik pi C-vitaminets betydning, Dissertation, Copenhagen, 1950. 3. Kut,xleb, H. J.: Schleimhautaffektionen wLhrend der Hchwangerschaft und deren RcDeutsche ZahnLrztl. Wchnschr. 41: 373, 193X. handlung durch AscorbinsLure, 4. Maier, A., and Orban, B.: Gingivitis in Pregnancy, J. Periodont. 19: 123, 1948. 5. Maier, A., and Orban, B.: Gingivitis in Pregnancy, ORAL SURG., ORAL MED., AM OI:AI, PATH. 2: 334, 1949. 6. Rehberg, P. Brandt: The Determination of Ascorbic Acid in Biological Fluids, .\cta physiol. Scandinav. 5: 277, 1943. Die Gingivitis in der Schwangerschaft und ihre AbhLngigkeit vou einrnl 7. Rchuck: in Deutsche Zahnlrztl. Wrhnschr. 47: Mange1 an Vitamin C und Calcium, Abstract 53, 1944. Vitamin C (Cantanj bei Gingivitis Gravitlarum, I)eutsche Zahni~rztl. 8. Rtroh, R,. E.: Wcshnschr. 39: 92,. 1936. 9. . Suter, Fr. : Die klmlschen Erscheinungsformen der Gingivitis Gravidarum uutl clir Rehandlung der Gingivitis Gravidarum mit Redoxon, Dissertation, Ziirich, 1938, The Gingivae During Preprr:~nc~~. S. N., and Stout, A. P.: 10. Ziskin, D. E., Blackberg, Surg., Gynec. & Obst. 57: 719, 1933. Pregnancy Gingivitis, A~I. J. ORTHODONTICS AND ORAL 11. Ziskin, D. E., and Xesse, G. J.: HT:RG. (Oral Surg. Sect.) 32: 390, 1946. 8, VESTER VOLDGADE.
Pathology GRAVIDARUM”
Studies on Clinic and on Etiology With Special Reference to the Influence of Vitamin C FRODE HILMING,
DR. ODONT., COPENHAGEN, DENMARK
T
HERE are many unsolved problems of a clinical and etiological nature conIt has long been nected with gingivitis gravidarum (pregnancy gingivitis). a matter of discussion whether there is a specific form of gingivitis in pregnancy, or whether it occurs only occasionally among pregnant women. Three main schools of thought have prevailed in regard to its etiology: Some believe in a purely local etiology, others, in vitamin C deficiency as a primary factor, and still others, in the importance of hormonal factors. Clinical studies were made during the years 1943-1946, in order to find out whether the gingivitis occurring among pregnant women is of a sufficiently characteristic type to be considered specific to pregnancy, and whether a relat,ive vitamin C deficiency can cause gingivitis graviclarum.
Material and Methods The material consists of 203 pregnant women between the ages of 16 and 44. The patients were examined for the first time as early as possible, during the second, third, or fourth month of pregnancy, the second time usually a All the month later, and subsequently every other month until parturition. patients were examined at least once after delivery, usually during puerperium (twelve to fourteen days following parturition). A total of 1,092 clinical examinations were made by the author personally and under identical light conditions. The stomatological examination was recorded on charts in accordance with ARPA’s system (Fig. 1). As will be seen, each gingival papilla was examined separately, abbreviations for slightly hyperemic, 1. hae., greatly hypertrophic, st. ht., etc., having been employed. The figures in the crowns indicate the distance in millimeters from the deepest point of the incisal edge to the papillary tip or the gingival border; the object is to obtain an exact measure for possible growth of hypertrophic formations. The measurements were readily made with a graduated probe. The occurrences of gingivitis are here classified into five different degrees, as follows : 1. Gingivitis levi gradu (1. g.): Slight edema, and, possibly, slight cyanosis, not extended to the entire gingiva, and at the most a few spots may be slightly hyperemic or slightly hypertrophic. *This is a concentration of a book submitted for the acquirement of the Danish Doctor for ReOdontologiae degree. The studies were performed for the Danish ARPA (Association search upon Paradentopathy) in the Obstetric Department (Chief, Erik Rydberg, Prof. Dr. Med.) of the Danish State Hospital and in the Zoophysiological Institute (Chief P. Brandt Rehberg, Prof. Dr. Phil.) of the University of Copenhagen.
734
GINGIVITIS
GRAVIDARUM
: :1,-i
2. Gingivitis Zevi-me&o gradu (l-mea. .(I.): More edema, and more cxlt.nOtherwise the gingivitis is of a mild character. 3. Gingivitis me&o grudu (med. g.): Pronounced edema, distinct hyperemia or cyanosis, in large parts of the gingiva, frequently excessive h,Ip~U?riliil sive.
Fig.
I.
