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Vitamin C and human wound healing
Vitamin C and human wound healing W. M. Ringsdorf; DEPARTMENT
OF
Jr., D.M.D., ORAL
M.S.,* and E. Cheraskin,
DIAGNOSIS,
UNIVERSITY
OF
ALABAMA
M.D., D. M. D., Birmingham, SCHOOL
OF
Ala.
DENTISTRY
Clinical studies provide evidence that wound healing in subjects judged not deficient in vitamin C can be significantly accelerated with supplements of this nutrient above the recommended daily allowance (RDA). The authors administered daily dosages of 500 to 3,000 mg., which is roughly 8 to 50 times the RDA of 60 mg., to subjects recovering from surgery, other injuries, decubital ulcers, and leg ulcers induced by hemolytic anemia. Genetic impairment of collagen synthesis has also been observed to be responsive to ascorbic acid supplementation in an B-year-old boy with Type VI Ehlers-Danlos syndrome. Four grams of ascorbic acid daily produced a significant improvement in the quality of newly synthesized collagen but did not alter that formed prior to the supplementation of C. The combined evidence in this review provides a substantial the interrelationships between
base for further research, vitamin C and the body’s
M any years ago Cannon’ put it superbly when he referred to the “wisdom of the body.” If the body were not wise, man could not survive. Every cell, tissue, organ, and system is programmed to heal. Every second of our lives we suffer injuries-a slight bump of the hand, the nick of the razor, carving the fingers along with the turkey, and other traumatic challenges such as major surgery. The only reason we make it is that for every injury there is a healing response. As long as the healing process keeps pace with the injuries, we remain healthy. When the recuperative capacity begins to lag behind, we become ill. When the lag is great, we die! Estimates from the 1975 National Health Survey? by the National Center for Health Statistics (Public Health Service) indicate that injuries accounted for 11.9 percent of the 1.1 billion physician visits during that year. That comes to 130,900,OOO visits (better than one out of ten), excluding those to hospital inpatients. Among all acute conditions requiring a doctor, injuries are a close second to acute respiratory problems (15.1 percent). Although these data from the 1975 National Health Survey are the latest for physician visits, more recent data from this source tabulate the number of persons injured in 197K3 During that particular year approximately 68 million persons were injured-a rate of 3 I .6 patients per 100 persons in the United States. Surgical statistics are also cited by the National Center for Health Statistics from the 1978 National Health Survey.l One or more surgical operations were performed in that year for an estimated 14.7 0030-4220/82/030231
+ 06$00.60/O
@ 1982 The C. V. Mosby
Co.
both clinical and healing potential.
experimental
trials,
concerning
million of the 35.6 million inpatients discharged from short-stay hospitals. Thus, almost one out of every two persons underwent surgery at least once while hospitalized in nonfederal short-stay hospitals during the calendar year 1978. Research evidence reveals that recovery from injury or surgery can be dramatically accelerated; in other words, recovery time can be reduced by 50 to 75 percent. All of us have experienced some inconvenience or missed out on something important because of the time required for healing. Athletic events are frequently lost because injury and the so-called normal period of recovery have prevented the winning combination of athletes from participating. There is a plethora of published proof that a deficiency of vitamin C impairs wound healing in experimental lower animals and human beings and that an excess accelerates healing above the normal level. This nutrient is unique among vitamins because it regulates the formation and maintenance of intercellular cement and collagen. Thus, the structural integrity of every tissue and organ is dependent on this vitamin. A deficit in vitamin C can, therefore, contribute to structural deterioration and/or aggravation of specific disease states of any tissue, organ, or system. A principal chemical flaw is the formation of defective collagen. This protein is a critical structural ingredient of blood vessels, the fibrous tissue in scars, and the matrix of the hard tissues (bone, cartilage). From studies on healthy adults eating a 231
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Ringsdorf
and Cheraskin
vitamin C-deficient diet (5 to 10 mg. daily) for periods up to 7 months, investigators have concluded that wound healing is dramatically delayed when there is a deficiency of vitamin C. They have also noted that the tensile strength (resistance to being torn open) of healing wounds in these subjects was decreased 50 to 60 percent when compared to control wounds.;-h Although most health professionals and nutrition specialists hold the opinion that diet supplies all the needed vitamin C, the published evidence concerning the effect of dietary supplementation upon wound healing indicates that an additional intake is very desirable. Even though the material in this article is limited to evidence from human studies, two reports of enhanced wound healing in lower animals are worthy of special mention. Collins and co-workers!’ graded gingival wound healing in days following a deliberate and standardized wound in twelve guinea pigs (three groups of four each) subsisting on a vitamin C-deficient diet. In the group with no supplement, the average healing time was 16.7 days. In a second group receiving injections of 2 mg. vitamin C per day (almost four times the amount reported to prevent scurvy), the wounds healed in 12.0 days. The third group of guinea pigs was injected with ten times this amount, or 20 mg. of vitamin C daily. Further acceleration of wound healing decreased their mean healing time to 8.0 days. Thus, supplementation with vitamin C above the daily requirement for guinea pigs significantly enhanced their wound-healing potential. Pfister and co-wokerslO-l” have proved that vitamin C helps burned eyes heal without serious complications. These researchers conducted double-blind experiments with rabbits to determine if vitamin C reduces or prevents cornea1 ulceration and perforation following a controlled caustic burn with sodium hydroxide. Administration of 1.5 Gm. of ascorbic acid daily or instillation of 10 percent ascorbic acid drops each hour for 14 hours per day dramatically reduced these complications by accelerating the healing potential. (It should be mentioned that the 1.5 Gm. of ascorbic acid given to rabbits averaging 6% pounds would be the equivalent of a 150 pound human being getting 35 Gm. of vitamin C daily!) The National Eye Institute is now conducting a study of eye burn patients in several research centers across the United States.‘j These patients will receive vitamin C, both orally and topically. From the existing information, the results should be exciting!
