Oral Conditions in Experimental Vitamin C and B Deficiency

Oral Conditions in Experimental Vitamin C and B Deficiency

594 T he J o urn al of t h e A m e r ic a n D en tal A s s o c ia t io n Table 2.—Results in Treated and Control Groups Treated Group I Pe...

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Table 2.—Results in Treated and Control Groups Treated

Group I Per Cent

No. Cases

21

4

-

2

7 7.7 14.8 7 .5

Control

Condition Day After Operation Pain

Edema

0 0

+

+

+ +

0

No. Cases

15 4 3 2 2

Group II Per Cent

57.6 15.5 11.5 7 .7 7 .7

Condition Day After Operation Pain

Edema

+ to -)— 1+

+ to H— |+ +

0 0 *

0 *

*No report.

Conclusions No actual conclusions can be drawn, owing to the small number of cases (fifty-three). It is highly suggestive that, in the cases treated with the crystalline penicillin, the postoperative pain and edema were greatly reduced, apparently to a much greater extent than coinci­ dence would dictate on a purely statis­ tical basis. This method of penicillin administra­ tion provides an immediate high local concentration of the drug at the trauma­ tized site and in the shortest possible time. I t is a less objectionable method of administration from the patient’s view­ point because it necessitates no addi­ tional injection procedures. The same

procedure has been used in other areas of the mouth with favorable results. For optimum comparative purposes, the lower third molar area was used exclu­ sively in this study. That surgical con­ servatism in avoiding traumatization of tissue must not be relaxed in the hope of “ covering up” carelessness is obvious.

Summary When an alternate series of fifty-three cases of lower third molar pericoronitis was subjected to direct postoperative implantation of 100,000 Oxford units of undissolved crystalline penicillin, there was apparently a reduction in the degree of postoperative pain and edema .—2310

Walton Avenue.

ORAL CONDITIONS IN EXPERIMENTAL VITAMIN C AND B DEFICIENCY Dan Y. Burrill, D.D.S., Louisville, Ky. In a study of the oral conditions of a group of volunteer subjects experi­ mentally deficient in vitamins C and B, From the Northwestern U niversity Dental School. The w ork described in this paper was done under a contract, recommended by the Com­ mittee on M edical Research, between the Office of Scientific Research and Development and Northwestern University. Jour. A .D .A ., V ol. 33, M ay 1, 1946

twelve students in the Northwestern University Medical School were first kept for two weeks on a diet that was adequate in all respects. During this time, preliminary observations and meas­ urements were made. Then all subjects were placed on a diet that was deficient in vitamins G and B, but was adequate in all other respects. Tw o men were

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selected by lot to act as controls. Each of vitamin C excretion in the urine day, they received in capsules the vita­ closely followed the blood levels. From mins that were lacking in the basic diet. April 12 through October, the vitamin The men selected by lot to be deficient C levels of all of the deficient subjects only in vitamin G received capsules were very low, as shown not only by the which supplied the vitamin B complex, periodic determinations, but also by but which looked the same as the other saturation tests at the end of the experi­ capsules. The remainder were given ment. Large quantities of vitamin C capsules which appeared to be the same, were absorbed over a considerable time but which contained no vitamins. All before the blood plasma and urinary ex­ of the subjects ate all* meals at Wesley cretion would remain at predepletion Memorial Hospital under the supervi­ levels. The two control subjects main­ sion of a special dietitian. The group re­ tained a-fairly high level of vitamin C at mained on the deficient diet more than all times. Details of the vitamin C de­ terminations and results of other studies seven months. During the control period, when all on the same subjects have been reported men were on an adequate diet, the by C. J . Farmer.1 teeth of all were thoroughly examined Findings and cleaned. The men were instructed in measures to keep their mouths clean 1. Mouth Conditions ; Clinical Exami­ and were supplied with toothbrushes nations.— The mouths of all subjects were and tooth paste as required. Roent­ in fair or good condition at the begin­ genograms were made of all teeth and ning of the experiment. Several showed the supporting bone. Colored photo­ beginning pocket formation about the graphs were obtained of the teeth and teeth. Some showed regions of local ir­ gums and the tongue. Capillary fragility ritation and inflammation caused by the tests were made by applying suction, ex­ presence of calculus and débris. Before pressed as 600 mm. negative pressure, the deficiency diet was started, all cal­ for thirty seconds, to the skin of the culus was removed and the pockets were arm in the cubital fossa, just above and reduced, where necessary, by the use of just below the elbow fold. A similar astringent packs. When the deficiency test was applied to the gums just above diet was started, the mouths were sub­ the anterior teeth, using negative pres­ stantially free from inflammation and sures of 600 and 640 mm., applied for irritation. thirty seconds. Each time the men appeared for tests During the deficiency period, the men and photographs, the mouths were care­ were seen once a month for examination, fully reexamined. In some, it was noted colored photographs of the teeth, gums that débris was accumulating and that and tongue and capillary tests. Near minor local irritation and inflammation the end of the experiment, the gums of were associated with the accumulation. all but three were examined by means With this exception, no soft tissue of a biomicroscope. changes were apparent at any time dur­ On March 26, 1942, the men started ing the period of deficiency or thereafter. on the deficient diet. Before the end There was no sign whatever of the of M ay, the blood plasma vitamin C classic symptoms of scurvy. There was levels of all but the controls had reached no tendency for the gums to bleed ex­ 0, and thereafter stayed at or close to cept in association with accumulation of 0 . The vitamin C content of the leuko­ débris, before mentioned. In those cytes and blood platelets reached or ap­ 1. Farm er, C. J . : Some Aspects of Vitam in proached 0 shortly thereafter. The levels C Metabolism.' Federation Proc. 3 :1 7 9 , r 944 -