(Ziskin and assoeiates,l”~ ‘I “raspberry red gums”) in small areas, and mcbrc pronounced hypertrophy. 4. Gingivitis me&o-magno gradu (med.-m. g.): A severe gingivit.is with all symptoms pronounced, and extended to the entire gingiva. However, provided
736
FRODE
HILMING
severe hyperemia and hypertrophy are present, the condition is not necessarily found in the entire gingiva, but may involve large areas. 5. Gingivitis magno gradu (nz. g.): A very severe gingivitis, highly developed hyperemia or cyanosis, marked hypertrophy, and extended to the entire gingiva. In the literature, we have little definite knowledge of the relationship between pregnancy and the associated gingivitis. It is therefore. impossible to have accurate criteria for a pregnancy gingivitis beforehand. As controls on nonpregnant women are lacking, in order to study the material at hand it is necessary to find the best possible criteria. It is repeatedly stressed in the literature that a pregnancy gingivitis disappears or is ameliorated after parturition. It is logical to expect that a gingivitis which is causally connected with pregnancy would be ameliorated after delivery. The studies revealed that the above assumption applied to one group of patients; the other group, however, showed no improvement after parturition. It appears reasonable to divide the patients studied into two groups according to the previously mentioned criteria, so that the cases of gingivitis in the group showing improvement from the final examination in pregnancy to the examination after parturition are called syecific, while the remainder, which displayed no improvement, are called nonspecific pregnancy gingivitis.
Results. Clinic of Pregnancy Gingivitis Among the 203 pregnant women examined the following main diagnoses were arrived at: Gingivitis gravidarum specifica Gingivitis gravidarum non specifica
95 = 47% 108 = 53%
Thus no completely healthy gingivae whatever were found in any of the patients during the entire period of study. We shall now inquire whether the two groups deviate from one another in other respects than the selected criteria. By following the clinical course of the material in Table I we find the greatest number of aggravations among the specific cases (84 per cent) in the eighth month of pregnancy, while in the ninth month there is a marked decrease in the number of aggravations. This month, with 43 per cent, shows the lowest number. In contrast, we find that in the groups of ameliorations the ninth month shows 41 per cent ameliorations, a figure which is three times as large as in any of the other months. In the nonspecific group we find in particular no increase in the number of aggravations toward the eighth month, and no culmination of ameliorations in the ninth month. The reason why, despite the criterion (no amelioration after delivery), there is 1 per cent amelioration following parturition is that this single patient displayed a progressive improvement throughout the period of study, an improvement which also continued after delivery, so that it was deemed advisable to classify this instance as nonspecific. Table II shows how the gingivitis diagnoses are divided into three stages of the study, i.e., the first examination, the point of culmination of the gingivitis,
GINGIVITIS
::ry
GRAVID.iRL’.\I
and condition after parturition. It should first be pointed out, however, that in the entire material there was but one patient who had completely healthy gingivae at the first examination, and subsrqurntl~ none. In a complctrlp heaIthy gingiva the gums should clin p fir~nl,~ ant! tightly to the twth in flw -----~~..--..-~~--.-
-__MONTH
AMELIORATION
AGGRAVATION
Gingivitis
III IV V VI VII VlII IX Post partum
100%
0% Gingivitis
III IV V VI VII VIII
ALTERATIONS
graridarum-~~cificn-----~-.‘ 277c 6% 16% 13% 23yr 7% 52 p/c8 0% 14% 9% 12% 41%
67% 71% 70% 48% 77% 84% 43%
SO
--.OF
-.--.-. -_-. NIJMBEK EXAMINATIONS
15 38 44 44 43
= 100% z.z 100% =
1ooa
Y.z loa; ZE 100%
95 = lno;l,
graaida u7c 147c 95% "97"
36% 47%
76% 36%
IX
Post partum
108
1 CT
=
.1noq
entire mouth, without any kind of epithelial damage or pocket formatiotls, the surface should be stippled, the color a palo pink, a.nd there must nomhcl~c 1~ any indications of edema or hypertrophy. TABLE
II.
DIWKG
DIAGNOSIS
--.-___
--__.-~-
__
__
AT FIRST EXAMINATION
Gingivitis
Gingiva Gingivit.. Gingivit. Gingivit. Gingivit. Ging-ivit. Total
sana I. g. I.-med. g. med. g. med.-m. g. m. g.
Gingiva sana Gingivit. 1. g. Gingivit. I.-med. g. Gingivit. med. g, Gingivit. med.-m. g. Gingivit. m. g. Total .--_-
1= 26 .zz 29 I.= 35 = 3=
1=
I%-
1%
95 = 1ooyo Gingivitis gkmidarum o= 070 37% 40 = 35 z.z 32%
20%
9= 3=
3%
108 =
a%
10070
PERIOD OF EXAMINATIOK ~---~-__-___--~~ AT TIME OP CTTLMINATION
uraritl~~~~~*-------~----~
28% 30% 37% 3%
21 zr
THE
0-z.