Oral March,
Surg. 1982
On the basis of the lower-animal experiments by Pfister and his co-workers, it is anticipated that the megadosage of vitamin C will accelerate new collagen formation considerably above the degeneration rate of damaged collagen. Although the end result of a bad burn is a scarred cornea, preservation of the anterior fluid-filled chamber back of the cornea and the lens of the eye will allow vision to be surgically restored by cornea1 transplantation. In mild or moderate burns, this treatment may prevent ulceration and allow healing of the cornea without scarring. Vitamin C therapy represents an about face in the treatment of eye burns for, in fact, the accepted treatment has been to retard, with medication, the degeneration of the damaged collagen. However, the vitamin C treatment bypasses this approach and turns toward acceleration of the formation of new and healthy collagen. RECOVERY INJURIES
FROM SURGERY
AND OTHER
A rapid utilization of vitamin C occurs during surgery and postoperatively. In a study of ten women (28 to 35 years of age) undergoing abdominal surgery, Shukla” administered 500 mg. of vitamin C daily from the first to the ninth postoperative day. (The hospital dietetic staff was instructed to refrain from serving any citrus fruit or juice during this period of time.) Between the third and sixth postoperative days, the plasma ascorbic acid level decreased sharply. From the sixth to the ninth day the decrease continued but at a less precipitous rate. Thus, during these 9 days, the plasma C level dropped from 2.6 mg. percent to 1.5, even though the patients were receiving 500 mg. of this vitamin daily. In another experiment on sixty-three surgical patients, the postoperative ascorbic acid requirements were assessed by measuring the vitamin in white blood cells (leukocytes). Irvin, Chattopadhyay, and Smythe’” found a 42 percent reduction in leukocyte ascorbic acid levels by the third postoperative day. These last two experiments suggest that during postsurgical recovery the vitamin C in the body migrates toward and concentrates in the healing site. Hunt”’ reported four decades ago that wound disruption had been reduced about 75 percent since the routine administration of ascorbic acid had been adopted for all major abdominal operations at St. Bartholomew’s Hospital in London. During the next 30 months he also observed that “leakage from suture lines has occurred in but one of a large number of operations.“‘”
Volume Number
53 3
Where it was practical to do so, 1,000 mg. of vitamin C was administered orally (in divided doses) each day for 3 days prior to surgery and 100 mg. daily thereafter. When infection, gastrointestinal disease, or achlorhydria was evident, these doses were increased. The St. Bartholomew’s Hospital policy was that vitamin C should be administered: “( 1) when clean and quick healing of the wound is particularly desirable, (2) in major abdominal operations, (3) when a hollow viscus (like the stomach) has been opened, (4) when postoperative complications are anticipated, (5) when there is evidence of a nutritional deficiency, and (6) in all cases of serious injury.“16
Bartlett, Jones, and Ryan” studied the effects of dietary supplementation with 100 and 1,100 mg. of ascorbic acid daily on the tensile strength of thigh wounds in a 62-year-old man. After 10 days of healing, the higher supplementation of vitamin C produced a threefold increase in the skin and a sixfold increase in the subjacent connection tissues. This is a rather dramatic increase in tissuebreaking strength and is especially noteworthy since the man exhibited no clinical evidence of vitamin C deficiency other than a plasma ascorbic acid level of 0.09 mg. percent. Levels of 0.00 to 0.20 have been observed to be quite common in the general population. Our own assessment of fasting (no food intake for 12 hours) plasma ascorbic acid levels in seemingly healthy junior dental students over a lo-year period showed that 10 to 20 percent of each class had a blood content of vitamin C within this deficient range! Holmes17-‘R coordinated the intravenous administration of 1,000 mg. of vitamin C to patients experiencing severe postoperative shock. To use Holmes’ words, “It produced astonishing recovery.” Since loss of plasma from permeability of the vascular system can induce shock, the decrease in capillary permeability and fragility by vitamin C may serve both therapeutically and in the prevention of shock. At Holmes’ suggestion, Kuehner”-‘* of Mercy Hospital in Pittsburgh consented to extend these observations. In April, 1945, Kuehner reported to Holmes that he had administered up to 2,000 mg. of vitamin C intravenously both before and after surgery to fifty seriously ill patients. These patients had undergone major abdominal operations, such as gastric resections, complicated gallbladder and liver surgery, and rectal and bowel resections. Kuehner’s analysis of the results was as follows: “I am definitely convinced that these cases have
Vitamin C and human wound healing
233
made a more prompt and more vital convalescence with less serious complications or sequellae than 50 such cases which were operated on without the aid of vitamin C.” To test the effectiveness of vitamin C in accidental trauma, Kuehner supplied 500 mg. orally to injured miners as soon as possible after their accidents. Again, Kuehner was convinced of the boost in healing potential: “I am thoroughly satisfied that there is betterment in these cases as compared with similar ones not given vitamin C. When they reached the hospital we seem to be able to go ahead with vital procedures indicated more readily than when we were not using vitamin C.” Curtis of the Ohio State University School of Medicine also accepted Holmes’ suggestion to test the value of vitamin C in preparing patients for surgery.‘:. Is On April 8, 1946, he wrote Holmes: “There is now little doubt of the value of vitamin C in the prevention of shock.” To test the practicality of administering this vitamin to dental patients, Ringsdorf and Cheraskin’” designed the following experiment. A 3 min. circular plug of gingival tissue was removed from each of two healthy junior dental students who had acceptable blood levels of ascorbic acid. Each day the wounds were painted with a 1 percent solution of toluidine blue, rinsed, and then photographed. Since this dye adheres only to connective tissue. the wound size could be judged clinically and measured accurately by observing the blue circle. The daily painting, rinsing, and photographing were continued until the wound was completely covered by the gingival tissue growing in from the wound margin. Thus, the blue circle became progressively smaller and healing was judged to be complete when there was an absence of toluidine blue stain. After a 2-week rest period, a similar wound was placed in the same area (between the upper lateral incisor and cuspid) on the other side of the two students’ mouths. The only difference was that each student received, on the day of surgery and daily thereafter, 250 mg. of ascorbic acid with each meal and at bedtime. Comparison of the first (regular diet only) and second (regular diet plus 1,000 mg. vitamin C daily) healing sequences revealed a 40 percent decrease in the time required for healing with this amount of ascorbic acid supplementation. This study was repeated in another pair of students given a 500 mg. tablet of ascorbic acid with each meal and at bedtime.‘” Again the wound-healing comparisons revealed a significant acceleration of healing by vitamin C.