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places, the tendency to bleed was no ficiency, or which were of controls and greater than would be expected in a which of men deficient in the vitamins nondeficient patient under the same studied. local conditions. There appeared no The photographs of the tongues were change in tendency to tooth decay. negative in the same way. No changes S. The Photographs in Color.— in surface texture or in color could be Photographs in color were taken of the seen, and it was impossible, on the basis gums, teeth and tongue, not so much of the photographs alone, to tell which to demonstrate the conditions found as men were deficient in vitamins and to provide a record that would be rea­ which were not. The photographs are not reproduced sonably free from bias and entirely free from the defects due to hazy recollec­ since they show only normal mouths. tions of previous conditions. Further­ 3. The Oral Roentgenograms.— Com­ more, the photographs could be repeat­ plete intra-oral roentgenograms were ob­ edly examined by anyone and, when tained for each man just before the be­ projected, would show mouth conditions ginning and just before the end of the more clearly than they could be seen on deficiency period. The initial films direct examination. The photographs showed beginning pocket formation were colored transparencies taken on 35 about the teeth of some of the men. mm. Kodachrome A film. The camera, Two men had periapical rarefaction. In with a ground-glass screen for focusing, one, a control, the root canal had al­ two photoflood lights in reflectors and ready been filled and the root resected. a framelike lip retractor, was mounted In the other, later deficient in vitamin on a single stand to, reduce to a mini­ C, a root canal filling was placed at mum the variables in taking the photo­ the beginning of the deficiency period. graphs. Each photograph was identi­ Comparison of the predeficiency fied by the date and the name of the roentgenograms with those made at the subject printed on a label on the lip re­ end of the deficiency period failed to tractor in such a way as to appear in the disclose any changes for the worse in the photograph. bone around .the teeth. The lamina At the end of the experiment, the dura in all cases appeared to have re­ transparencies were arranged in series mained intact and the internal struc­ for each man and were projected for ture of the bone was unchanged. The viewing. In the image thus enlarged, apical areas of rarefaction in the mouths details of the teeth, gums and tongue of the control and the deficient subject were clearly visible. Examination of the had filled in perceptibly. No new pocket projected images showed no changes of formation had occurred and the bone any nature that could be traced to the destruction associated with pockets pres­ deficiency. One man, a control subject ent at the beginning of the deficiency receiving a diet adequate in all respects, period had not progressed. On the con­ showed an increasing amount of inflam­ trary, there may have been a slight im­ mation in some of the interdental papil­ provement in the character of the bone lae and gum margins. Early in the beneath these pockets, though the dif­ deficiency, two others showed a slight ferences might be due to variations in marginal gingivitis, which had appar­ roentgenographic technic. Figures 1 to ently cleared up before the end of the 6 are representative roentgenograms. deficiency period. Without looking at 4. The Capillary Fragility Tests.— the names and dates on the pittures, it Capillary fragility tests on the skin of was impossible to tell which pictures were the arm and similar tests in the mouth taken before and which during the de­ were made at the same time in the hope

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Fig. i.— Low er anterior region of vitam in C deficient subject before (left) and at end of deficiency period (right), showing unchanged lamina dura.