0%
o= 11 rz 45 Lz 29 rz
w 12%
IO =
10%
95 ~011 0 I8
48% 30%
z.z 100oJo sp&&--0% = zz 17%
32 =
29%
40 zzx
37%
13
12%
___~__~__.-_-.j
zr
=
108 zz
5% 100%
~-~..-~~ POST
;
__PARTITnr~.._
o= 17 rz
0% 5ooJ,
37 zz I1 = o=
3970 11% 0%
o=
05%
95 =
low%,
o= 30 zz
27%
0%
38 zzz 35yp 31 zx Ma/, 5% 6~ 3 70 3= 308 zzr 100%
Table II further indicates that among the specific cases there is not OXIC-that is wholly slight (Z. g.) during the culmination, while there are 17 per cent among the nonspecific ones. It is also typical in the specific group that 40 per’ cent of the two severest degrees decrease as far as zero after delivery. The difterence between the two groups in the three stages of study is otherwise readily seen in Fig. 2, where the three severest forms of gingivitis from Table II (“more severe gingivitis”) are combined. Here we notice the larq~
738
FRODE
HILMING
difference in the number of more severe cases at the time of culmination and after parturition in the specific group (77 per cent), compared with the slight difference (16 per cent) in the nonspecific group. We further observe that among the specific group there are far fewer such cases after delivery than at the first examination. On the contrary, among the nonspecific group there are a far greater number of severe cases after parturition. Table II and Fig. 2 do not, however, show the development of the individual cases. On the other hand, this can be seen from Tables III and IV. The latter unquestionably gives the best impression of the possible significance of the pregnancy factor to the gravity of the individual cases. While we have no way of knowing whether the changes which may have been caused by the pregnancy had not already begun prior to the first examination, there is considerable certainty that the effect of the pregnancy must have ceased after delivery. The difference in the gingival condition after delivery and at the time of culmination will, therefore, provide as reliable a picture of the changes in the gingiva, assumed to have been caused by the pregnancy, as we can obtain at present. Ging.
grnv.
spec.
Gins. grav. non
spec.
-
9a
80 70 60 50 1
40
30 20 10 a& !
[
I
1 Fig.
Z.-Percentage
of total tion;
1 2
3
number of patients with more severe gingivitis. 2, culmination of gingivitis; 3, post partum.
1,
First
examina-
The most important thing to be observed in Table IV is that the majority of the patients in the specific group who had severe gingivitis (degrees 4 and 5) at the time of culmination had, in contrast to the corresponding cases in the nonspecific group, improved so much after parturition that they now belong in the slight degrees 1 and 2. This means that pregnancy had made them correspondingly worse. While a further 61 cases in the specific group improved two degrees and more post partum, this was observed in.only eight nonspecific cases. Therefore, we can assume that in the majority of cases the specific pregnancy gingivitis is a rather severe gingivitis during its culmination.
Fig. 3 charts the culmination of the cases of gingivitis at various t,irileq The majority of the specific cases culminate in the eight11 during pregnancy. month of pregnancy, whiIe a somewhat smaller number cubninate in the nirrt h month. A much smaller number culminate at an car-lit-r stage. The rising t1umher of culminations toward the end of pregnancy is not to he found among 1hc nonspecific cases. They seem to culminate irregularly, extending over t11c cut irth period of study. TltktrIE
III.
DEGREES OF DIAGN~SIR
.tT FHWI~ ExnhrrziA7w~ --.~-..-_------. NUMBER OF PATIENTS
1 ::
ANI) ('r-r3
17 1
JNATIOS .~
5 .,
i
The question at what point in pregnancy gravidity begins to affect, ihe gingiva is an interesting one. In the literature it has been fixed from the second to as far as the seventh month. In order to arrive at a safe solution of this problem it would be necessary to keep track of the patients from shortly, prior to conception. Since this cannot be done in pract,ice, we shall have to be content with finding out how early in the period of examination the sperific wscs TABLE
IV.
DEGREES OF DIAGNOSIS NUMBER
AT CIZBIINATION
AKD POST PARTIW
OF PATIEh-TR
can be traced. For this purpose we used those patients who were examined for the first time in the second month, and compared the condition of the gingiva at t,his point with the same individual’s condition after delivery. As we know, t,he specific cases improve spontaneously post partum, and since there have been no treatments which could have brought about this improvement, and since we
740
FRODE HILMING
cannot assume, either, that the parturition itself can have any curative effect on gingivitis, we must assume that the improvement takes place because the causative factors connected with the pregnancy cease at parturition. Among those patients in whom the condition post partum was better than at the first examination in the second month, the gingivitis must have commenced prior to the first examination. The same thing presumably applies to those patients in whom the gingival condition was the same following delivery as at the first examination, when the next pregnancy examination showed aggravation. These criteria proved to be existent among two-thirds of the patients, and so there seems good reason to believe that the specific pregnancy gingivitis most frequently commences at about the second month. Although we dare not form firm conclusions from the relatively small number of patients who were examined several times after parturition (during puerperium, eight, after puerperium, fourteen), there is much to indicate that the specific pregnancy gingivitis improves as soon as the first few days after delivery, while further amelioration thereafter is rare. So%
Ging. grav. spec.
Cling. grav. non spec.
44% 30%
d-l
40% /O%
Fig. 3.-Commencement
of culmination
of gingivitis.
It is a question of great practical interest whether the specific pregnancy gingivitis results in any permanent damage to the gingiva despite its spontaneous amelioration after delivery, or whether it can be regarded as completely harmless owing to its disappearing entirely and leaving the gingiva in the same condiIt has been observed that 71 per cent of the patients tion as prior to pregnancy. with specific gingivitis suffered no permanent damage, whereas 16 per cent developed a lasting aggravation, and 13 per cent perhaps did so. Thus, twenty-nine per cent may have suffered lasting damage from their specific pregnancy gingivitis, a fact which should warn against taking pregnancy gingivitis too lightly from a therapeutic point of view on the basis of the common belief that it probably disappears automatically after parturition.