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Ringsdorf and Cheraskin
Table
I. Reduction in lesion area after 1 month Group
A (placebo) (percent) 50 54 4 60 22 39 45 14 60 80
Group I
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B (ascorbic (percent)
acid)
81 72 87 87 21 90 100 100 100 100
Measured in days, healing on a regular diet with no supplement of C took 18 days. The second wound, however, under the influence of 2,000 mg. of vitamin C daily, required only 9 days for complete healing. Thus, a 50 percent decrease in the time required for oral wound healing was achieved with a daily vitamin C dosage of 2 Gm. Khosla and Gough” evaluated the management of postextraction third molar sockets with a combination of vitamin C and B complex (C-300 mg., B,- 15 mg., B,- 10 mg., B,-5 mg., nicotinamide-50 mg., calcium pantothenate- 10 mg.). The incisions in the twenty-seven control patients and in the thirty-six experimental patients were closed with black silk sutures. In addition, the experimental group received one capsule daily of the C-Bcomplex combination. When this group was compared with the control group, it was found that the experimental subjects receiving the vitamin supplement experienced less postoperative pain and an enhanced rate of socket healing. DECUBITAL
ULCERS
Pressure sores develop quite frequently in patients who are confined to bed or a wheelchair for an extended period of time. In two paraplegics whose pressure sores were biopsied before and after the administration of 1,000 mg. of ascorbic acid daily for 5 and 10 days, Hunter and RajanZ2observed a marked increase in collagen formation in the ulcers. However, there was no follow-up beyond the 5- and lo-day intervals to determine whether vitamin C accelerated the healing of these pressure sores.Although neither of the patients showed any clinical evidence of ascorbic acid deficiency, supplementation with vitamin C (seventeen-fold higher than the RDA) significantly increased collagen formation. White blood cell (leukocyte) content of ascorbic acid was found to be low (less than 15 mcg.110”
Surg. 1982
WBC) in 23 percent of the ninty-one paraplegic patients studied by Burr and Rajan.‘:’ Patients with pressure sores, however, had significantly lower leukocyte ascorbic acid levels than those without sores. Approximately three times as many of the paraplegic patients with sores had leukocyte ascorbic acid levels below 15 mcg./ 1O”WBC as compared to those free of pressure sores. Since the white blood cell content of vitamin C is considered one of the more accurate estimates of tissuecontent, seven of those with low levels (but no other clinical evidence of vitamin C deficiency) were given 500 mg. of ascorbic acid twice daily for 3 days. Biopsies before and after the supplementation showed a definite increase in collagen formation. However, as in the previous citation,“” there was no follow-up beyond the 3-day interval to determine the effect of vitamin C upon the rate of healing. To assessthe value of ascorbic acid in the healing of pressuresores,Taylor and a team of co-workers”’ conducted a double-blind controlled trial on twenty surgical patients suffering from pressure sores. Ten received tablets containing 500 mg. of ascorbic acid twice daily and ten were administered identical white tablets of inert material twice daily. The pretreatment leukocyte ascorbic acid levels were almost identical in both groups and above the lower limits of the normal range of 18 mcg.1 lO*WBC (24.0 and 22.0 mcg./lO”WBC for the placebo and vitamin C groups, respectively). After a month’s treatment, the mean level in the vitamin C-supplemented group had risen to 65.5 mcg.1 lO”WBC, while the placebo level remained at 25.8. Healing of the ulcers was assessedweekly by a photographic technique which provided the ulcer size and healing rate in square centimeters. All patients had standard hospital beds and mattresses. the same basic hospital diet, and similar local treatment of the pressure sores. Table I shows the percentage reduction in area of each lesion after one month. The average reduction in ulcer size in those receiving the placebo for a month was 42.7 percent. However, twice as much healing had occurred during this same time in the patients receiving 1,000 mg. of vitamin C daily (84 percent). These changes differed significantly when analyzed statistically (P < 0.005). In the vitamin C group four of the ulcers had completely healed before the month ended. Actually, 3 or 4 months is the usual time required for ulcers such as these to heal. The rates of healing in square centimeters per week were 1.45 and 2.47, respectively, for the placebo and vitamin C groups.