Fig. 2.— Low er anterior region of control subject before (left) and at end of deficiency period (right). (Com pare Fig. i.)

that some parallel could be found be­ tween the results on the arm and those in the mouth. There was no such p ar­ allel. T h e vitam in deficiency appeared to increase the fragility of the capillaries in the arm , though the changes were not striking and were not the same in all of the subjects. In most, the fragility was greatest after one or two months on the deficient diet, becoming less as the diet continued, though the vitamin concentration remained low. T h e capillary tests on the gums gave uniformly negative results. O ne or two petechiae were produced at times in all of the subjects, both control and defi­

cient. N o more than two were ever pro­ duced and increased vacuum or a longer time failed to produce more. It was found that the petechiae became less and less frequent as time went on, and it was concluded that the random varia­ tions were produced by variations and im provement in technic. Possibly, the gum tissues are too tough to be tested in this way. I t was clear that no changes measurable by the method used were produced by the deficiency and that, so far as these tests showed, the fragility of the gum capillaries did not increase along with the increase in the fragility of the arm capillaries.

Fig. 3.— V itam in C and B deficiency case before (below) and at end of deficiency period (above), showing unchanged lamina dura and no increased pocket formation.

Fig. 4.— V itam in C deficiency case before (below) and at end of deficiency period (above), showing no increase in pocket depth.

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entire field as it appeared, but only to record the general configurations o f the capillaries, whether simple or involved, the length o f the loops, the presence of apparent sacculation or dilation and the like. Reproductions of the. sketches are shown in Figure 7. T h e surface characteristics of the gums were substantially the same in all subjects, both deficient and control. A w ay from the gum margins, the gums were slightly pitted. T he pits were present in every case except No. 4902, who was not an experimental subject. In this case the gums were markedly in­ Fig. 5.— V itam in C deficiency case, show­ ing periapical rarefaction before (below) and flamed and swollen and the surface was at end of deficiency period (above). T he root smooth. T h e basal blood plasma vitamin canal was filled at the beginning of the defi­ C level in this case was 0.64 mg. per ciency period. hundred cubic centimeters, which ap­ pears to be normal for people in this vicinity. T h e inflammation and swelling, 5. Examination by the Biomicroscope. which were limited to the gums over — Ju st before the end o f the deficiency the upper anterior teeth, were believed period, the gums o f all but three of the to have been caused by the drying ef­ subjects were exam ined with a m icro­ fect of mouth breathing at night. scope specially adapted for viewing the These capillary examinations indi­ capillaries. A t this time, the blood vita­ cated no consistent difference between min C levels and the urinary vitamin C the deficient and the nondeficient sub­ levels of the deficient subjects had been substantially at zero for five months. ject. T h ere was considerable variation T h e two control subjects were examined between individuals whether deficient or and, as a further check, the gums of not. Changes in capillaries were seen several persons not on the diet were also where there was marked inflammation. examined. T h e biomicroscope used was a binocu­ lar microscope mounted on a stand with a slit lamp designed to throw a bright and sharply defined line of light on the tissues before the lenses. T h e capillaries could be seen distinctly and could be followed a short distance into the tis­ sues. T h e surface characteristics of the gum could be plainly seen and the inter­ meshing pattern of epithelial and con­ nective tissue papillae could be made out. A t each examination, a rough sketch was drawn and a brief description w rit­ ten to record the observations. T he sketches did not purport to show the

Fig. 6.— Control case, showing periapical rarefaction before (left) and at end of de­ ficient period (right). The root canals were filled and the apex of the central incisor re­ sected just before the beginning of the ex­ periment.