No clinical symptoms have been found in this material which are not observable in nonpregnant women as well, a finding which is in agreement with the newer literature on this subject (Ziskin and associates”‘~ I1 and Maier and Orba+ “). However, in order to see to what extent the clinical symptoms
GINGIVITIS
ml-41
GRAVIDARUM
may be charact,eristic of the specific pregnancy gingivitis, each symptom has been compared to the conditions of the nonspecific group. -4 few illustrations of this will be given. Table V shows how the cases of sperific gingivitis are of a more compliesled character and of a more severe type than the nonspecific cases. The frt~quc~nc~) of hyperemia escessiva (raspberry red gums) is far greater in the spetritk group than in the nonspecific one. TABLE
V.
FREQUENCY
AND EXTEKT
OF VAIUOUS
BmPTom IN eaterPATIE~~TS
.--
_-
HYPEREMIA 95 =
I Gingivitis
100%
Slight cases (1-3 papillae, generally only in fev examinations) 15 out of 95 = 16”+?z Gingivitis
104 Yz 96% Slight cases ( I-3 papillae, generally only in few examinations) --___-.-_31 of 104 = 3noJc
FXCESSIVA gravidar2lm 46 zz 48%
Slight
1iYYERTROYllY spetifica (!k5 patknts) 80 zz 849%
Slight
cases
Slight
cases
9 of 13 =
69%
EXVESSIVA -.-. 9 =
9%
rases
25 of 46 ~54% 16 of 80 = gravidarzlm non specifica (308 13 rz 11% 71 = 66~
Slight
I i-__--
20% patients) --
-----~_ ,37 =
--34%
cases
36 of 71 =
._~ ~-..---.
.jlCz .--.
______
Fig. 4 indicates the intense frequency of hyperemia in the last months in the specific group, and the very great decrease in the frequency after part IIrition, in contrast to the nonspecific group. Fig. 5 shows that in the majority of the spccifie caasesthe hyperemia culn~inates in the last two months, in marked contrast t,o t,hc conditions in t,he notispecific group. Fig. 6 indicates the specific course of the symptom hyperemia c.rces.siw. The great frequency in the eighth month in the specific group is notahle. In Fig. 7 we find that the frequency of hypertrophy rises considerably between the fourth and fifth months, and culminates in the eighth and ninth months. Then it decreases by about one-half following parturit.ion. It is interesting to note that t.he average number of hypertrophies among the nonspecific group is about equal to the specific cases in t,he first rnont,h and after deliver>-, despite the fairly large number. This indicates that among the gingivitis cases in this material about 45 per cent have hypertrophy without, the influence ot pregnancy, a thing which cannot be discovered unless one keeps track of tile It is likely that the general stressing in tile patients throughout pregnancy. literature of hypertrophy as a characteristic symptom of pregnancy gingivitis is somewhat overemphasized. Fig. 8 shows the specific hypertrophic cases culminating in the last, tu,o months, and a few after delivery, while in the nonspecific group the times of culmination are evenly spread throughout the entire period of examination. Table VI indicates the development of hypertrophp among t)he individual Thus we see that cases from the first examination to the point of culmination.
742
FRODE HILhlING
scarcely half of the specific cases and somewhat more than half of the nonspecific cases displayed no aggravation at that point when the gingivitis was worse with respect to the other symptoms. This corresponds to what we found out from Fig. 7. We further observe that greater aggravations of the hypertrophies (two to four degrees of diagnosis aggravated) are to be found among Ging.
av. spec.
Ging. grav. non spec.
i i Fig. I.-Percentage
of the total
40%
number
in each month where
hyperemia.
was
Ging. grav. non spec.
Ging. grav. spec. r
20%
1
20%
23~. 5.-Percentage
of examinations present.
of
cases
in
which
hyperemia culminaFes aPter partutItIon.
in each month
of pregnancy
Or
scarcely one-fourth of the specific cases, and a really violent development (from one to five) is to be found in one patient only. On the background of the Iiterature it again seems startling that a larger number did not deveIop severe hypertrophies, particularly since in the nonspecific group there were but five
GINGIVITIS
GRAVIDARI*?J
Cling. grav. non spec.
Ging. grav. spec.
Fig.
(i.-Percentage
of
the
total
number of examinations excrssiva was present.
Chg. grav. spec.
in
enrh
month
where
hypm~wiw
Ging. gray. 11011 spec.
80% 10% LO% 50% 40% 30% 20% 10% 0% Fig.
i.-Percentage
! of
40%
i the
total
number
of was
Ging. grav. spec.
examinations present.
in
each
month
!vhrre
hypertrmphy
Ging. grav. non spec.
30% LoI/, IO% 0% Fig.