Volume Number
53 3
If vitamin C induced such a dramatic acceleration in healing of pressure sores, it might play an important role in their prevention. It is possible that this scourge in confined subjects could be practically eliminated by daily supplementation with vitamin C. A recognized feature of hereditary hemolytic anemias is an increased incidence of leg ulcers. These become a therapeutic problem if they develop in patients with a mild form of thalassemia major compatible with survival into adult life. In many instances the ulcers, and not the anemia, become the major disability because of painful recurring infections. Although bed rest and antiseptic dressings to the ulcer may encourage healing, this present treatment leaves much to be desired. To determine whether orally administered vitamin C could enhance the healing of thalassemia leg ulcers, Afifi and associates”j designed a doubleblind cross-over study with 3 Gm. of ascorbic acid versus placebo daily. Eight patients with beta thalassemia major (18 to 33 years of age) were chosen from two related families. All the patients had two to four leg ulcers each for at least 2 years prior to this trial. The ulcers ranged from 2 to 4 cm. in diameter. All patients had been receiving a good mixed diet and showed no evidence of a vitamin C deficiency. During the study period, all subjects were told to continue their normal antiseptic dressing procedure for ulcer care and to continue raising their legs to a horizontal position for 14 hours each day (including sleep). This regimen was found to be compatible with the patients’ normal working and domestic life. The patients were divided into two groups of four. Group I received 1,000 mg. of effervescent ascorbic acid three times daily for the first 8 weeks and 1,000 mg. of a placebo effervescent table three times daily during the second 8-week period. Group II was given these preparations in the reverse order. During the first 8-week period, seven of the fourteen leg ulcers in the four Group I patients were completely healed and five were partially healed while the patients were receiving 3 Gm. of ascorbic acid daily. This dramatically contrasts with the fact that of the twelve leg ulcers in the four Group II patients receiving placebo tablets, only four were partially healed in the same s-week period. Statistical analysis revealed a highly significant difference in these results (P < 0.01). Group II patients, however, duiing the succeeding 8 weeks of ascorbic acid supplementation, ended the period with nine of the twelve ulcers totally healed. It is interesting that, even though the patients were on the placebo during the second 8 weeks, four additional ulcers in Group
Vitamin C and human wound healing
235
I completely healed. This is obviously a carry-over of the improved ascorbic acid status reached during the previous period of supplementation. Thus, high doses of ascorbic acid were therapeutically effective even though these patients had an allegedly acceptable vitamin C intake. These favorable results provided evidence additional to that already cited that the addition of this vitamin to the currently prescribed healing regimens would accelerate the response and significantly shorten the recovery period. GENETIC IMPAIRMENT SYNTHESIS
IN COLLAGEN
In recent years increased knowledge concerning the synthesis of collagen has generated the description of several inherited disorders of its biosynthesis. Collectively, these diseases are clinically described as Ehlers-Danlos syndrome and subclassified into at least seven types. In many inherited disorders, knowledge of the cofactor requirements for the specifically impaired enzyme reactions and the subsequent administration of pharmacologic amounts of the vitamin precursors of these active cofactors have resulted in dramatic clinical improvement. Since Ehlers-Danlos syndrome, Type VI, involves a specifically impaired enzyme which uses vitamin C as its principal reducing agent, Elsas, Miller, and Pinnell’” elected to determine if pharmacologic doses of ascorbic acid could help reverse the collagen lysyl hydroxylase deficiency. These investigators selected an 8-year-old boy with Type VI Ehlers-Danlos syndrome who had hydroxylysine-deficient collagen in his body (10 percent of normal). Without sufficient quantities of lysyl hydroxylase (only 17 percent of normal in this patient), the amino acid lysine cannot be incorporated into collagen.2i The defective collagen in this patient produced muscle weakness, lax joints, friable skin, many hemorrhagic scars, a high-arched palate, and small corneas. Throughout his life, multiple lacerations had occurred after minor trauma and the poor wound-healing capacity resulted in abnormal scar formation. Most of the child’s joints could be extended greatly beyond their normal range, and he could actually touch the tips of both shoulders under his chin. The patient’s dietary history indicated an intake of approximately 50 mg. of ascorbic acid per day over the past year, and his urinary and plasma levels of vitamin C were within the normal range of 8 to 37 mg./per day/per gram of creatine and 0.2 to 2 mg. percent, respectively. Excretion studies after a single oral dose of 4,000 mg. of ascorbic acid were similar
236
Ringsdorf and Cheraskin
to that in three control subjects. Plasma levels of vitamin C after loading also rose, similar to those in the controls. From these tests. it was concluded “that ascorbate deficiency was not present.” Over a 2-year period the investigators administered 4,000 mg. of ascorbic acid daily. This produced a significant increase in the formation of hydroxylysine and clinical evidences of improvement-better wound healing, an increase in muscle strength, cornea1 growth, return of bleeding time to normal, and an increase in pulmonary residual volume. These results suggested that the quality of newly synthesized collagen had greatly improved. No clinical change in the loose joints and friable skin indicated that incorporation of hydroxylysine into preformed collagen did not occur. This was substantiated by measurements of this amino acid in the skin. CONCLUSIONS
Clinical studies provide evidence that wound healing in subjects judged not to be deficient in vitamin C can be significantly accelerated with supplements of this nutrient above the RDA. We administered daily dosages of 500 to 3,000 mg., which is roughly 8 to 50 times the RDA of 60 mg., to subjects recovering from surgery, other injuries. decubital ulcers, and leg ulcers due to hemolytic anemia. Genetic impairment of collagen synthesis has also been observed to be responsive to ascorbic acid supplementation in an 8-year-old boy with Type VI Ehlers-Danlos syndrome. Four grams of ascorbic acid daily produced a significant improvement in the quality of newly synthesized collagen but did not alter that formed prior to the supplementation of vitamin C. The combined evidence in this review provides a substantial base for further research. both clinical and experimental trials, concerning the interrelationships between vitamin C and the body’s healing potential.
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9.
10.
II
12
13 14. 15.
16. 17. 18. 19.
20. 21.
22.
23. 24.