599

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Fig. 7.— Sketches of gum capillaries as seen through the biomicroscope. The heavy dots represent apparent sacculations, which m ay have been only deviations of the capillaries aw ay from the observer, so that one portion of the capillary is superimposed on another portion. The line at the left of each sketch indicates the apparent contour of the gum margin, as if seen in section.

These changes were extreme tortuosity of the capillaries, minor hemorrhage beneath the epithelium and swelling and waterlogging of the tissues, as were seen in Case 4902. Pitting of the gums, since it was seen in all instances except this one, is probably a normal condition.

Comment Deficiencies as severe as those pro­ duced in the experimental subjects are rarely seen in our clinic. It had been hoped that the findings in this experi­ ment would give affirmative, rather than negative, information concerning the re­

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lationship of the vitamins studied to mouth conditions. Since it is known that neglect and the presence of débris can produce mouth symptoms that might be attributed to vitamin deficien­ cies, such factors, were excluded by in­ suring that the mouths of' the subjects were reasonably clean. Had the mouths been dirty, it is possible that differences might have been seen between the con­ trols and the deficient subjects, but there is no indication in this experiment that there were differences. Furthermore, dirt is an uncontrollable variable. The results obtained are in accord with reported findings in clinic patients at the Northwestern University Dental School.2 In that study, it was found that the mean and median vitamin C levels were lower in gingivitis or pyor­ rhea than when the mouths were nor­ mal, but the differences in mean and median were small in proportion to the ranges of variation in vitamin C levels in every group. The correspondence seemed to be between the condition of the mouth and the tendency of the patient to neglect both mouth and diet. The literature was briefly reviewed in that article. The results of the present investiga­ tion are substantially in accord with those in some reports3’ 4 and at variance with those in others.5’ 6 They do not 2. Burrill, D. Y . : Relationship of Blood Plasma Vitam in C Level to Gingival and Periodontal Disease. J . D. Res. 2 1 : 3 5 3 , A u ­ gust 1942. 3. Crandon, J . H .; Lund, C . C ., and D ill, D. B .: Experim ental Human Scurvy. New Englaild J . Med. 223: 35 3, September 5, 1940. 4. Restarski, J . S., and Pijoan, M .: Gingi­ vitis and Vitam in C . J.A .D .A . 3 1 : 1 3 2 3 , Oc­ tober 1 , 1944. 5. K ruse, H. D .: Gingival Manifestations of Avitaminosis C. M ilbank M em. Fund Q uar. 2 0 :2 9 0 , Ju ly 1942. 6. Blockley, C. H ., and Baenziger, P. E .: Investigation into Connection Between V ita ­ min C Content of Blood and Periodontal Dis­ turbances. Brit. D . J . 7 3 :5 7 , August 1, 1942,

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constitute evidence on the question of whether massive doses of vitamins are useful in the treatment of oral disorders.7 It is possible that treatment of a con­ dition not due solely to lack of a vita­ min might be furthered by administra­ tion of the vitamin.

Summary and Conclusions In a study of the oral conditions of five subjects deficient in vitamin C, four deficient in vitamins C and B and two control subjects, the deficiency was pro­ duced by a controlled diet and lasted for seven months. The subjects were seen periodically for examination, col­ ored photographs and capillary fragility tests. Oral roentgenograms were made at the beginning and at the end of the experiment. The capillaries of the gums were studied by means of a capillary microscope at the end of the deficiency period. No oral changes of any kind attribut­ able to the vitamin deficiencies were found. There was no increased tend­ ency to inflammation, swelling or bleed­ ing of the gums. There was no loosening of the teeth. The deficiency did not in­ terfere with bone healing in apical rare­ faction. There was no increase in depth of periodontal pockets and no apparent disturbance of the lamina dura. There was no apparent change in the configura­ tion of the gum capillaries or in their strength. It is concluded that even severe vitarnin G and B deficiencies do not produce symptoms in clean mouths of young adults, at least within a period of seven months; and that, at least for the period of time covered by this study, dietary adequacy is less important for oral health than is oral cleanliness. — 12g

East Broadway. 7. R oth, H. : Vitam ins as an A djunct in Treatm ent of Periodontal Disease. J.A .D .A . 3 2 : 6 o, Jan u ary 1, 1945.