R.-Percentage
of cases
in which
hypertrophy culminates post pa&urn.
in each
month
of pregnancy
or
744
FRODE HILMING
cases displaying an only fairly significant development from the first examination to the point of culmination (i.e., here from one degree to three). Pregnancy tumors in the generally current interpretation of large, isolated intumescences of the gingiva were not found in this material. However, if it is so desired, each one of the tremendously hypertrophied papillae in the one severe case of generalized hypertrophy (development from degree of hypertrophy one to five degrees in Table VI) (Case 83) can very well be considered a pregnancy tumor, and this also supports Maier and Orban’+ 5 interpretation of pregnancy tumors as localized, especially highly developed inflammatory hypertrophies. The frequency of pregnancy tumors in this material would in that case be 0.5 per cent, which corresponds exactly to the frequency of this gingival manifestation in Maier and Orhan’s materiaL41 ’ 70%
II
III
IV
V
VI
VII
VIII
IS
Ging. grav. spec.
Ging. grav. non spec.
YO% 30%
bI
20% 10%
01
Fig.
9.-Gingival
bleeding
after
/ k
I01 i!
Percentual distribution provocation. the various degrees of bleeding.
Of
of the examinations
a3
in
In this study we have objectively examined for gingival bleeding by passing a blunt probe over the interdental gingival papillae with a certain pressure, and we have classified the tendency of bleeding into three degrees, according to severity.
GINGIVITIS
GRAVIDARURI
-; ,1 ,‘i
Fig. 9 accordingly shows with respect t,o the specific gingivitis cases au increase of second and third degree bleeding as pregnancy advances, with a culmination in t,he eighth month in almost 15 per cent of the severest bleedings. a,nti about 50 per cent of the medium severe ones: in the ninth month the SNYY~’ bleedings again appear to diminish, and after parturition the condition of orll~* 3 per cent of the medium severe bleedings and the remainder of light casts autl those without bleeding improved vigorousl>-. The same typical rourse c*nnnot. howwr, be ohscrved in the nonspecific group.
Some European aut,hors, particularly the older ones, were advocates of a purely local etiology, whereas in recent years nutrition factors and hormonal factors have been looked upon as the causes of pregnancy gingivitis. f’ery recently, however, Maier and Orban + 5 have again support,ed a local etiology. In the conclusions of their work Maier and Orban4 accordingly said: “Gingivitis in pregna.ncy is an inflammatory condition, most probably of local. i vritatire origin. ” One definite thing in this study is readily capable of discounting t,he importance of local factors. As we know, the specific pregnancy ging&itis frequently improves to an even very considerable extent, and in the course of but a few days after delivery, despite the fact t,hat the factors locally affecting the gingivitis remain the same, since the patients in this study received no trcatment capable of abolishing these factors from the final examination during pregnancy to the examination during puerperium. The local factors can, as in any other gingivitis, have an a.ggravating effect, so that the pathologic manifestations grow worse when local factors are present, but, they cannot, cause the specific pregnancy gingivitis. For many years, mainly as a result of the works of Stroh,8 Kutzleb,” Suter” and Schuck,’ the belief prevailed in Europe that a vitamin C factor was conIt is true that in 1945 Fredrikson,’ siderably important in pregnancy gingivitis. without documenting his assertion, maintained that he was unable to find any connection between the serum ascorbic acid values and gingivitis in his matcrial of pregnant women; however, practicing physicians and dentists in Europe
746
FRODE
HILMING
still commonly try to cure pregnancy gingivitis with vitamin C therapy, even more so as the vitamin C requirements of pregnant women are thought to be considerably increased. In this study venous blood was taken at each examination of the pregnant women, and the content of ascorbic ,acid in serum (with Rehberg’@ electrophotometric method) was determined. Furthermore, 61 patients were given a daily supplement of 50 mg. vitamin C (two tablets of “Ido-C”) from the first examination to parturition, whereas the remaining 142 pat.ients of the material received no such supplement to their diet. Fig. 10 shows how that part of the material which received the vitamin C supplement presents higher average values of serum ascorbic acid than the other part which received no supplement. Both curves show typical Scandinavian seasonal variations according to the varying supply of vegetables and fruit. Jan.
Feb. Mar.
Apr.
Maj
Jun.
Jul.
Aug.
Sep. Okt.
Nov.
Dec.
t,oo~s’o
9 9s 9 96 0.W 0.80 0.75 O,?O o.bS 0.60 45s
0.50 0.W QW 0.35 0.30 0.15
slowj% Fig. c&“,“,)mg.
IO.-Ayerage seasonal curves of 60 pregnant women who received a daily supplement ascorbx acid (+C curve) and of 142 pregnant women wthout any supplement (tC
Thus, after it has been demonstrated that among those patients who received the vitamin C supplement the organism contains more ascorbic acid than among those who received none, we shall now inquire how this difference in the vitamin C level of the two groups affects their gingivitis. From Table VII it can be seen that in the supplemental vitamin C group the majority of the patients had specific pregnanoy gingivitis, while on the other hand, the majority of the group not receiving the vitamin C supplement had nonspecific pregnancy gingivitis. Table VIII furthermore shows how the number of ascorbic acid values obtained is identical in the corresponding levels in the specific and nonspecific cases.
GINGIVITIS
747
GRAVIDARUM
Tables VII and VIII have shown that a daily supplement of 50 mg. viiamin C has not been capable of reducing the frequency of gingivitis grucidmrunt specifica, and that the specific pregnancy gingivitis cannot be caused hy a tieficiency of vitamin C, as the values of se1’um ascorbic acid are placzecl OII I hc TABLE
VII _________---.. -____.___~--
-Gingivit. - Gingivit. Total
gravid. gravid.
spec. non spec.