25. I. Cannon, W. B.: The Wisdom of the Bodv, New York, 1932. W. W. Norton Company. 2. Gentile. A.: Phvsician Visits. Volume and Interval Since Last Visit, United Siates, 1975, Vital and Health Statistics, Series 10, Data from the National Health Survey: No. 128, DHEW publication (PHS) 79-1556, U. S. Government Printing Office. 3. Givens, J. D.: Current Estimates from the Health Interview Survey. United States, 1978, Vital and Health Statistics. Series 10, Data from the National Health Survey: No. 130. DHEW publication (PHS) 80-1551. U. S. Government Printing Office. 4. Haupt, B. J.: Utilization of Short-Stay Hospitals. United States, 1978, Vital and Health Statistics, Series 13, Data from
National Health Survey: No. 46, DHEW publication (PHS) 80-1797. U. S. Government Printing Office. Bartlett. M.. Jones, C. M., and Ryan, A. E.: Vitamin C and Wound Healing. II. Ascorbic Acid Content and Tensile Strength of Healing wounds in Human Beings. N Engl J Med. 226: 474-481, 1942. Boume. G. H.: The Effect of Vitamin C on the Healing ofWounds. Proc. Nutr. Sot. 4:204-216. 1946. Schwartz. P. L.: Ascorbic Acid in Wound Healing-A Review. J. Am. Diet. Assoc. 56:497-503, 1970. Wolfer. J. A.. Farmer, C. .I.. Carroll, W. W., and Manshardt. D. 0.: An Experimental Study in Wound Healing in Vitamin C Depleted Human Subjects, Surg. Cinecol. Obstet. 8&l-15. 1947. Collins, C. K., Lewis. A. E.. Ringsdorf. W. M.. Jr., and Cheraskin. E: EfTect of Ascorbic Acid on Oral Healing in Guinea Pigs, Int. J. Vitam Nutr. Res. 37:492-495, 1967. Pfister. R. R.. and Paterson, C. A.: Additional Clinical and Morphological Observations on the Favorable Effect of Ascorbate in Experimental Ocular Alkali Burns, Invest. Ophthalmol. Vis. Sci. 16:478-487. 1977. Pfister. R. R.. Paterson. C. A., and Hayes, S. A.: Topical Ascorbate Decreases the Incidence of Cornea1 Ulceration After Experimental Alkali Burns. Invest. Ophthalmol. Vis. Sci 17:1019-1024. 1978. Levinson. R. A.. Paterson. C. A.. and Pfister. R. R.: Ascorbic Acid Prevents Cornea1 Ulceration and Perforation Following Experimental Alkali Burns, Invest. Ophthalmol. Vis. Sci. 15:986-993. 1976. Medical News: Vitamin C May Enhance Healing of Caustic Comeal Burns. J.A.M.A. 243:623, 1980. Shukla. S. P.: Plasma and Urinary Ascorbic Acid Levels in the Postoperative Period, Experientia 25:704. 1969. Irvin, T. T.. Chattopadhyay, D. K.. and Smythe. A.: Ascorbic Acid Requirements in Postoperative Patients. Surg. Ciynecol. Obstet. 147:49-55. 1978. Hunt. A. H.: The Role of Vitamin C in Wound Healing, Br. J. Surg. 28:436-461. 1941. Holmes, H. N.: Shock. Science %:384-386. 1942. Holmes. H. N.: The Use of Vitamin C in Traumatic Shock. Ohio State Med. J. 42:1261-1264. 1946. Cheraskin, E.: The Ecology of Periodontal Disease, Report, of Proceedings, Workshop on Diet, Nutrition and Periodontal Disease. American Society of Preventive Dentisty, 7-27. 4-7 August, 1974. Ringsdorf. W. M.. Jr.: Unpublished data. Khosla. V. M.. and Gough, J. E.: Evaluation of Three Techniques for the Management of Postextraction Third Molar Sockets. Oral Surg. 31:189-198. 1971. Hunter. T., and Rajan, K. T.: The Role of Ascorbic Acid in the Pathogenesis and Treatment of Pressure Sores. Paraplegia 8:211-216, 1971. Burr. R. G.. and Rajan, K. T.: Leucocyte Ascorbic Acid and Pressure Sores in Paraplegia, Br. J. Nutr. 28~275-281, 1972. Taylor. T. V.. Rimmer, S.. Day, B.. Butcher. J., and Dymock. 1. W.: Ascorbic Acid Supplementation in the Treatment of Pressure Sores. Lancet 2:544-546, 1974. Afiti. A. M.. Ellis. L.. Huntsman, R. G.. and Said. M. 1.: High Dose Ascorbic Acid in the Management of Thalassaemia Leg Ulcers-A Pilot Study. Br. J. Dermatol. 92: 339-341. 1975. Elsas. L. J.. Miller. R. L., and Pinnell, S. R.: Inherited Human Collagen Lysyl Hydroxylase Deficiency: Ascorbic Acid Response. J. Pediatr. 92:378-384, 1978. Passmore. R.: How Vitamin C Deficiency Injures the Body. Nutr. Today 12:6-l I. 27-31, 1977. the
5.
26.
27.
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Reprint requests to: Dr. W. M. Ringsdorf, Jr. Department of Oral Diagnosis University of Alabama School University Station Birmingham, Ala. 35294
of Dentistry
OF
Jr., D.M.D., ORAL
M.S.,* and E. Cheraskin,
DIAGNOSIS,
UNIVERSITY
OF
ALABAMA
M.D., D. M. D., Birmingham, SCHOOL
OF
Ala.