WITHOUT SUPPLEMENTAL VITAMI?: ~--___~~_ C
60 pat. = 82 pat. = 142 pat. =
42% 58% 100%
WITH
SI:PPLEB~ENTAl, VITAMIN (!
35 pat. = 26 pat. = -I____ 61 pat. =
- --
.
,XCr,, 43% lOilCr,
same level as in the nonspecific cases, i.e., equally distributed over a higher and a lower level, only a few of both kinds of gingivitis having particularly low values. TABLE VIII. ACCORDING -
PERCEPITTUAL DISTRIBUTION OF DETERMINATIONS OF SERUM ASCORBIC Awl TO LEVEL (b1~./100 ML.) DURING MONTHS OF PREGNANCY III-VIII, IN<‘. .--~ -~__- ___-__ --__-_... NUMBER 01; 0.20-0.49 O-0.19 EXAIZIINATK&~~-~~ O.%)---1.10 1
Gingirit. gravid. SPW. Gingivit. gravid. non spec.
f ) i )
-Vit. +Vit. -Vit. +Vit.
C C C C
11.9%
4K4%
-Il.‘i%
294
11.8%
44.6%
43.6%
330 =
rzz l(W’i;~ l!W’,;
TABLE IX. N~JMBER OF PATIENTS WITH AND WITHOIJT C SUPPLEJIENT IN THE YA~;I(II.~ DEGREES OF DIAGNOSIS AT FIRST EXAMINATION AND CULMINATION. FURTHER AVEXA(;~:S OF THE CORRESPONDING SERUM ASCORBIC ACID VALUES IN MG./IOO ML. OF &,I, EXAMINATIONS FROM FIRST EXAMINATIOK TO GINGIVITIS CULMINATION =_-~______-__.~._
___-o -k c -C I+C -c
2tc __---c 3fC --- -c 4+C -c 5+c-C
0
-
‘-
1
Culmination.-____ 3 2 1 (0.44)
4 (0.64) 5 (0.46) 1 (0.77)
--___ 7 7 -5) 8 T@q 9
(0.61) (0.37) (0.48) (0.44)
748
FRODE HILMING
Now the natural thing to do is to find out whether the C supplement to the diet and the relatively high vitamin C content in the blood could have any mitigating effect upon the degree of gravity of gingivitis, The ascorbic acid values shown in Table IX are average figures of the individual averages for TABLE X.
EXTRACTS F~oar
CASE REPORTS
Diagn. Diaan. <, Diagn. Diagn.
Mens. III. Mens. V. Mens. VII. Mens. IX. Post partum
Diagn. Diagn. Diagn. Diagn. Diagn.
Mens. II. Mens. IV. Mens. VI. Mens. VIII. Post partum
Diagn. Diagn. Diagn. Diagn. Diagn.
Mens. III. Mens. IV. Mens. VI. Mens. VIII. Mens. IX. Post partum
Diagn. Diagn. Diagn. Diagn. Diaan. Diagn.
Mens. IV. Mens. V. Mens. VI. Eens. IX. Post partum
Diagn. Diagn. Diagn. Diagn. Diagn.
Mens. II. Mens. III. M/lens. V. Mens. VII. Post partum
Diagn. Diagn. Dia&. Diagn. Diagn.
Mens. II. Mens. III. Mens. V. Mens. VIII. Post partum
Diagn. Diagn. Diagn. Diagn. Diagn.
Mens. II. Mens. IV. Mens. VI. Mens. VIII. &fens. IX. Post partum
Diagn. Diagn. Diagn. Diagn. Diagn. Diagn.
no. 24. specifica September November March March Journ. no. 104. spec. - 2. April 3. June 4. August 3. October 2. November Journ. no. 159. spec. - 4. October 4. November 5. January 5. March 3. May Journ. no. 200. snec. - 2. March ’ 3. March 4. May 4. July 5. hlmst 2. Auffust Journ. no. 38. non spec. 1. October 3. December 3. December 4. March 4. May Journ. no. .47. non snec. November 5. 5. December 5. February April 3. 3. June Journ. no. 71. non 8oec. January x 5. 5. February April 5. 5. July 5. August Journ. no. 157. non spec. 3. October 3. iSovember 3. J-anuary 2. Mar& April 2. 2. May
C. -.
Journ.
Mens. III. Mens. V. Mens. IX. Post partum
4. 4. 5. 2.
1
Ser. Ser. Ser. Ser.
asc. ax. asc. asc.
0.74 0.49 0.29 0.36
mg./lOO mg./lOO mg./lOO mg./lOO
ml. ml. ml. ml.
Ser. Ser. Ser. Ser. Ser.
asc. asc. asc. asc. asc.
0.34 0.28 0.98 0.84 0.73
mg./lOO mg./lOO mg./lOO mg./lOO mg./lOO
ml. ml. ml. ml. ml.
Ser. Ser. Ser. Ser. Ser.
ase. asc. asc. ax. asc.
0.35 B 0.28 0.24 0.20
mg./lOO mg.jlOO mg./lOO mg./lOO mg./lOO
ml. ml. ml. ml. ml.
c.
C.
c. ser.
asc.
Ser. Ser. Ser. Ser. Ser.
asc. ase. ax. ax. ax.
0.86 0.28 0.41 1.15 0.79 0.64
mg./loo mg./lOO mg./lOO mg./lOO mg./lOO mg./lOO
ml. ml. ml. ml. ml. ml.
Ser. Ser. Ser. Ser. Ser.
ax. asc. asc. asc. ax.
? 0.24 0.36 0.30 0.17
mg./lOO mg./lOO mg./lOO mg./lOO mg./lOO
ml. ml. ml. ml. ml.
Ser. Ser. Ser. Ser. Ser.
asc. 0.44 mg./lOO asc. 0.34 mg./lOO a8c. 0.37 mg./lOO asc. 0.32 mg./lOO ax. 0.10 mg./lOO
ml. ml. ml. ml. ml.
Ser. Ser. Ser. Ser. Ser.
ax. asc. ax. asc. ax.
0.35 0.41 0.21 0.55 0.86
mg./lOO mg./lOO mg./lOO mg./lOO mg./lOO
ml. ml. ml. ml. ml.
Ser. Ser. Ser. Ser. Ser. Ser.
asc. asc. asc. asc. ax. asc.
0.94 0.80 0.32 0.02 0.26 0.18
mg./lOO mg./lOO mg./lOO mg./lOO mg./lOO mg./lOO
ml. ml. ml. ml. ml. ml.
- c.
-
-
-
c.
c.
c.
all examinations from the first examination to the point of culmination, since it seems reasonable to assume that a relatively low vitamin C content in the blood is likely to have existed for some time, providing that it could have caused the development of gingivitis. By including all values found in the period of time under discussion &we have endeavored to obtain as reliable a
picture as possible of the organism’s vitamin (‘ standard during the l)erio(l in which the gingivitis develops. Ta.ble IX does not indicate t.hat the C supplement or the level of s(‘I’~w~ ascorbic acid has any influence upon the gravity of gingivitis. whether sgc~~fi~’ or nonspecific. Since ascorbic acid values for some patients are lacking in Table Ix. hc~ ever, the complete course among some characteristic rases from both WOI~J)~ should be shown before any final conclusions are drawn. Tables TX and X indicate that a relatively low content of vitamin (‘ itI the blood can be of no importance to the gravity either of t,he specific or iho nonspecific cases of pregnancy gingivitis, as the values of serum ascorbic? acid follow tbe seasonal variations shown in Fig. 10 without any relation to i hc, gingival condition. (see IIifmingZ), WC shall Without here going into any documentation finally remark that nothing indicates that the typical amelioration oil a IUM of the specific cases in the ninth month is due to a better vitamin (’ lev-cll. or that the characteristic amelioration after delivery in all specific cases has anything to do with this. Nor has this study brought anF evidence that the increased tendency to gingival bleedin, 0 which is an import.ant. symptom in the specific pregnancy gingivitis is caused 1,~ a relatively low content of <.it,;lmitt C in the blood.
Conclusions In the examination
of 203 pregnant, women, with the exception of tmc patient gingivit.is was found among all who had eomplet,ely healthy gingiv;le at, t,he first exa.mination, but subsequentl;v cont.racted gingivitis. The classification of the patient material into 95 = 47 per cent. gingivitis gravidururn specifica and 108 = 53 per cent. gin,gititis gral:ida,runz non $pecificu, respectively, according to the criteria : ’ ‘hmelioration from final examination during pregnancy until after delivery,” and ‘(n-0 amelioration from final esamination during pregnancy until after delivery” must, following these stuc Kes? have proved justifiable. For among t.he first group we found a characteristic clinical course which diverged markedly from the other group, which presumably justifies maintaining that there is a gingivitis which on the ba.sis it’ its clinical course alone must be considered specific to pregnancy. The majority of the cases of specific gingivitis in this material appear to The gingivitis have begun not much later than the second month of’ pregnancy. symptoms thereupon increase during pregnancy, to reach a climax toward the end. The majority culminate in the eighth month, whereas a considerable number (here about 41 per cent) improve in the ninth month, although there appears to be no rule as to when during the ninth month the amelioration Mommertees. The discovery of a clinical amelioration in the ninth month in ahout half of the specific cases may have some bearing on %&kin and 5esse’s11 demonstration of the reappearance of a slight keratinization of the epithelium in most of their cases in this month. The ameliorat,ion that takes place after t]cIivcr~ that indicates that it usnall~- sets is often very considerable, and there is ~rluch in as early as during the first few days of puerperium.