DENTISTRY
Clinical studies provide evidence that wound healing in subjects judged not deficient in vitamin C can be significantly accelerated with supplements of this nutrient above the recommended daily allowance (RDA). The authors administered daily dosages of 500 to 3,000 mg., which is roughly 8 to 50 times the RDA of 60 mg., to subjects recovering from surgery, other injuries, decubital ulcers, and leg ulcers induced by hemolytic anemia. Genetic impairment of collagen synthesis has also been observed to be responsive to ascorbic acid supplementation in an B-year-old boy with Type VI Ehlers-Danlos syndrome. Four grams of ascorbic acid daily produced a significant improvement in the quality of newly synthesized collagen but did not alter that formed prior to the supplementation of C. The combined evidence in this review provides a substantial the interrelationships between
base for further research, vitamin C and the body’s
M any years ago Cannon’ put it superbly when he referred to the “wisdom of the body.” If the body were not wise, man could not survive. Every cell, tissue, organ, and system is programmed to heal. Every second of our lives we suffer injuries-a slight bump of the hand, the nick of the razor, carving the fingers along with the turkey, and other traumatic challenges such as major surgery. The only reason we make it is that for every injury there is a healing response. As long as the healing process keeps pace with the injuries, we remain healthy. When the recuperative capacity begins to lag behind, we become ill. When the lag is great, we die! Estimates from the 1975 National Health Survey? by the National Center for Health Statistics (Public Health Service) indicate that injuries accounted for 11.9 percent of the 1.1 billion physician visits during that year. That comes to 130,900,OOO visits (better than one out of ten), excluding those to hospital inpatients. Among all acute conditions requiring a doctor, injuries are a close second to acute respiratory problems (15.1 percent). Although these data from the 1975 National Health Survey are the latest for physician visits, more recent data from this source tabulate the number of persons injured in 197K3 During that particular year approximately 68 million persons were injured-a rate of 3 I .6 patients per 100 persons in the United States. Surgical statistics are also cited by the National Center for Health Statistics from the 1978 National Health Survey.l One or more surgical operations were performed in that year for an estimated 14.7 0030-4220/82/030231
+ 06$00.60/O
@ 1982 The C. V. Mosby
Co.
both clinical and healing potential.
experimental
trials,
concerning
million of the 35.6 million inpatients discharged from short-stay hospitals. Thus, almost one out of every two persons underwent surgery at least once while hospitalized in nonfederal short-stay hospitals during the calendar year 1978. Research evidence reveals that recovery from injury or surgery can be dramatically accelerated; in other words, recovery time can be reduced by 50 to 75 percent. All of us have experienced some inconvenience or missed out on something important because of the time required for healing. Athletic events are frequently lost because injury and the so-called normal period of recovery have prevented the winning combination of athletes from participating. There is a plethora of published proof that a deficiency of vitamin C impairs wound healing in experimental lower animals and human beings and that an excess accelerates healing above the normal level. This nutrient is unique among vitamins because it regulates the formation and maintenance of intercellular cement and collagen. Thus, the structural integrity of every tissue and organ is dependent on this vitamin. A deficit in vitamin C can, therefore, contribute to structural deterioration and/or aggravation of specific disease states of any tissue, organ, or system. A principal chemical flaw is the formation of defective collagen. This protein is a critical structural ingredient of blood vessels, the fibrous tissue in scars, and the matrix of the hard tissues (bone, cartilage). From studies on healthy adults eating a 231
232
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and Cheraskin
vitamin C-deficient diet (5 to 10 mg. daily) for periods up to 7 months, investigators have concluded that wound healing is dramatically delayed when there is a deficiency of vitamin C. They have also noted that the tensile strength (resistance to being torn open) of healing wounds in these subjects was decreased 50 to 60 percent when compared to control wounds.;-h Although most health professionals and nutrition specialists hold the opinion that diet supplies all the needed vitamin C, the published evidence concerning the effect of dietary supplementation upon wound healing indicates that an additional intake is very desirable. Even though the material in this article is limited to evidence from human studies, two reports of enhanced wound healing in lower animals are worthy of special mention. Collins and co-workers!’ graded gingival wound healing in days following a deliberate and standardized wound in twelve guinea pigs (three groups of four each) subsisting on a vitamin C-deficient diet. In the group with no supplement, the average healing time was 16.7 days. In a second group receiving injections of 2 mg. vitamin C per day (almost four times the amount reported to prevent scurvy), the wounds healed in 12.0 days. The third group of guinea pigs was injected with ten times this amount, or 20 mg. of vitamin C daily. Further acceleration of wound healing decreased their mean healing time to 8.0 days. Thus, supplementation with vitamin C above the daily requirement for guinea pigs significantly enhanced their wound-healing potential. Pfister and co-wokerslO-l” have proved that vitamin C helps burned eyes heal without serious complications. These researchers conducted double-blind experiments with rabbits to determine if vitamin C reduces or prevents cornea1 ulceration and perforation following a controlled caustic burn with sodium hydroxide. Administration of 1.5 Gm. of ascorbic acid daily or instillation of 10 percent ascorbic acid drops each hour for 14 hours per day dramatically reduced these complications by accelerating the healing potential. (It should be mentioned that the 1.5 Gm. of ascorbic acid given to rabbits averaging 6% pounds would be the equivalent of a 150 pound human being getting 35 Gm. of vitamin C daily!) The National Eye Institute is now conducting a study of eye burn patients in several research centers across the United States.‘j These patients will receive vitamin C, both orally and topically. From the existing information, the results should be exciting!