750
FRODE
HILMING
In contrast to the characteristic course described here there is no similar regularity among the nonspecific cases. With respect to the symptoms, none are to be found among the specific pregnancy gingivitis cases which cannot also be found among the nonspecific pregnancy gingivitis group, as well as in gingivitis in nonpregnant women. There are, however, certain characteristic features in the symptomatology. In by far the prevailing majority of the cases the specific pregnancy gingivitis is a subacutely occurring inflammation of the gingiva; hyperemia and a tendency toward bleeding, which presumably commence at a very early period, are characteristic symptoms, and the particular, excessive hyperemia (raspberry red gums) is perhaps the most characteristic phenomenon. Among the specific cases the pregnancy must accordingly be said to have furthered the inflammations of t.he gingiva or been a predisposing factor. Hypertrophy of the gingiva does not appear to be as characteristic a manifestation as was formerly believed, since about half of the specific cases did not develop new hypertrophic formations as a result of pregnancy. However, rather vigorous hypertrophies developed in about one-fourth of the patients. The so-called epulis gravidwuna (pregnancy tumors) in agreement with Maier and Orban,“, 5 hardly other than particularly violent hypertrophic formations which are also to be found outside of pregnancy. Such formations were found in but one case of a generalized type. The term epulis gravidarum should surely be discarded in favor of gingivitis g,ravidarum hypertrophicans m.g., or a similar term. However, in accordance with this material the tendency toward severe hypertrophic formations is found only among a minority of the specific pregnancy cases. Among the majority of the specific cases the pregnancy brings about a severe aggravation of the gingival condition existing prior to gravidity, while among a smaller number only slight aggravations develop. While we formerly tended to believe that a pregnancy gingivitis required no or only slight treatment, because it was expected to disappear spontaneously after parturition, these studies indicate that a certain (although unquestionably the smallest) part of the cases of specific pregnancy gingivitis leave behind a permanent aggravation in the condition of the gingiva, even though they improve after delivery. And since nothing other than the course of the disease, which first stops during puerperium, justifies a safe differential diagnosis between a specific and a nonspecific pregnancy gingivitis, it should immediately be emphasized that no one should take it for granted that we are doubtless which will automatically concerned with a ‘ ‘harmless ’ ’ pregnancy gingivitis disappear after delivery. On the contrary, every case of gingivitis detected during pregnancy should be treated at once, with all means at hand. Concerning the etiology, this study has shown that local irritative factors cannot be the cause of gingivitis gravidarum specifica, as the latter improves after parturition in spite of local factors being to the same extent still present. On the other hand, local factors may condition gingival reactions and have an aggravating effect, acting in connection with the primary endogenous factors.
The specific pregnancy gingivitis is not caused by a deficiency of vitamin (‘, and it does not depend on the ascorbic acid level of the organism, cilher with respect to occurrence, gravity, or clinical course. A daily supplement ot’ 50 mg. vitamin C had no effect on t,he gingiva, although it is clearly demtrnst~rnhl(~ that by means of a supplement of this kind it is possible to maintain : he vitamin C content of the blood on a considerably higher leacl during pregnarlc’)’ than would be possible without it. Sor is there any evidence that thtb II~)~Ispecific cases of pregnancy gingivitis are ~a.usetl b,v a deficiency ol’ vitamin (‘. Should it be correct that very large closes of vitamin C have had a bcnctic+l effect in a few cases of pregnancy gingivitis, as has hern reported in the lil(:1*:1ture,“, $athis cannot be decided from this study. However. such an eff’ecdtswords very unlikely, and our present knowledge of vitamin C’ cannot accol~nt for it. The characteristic clinical course of t hc specific pregnancy gingivitis which has for the first time been demonstrated in this study seems to indiv:t?r a hormonal etiology.
References I. Fredrikson, H. : The Vitamin C Balance During Pr~gnanry, Acta ohst. gynec. ticanclirrav. 25: 1, 1945. F. : Gingivitis 2. Hilming, gravidarum. Undersagelser over klinik og atiologi rued s;pt.ligt henblik pi C-vitaminets betydning, Dissertation, Copenhagen, 1950. 3. Kut,xleb, H. J.: Schleimhautaffektionen wLhrend der Hchwangerschaft und deren RcDeutsche ZahnLrztl. Wchnschr. 41: 373, 193X. handlung durch AscorbinsLure, 4. Maier, A., and Orban, B.: Gingivitis in Pregnancy, J. Periodont. 19: 123, 1948. 5. Maier, A., and Orban, B.: Gingivitis in Pregnancy, ORAL SURG., ORAL MED., AM OI:AI, PATH. 2: 334, 1949. 6. Rehberg, P. Brandt: The Determination of Ascorbic Acid in Biological Fluids, .\cta physiol. Scandinav. 5: 277, 1943. Die Gingivitis in der Schwangerschaft und ihre AbhLngigkeit vou einrnl 7. Rchuck: in Deutsche Zahnlrztl. Wrhnschr. 47: Mange1 an Vitamin C und Calcium, Abstract 53, 1944. Vitamin C (Cantanj bei Gingivitis Gravitlarum, I)eutsche Zahni~rztl. 8. Rtroh, R,. E.: Wcshnschr. 39: 92,. 1936. 9. . Suter, Fr. : Die klmlschen Erscheinungsformen der Gingivitis Gravidarum uutl clir Rehandlung der Gingivitis Gravidarum mit Redoxon, Dissertation, Ziirich, 1938, The Gingivae During Preprr:~nc~~. S. N., and Stout, A. P.: 10. Ziskin, D. E., Blackberg, Surg., Gynec. & Obst. 57: 719, 1933. Pregnancy Gingivitis, A~I. J. ORTHODONTICS AND ORAL 11. Ziskin, D. E., and Xesse, G. J.: HT:RG. (Oral Surg. Sect.) 32: 390, 1946. 8, VESTER VOLDGADE.