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On the basis of the lower-animal experiments by Pfister and his co-workers, it is anticipated that the megadosage of vitamin C will accelerate new collagen formation considerably above the degeneration rate of damaged collagen. Although the end result of a bad burn is a scarred cornea, preservation of the anterior fluid-filled chamber back of the cornea and the lens of the eye will allow vision to be surgically restored by cornea1 transplantation. In mild or moderate burns, this treatment may prevent ulceration and allow healing of the cornea without scarring. Vitamin C therapy represents an about face in the treatment of eye burns for, in fact, the accepted treatment has been to retard, with medication, the degeneration of the damaged collagen. However, the vitamin C treatment bypasses this approach and turns toward acceleration of the formation of new and healthy collagen. RECOVERY INJURIES
FROM SURGERY
AND OTHER
A rapid utilization of vitamin C occurs during surgery and postoperatively. In a study of ten women (28 to 35 years of age) undergoing abdominal surgery, Shukla” administered 500 mg. of vitamin C daily from the first to the ninth postoperative day. (The hospital dietetic staff was instructed to refrain from serving any citrus fruit or juice during this period of time.) Between the third and sixth postoperative days, the plasma ascorbic acid level decreased sharply. From the sixth to the ninth day the decrease continued but at a less precipitous rate. Thus, during these 9 days, the plasma C level dropped from 2.6 mg. percent to 1.5, even though the patients were receiving 500 mg. of this vitamin daily. In another experiment on sixty-three surgical patients, the postoperative ascorbic acid requirements were assessed by measuring the vitamin in white blood cells (leukocytes). Irvin, Chattopadhyay, and Smythe’” found a 42 percent reduction in leukocyte ascorbic acid levels by the third postoperative day. These last two experiments suggest that during postsurgical recovery the vitamin C in the body migrates toward and concentrates in the healing site. Hunt”’ reported four decades ago that wound disruption had been reduced about 75 percent since the routine administration of ascorbic acid had been adopted for all major abdominal operations at St. Bartholomew’s Hospital in London. During the next 30 months he also observed that “leakage from suture lines has occurred in but one of a large number of operations.“‘”
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Where it was practical to do so, 1,000 mg. of vitamin C was administered orally (in divided doses) each day for 3 days prior to surgery and 100 mg. daily thereafter. When infection, gastrointestinal disease, or achlorhydria was evident, these doses were increased. The St. Bartholomew’s Hospital policy was that vitamin C should be administered: “( 1) when clean and quick healing of the wound is particularly desirable, (2) in major abdominal operations, (3) when a hollow viscus (like the stomach) has been opened, (4) when postoperative complications are anticipated, (5) when there is evidence of a nutritional deficiency, and (6) in all cases of serious injury.“16
Bartlett, Jones, and Ryan” studied the effects of dietary supplementation with 100 and 1,100 mg. of ascorbic acid daily on the tensile strength of thigh wounds in a 62-year-old man. After 10 days of healing, the higher supplementation of vitamin C produced a threefold increase in the skin and a sixfold increase in the subjacent connection tissues. This is a rather dramatic increase in tissuebreaking strength and is especially noteworthy since the man exhibited no clinical evidence of vitamin C deficiency other than a plasma ascorbic acid level of 0.09 mg. percent. Levels of 0.00 to 0.20 have been observed to be quite common in the general population. Our own assessment of fasting (no food intake for 12 hours) plasma ascorbic acid levels in seemingly healthy junior dental students over a lo-year period showed that 10 to 20 percent of each class had a blood content of vitamin C within this deficient range! Holmes17-‘R coordinated the intravenous administration of 1,000 mg. of vitamin C to patients experiencing severe postoperative shock. To use Holmes’ words, “It produced astonishing recovery.” Since loss of plasma from permeability of the vascular system can induce shock, the decrease in capillary permeability and fragility by vitamin C may serve both therapeutically and in the prevention of shock. At Holmes’ suggestion, Kuehner”-‘* of Mercy Hospital in Pittsburgh consented to extend these observations. In April, 1945, Kuehner reported to Holmes that he had administered up to 2,000 mg. of vitamin C intravenously both before and after surgery to fifty seriously ill patients. These patients had undergone major abdominal operations, such as gastric resections, complicated gallbladder and liver surgery, and rectal and bowel resections. Kuehner’s analysis of the results was as follows: “I am definitely convinced that these cases have
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made a more prompt and more vital convalescence with less serious complications or sequellae than 50 such cases which were operated on without the aid of vitamin C.” To test the effectiveness of vitamin C in accidental trauma, Kuehner supplied 500 mg. orally to injured miners as soon as possible after their accidents. Again, Kuehner was convinced of the boost in healing potential: “I am thoroughly satisfied that there is betterment in these cases as compared with similar ones not given vitamin C. When they reached the hospital we seem to be able to go ahead with vital procedures indicated more readily than when we were not using vitamin C.” Curtis of the Ohio State University School of Medicine also accepted Holmes’ suggestion to test the value of vitamin C in preparing patients for surgery.‘:. Is On April 8, 1946, he wrote Holmes: “There is now little doubt of the value of vitamin C in the prevention of shock.” To test the practicality of administering this vitamin to dental patients, Ringsdorf and Cheraskin’” designed the following experiment. A 3 min. circular plug of gingival tissue was removed from each of two healthy junior dental students who had acceptable blood levels of ascorbic acid. Each day the wounds were painted with a 1 percent solution of toluidine blue, rinsed, and then photographed. Since this dye adheres only to connective tissue. the wound size could be judged clinically and measured accurately by observing the blue circle. The daily painting, rinsing, and photographing were continued until the wound was completely covered by the gingival tissue growing in from the wound margin. Thus, the blue circle became progressively smaller and healing was judged to be complete when there was an absence of toluidine blue stain. After a 2-week rest period, a similar wound was placed in the same area (between the upper lateral incisor and cuspid) on the other side of the two students’ mouths. The only difference was that each student received, on the day of surgery and daily thereafter, 250 mg. of ascorbic acid with each meal and at bedtime. Comparison of the first (regular diet only) and second (regular diet plus 1,000 mg. vitamin C daily) healing sequences revealed a 40 percent decrease in the time required for healing with this amount of ascorbic acid supplementation. This study was repeated in another pair of students given a 500 mg. tablet of ascorbic acid with each meal and at bedtime.‘” Again the wound-healing comparisons revealed a significant acceleration of healing by vitamin C.
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Table
I. Reduction in lesion area after 1 month Group
A (placebo) (percent) 50 54 4 60 22 39 45 14 60 80
Group I
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B (ascorbic (percent)
acid)
81 72 87 87 21 90 100 100 100 100
Measured in days, healing on a regular diet with no supplement of C took 18 days. The second wound, however, under the influence of 2,000 mg. of vitamin C daily, required only 9 days for complete healing. Thus, a 50 percent decrease in the time required for oral wound healing was achieved with a daily vitamin C dosage of 2 Gm. Khosla and Gough” evaluated the management of postextraction third molar sockets with a combination of vitamin C and B complex (C-300 mg., B,- 15 mg., B,- 10 mg., B,-5 mg., nicotinamide-50 mg., calcium pantothenate- 10 mg.). The incisions in the twenty-seven control patients and in the thirty-six experimental patients were closed with black silk sutures. In addition, the experimental group received one capsule daily of the C-Bcomplex combination. When this group was compared with the control group, it was found that the experimental subjects receiving the vitamin supplement experienced less postoperative pain and an enhanced rate of socket healing. DECUBITAL
ULCERS
Pressure sores develop quite frequently in patients who are confined to bed or a wheelchair for an extended period of time. In two paraplegics whose pressure sores were biopsied before and after the administration of 1,000 mg. of ascorbic acid daily for 5 and 10 days, Hunter and RajanZ2observed a marked increase in collagen formation in the ulcers. However, there was no follow-up beyond the 5- and lo-day intervals to determine whether vitamin C accelerated the healing of these pressure sores.Although neither of the patients showed any clinical evidence of ascorbic acid deficiency, supplementation with vitamin C (seventeen-fold higher than the RDA) significantly increased collagen formation. White blood cell (leukocyte) content of ascorbic acid was found to be low (less than 15 mcg.110”
Surg. 1982
WBC) in 23 percent of the ninty-one paraplegic patients studied by Burr and Rajan.‘:’ Patients with pressure sores, however, had significantly lower leukocyte ascorbic acid levels than those without sores. Approximately three times as many of the paraplegic patients with sores had leukocyte ascorbic acid levels below 15 mcg./ 1O”WBC as compared to those free of pressure sores. Since the white blood cell content of vitamin C is considered one of the more accurate estimates of tissuecontent, seven of those with low levels (but no other clinical evidence of vitamin C deficiency) were given 500 mg. of ascorbic acid twice daily for 3 days. Biopsies before and after the supplementation showed a definite increase in collagen formation. However, as in the previous citation,“” there was no follow-up beyond the 3-day interval to determine the effect of vitamin C upon the rate of healing. To assessthe value of ascorbic acid in the healing of pressuresores,Taylor and a team of co-workers”’ conducted a double-blind controlled trial on twenty surgical patients suffering from pressure sores. Ten received tablets containing 500 mg. of ascorbic acid twice daily and ten were administered identical white tablets of inert material twice daily. The pretreatment leukocyte ascorbic acid levels were almost identical in both groups and above the lower limits of the normal range of 18 mcg.1 lO*WBC (24.0 and 22.0 mcg./lO”WBC for the placebo and vitamin C groups, respectively). After a month’s treatment, the mean level in the vitamin C-supplemented group had risen to 65.5 mcg.1 lO”WBC, while the placebo level remained at 25.8. Healing of the ulcers was assessedweekly by a photographic technique which provided the ulcer size and healing rate in square centimeters. All patients had standard hospital beds and mattresses. the same basic hospital diet, and similar local treatment of the pressure sores. Table I shows the percentage reduction in area of each lesion after one month. The average reduction in ulcer size in those receiving the placebo for a month was 42.7 percent. However, twice as much healing had occurred during this same time in the patients receiving 1,000 mg. of vitamin C daily (84 percent). These changes differed significantly when analyzed statistically (P < 0.005). In the vitamin C group four of the ulcers had completely healed before the month ended. Actually, 3 or 4 months is the usual time required for ulcers such as these to heal. The rates of healing in square centimeters per week were 1.45 and 2.47, respectively, for the placebo and vitamin C groups.
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If vitamin C induced such a dramatic acceleration in healing of pressure sores, it might play an important role in their prevention. It is possible that this scourge in confined subjects could be practically eliminated by daily supplementation with vitamin C. A recognized feature of hereditary hemolytic anemias is an increased incidence of leg ulcers. These become a therapeutic problem if they develop in patients with a mild form of thalassemia major compatible with survival into adult life. In many instances the ulcers, and not the anemia, become the major disability because of painful recurring infections. Although bed rest and antiseptic dressings to the ulcer may encourage healing, this present treatment leaves much to be desired. To determine whether orally administered vitamin C could enhance the healing of thalassemia leg ulcers, Afifi and associates”j designed a doubleblind cross-over study with 3 Gm. of ascorbic acid versus placebo daily. Eight patients with beta thalassemia major (18 to 33 years of age) were chosen from two related families. All the patients had two to four leg ulcers each for at least 2 years prior to this trial. The ulcers ranged from 2 to 4 cm. in diameter. All patients had been receiving a good mixed diet and showed no evidence of a vitamin C deficiency. During the study period, all subjects were told to continue their normal antiseptic dressing procedure for ulcer care and to continue raising their legs to a horizontal position for 14 hours each day (including sleep). This regimen was found to be compatible with the patients’ normal working and domestic life. The patients were divided into two groups of four. Group I received 1,000 mg. of effervescent ascorbic acid three times daily for the first 8 weeks and 1,000 mg. of a placebo effervescent table three times daily during the second 8-week period. Group II was given these preparations in the reverse order. During the first 8-week period, seven of the fourteen leg ulcers in the four Group I patients were completely healed and five were partially healed while the patients were receiving 3 Gm. of ascorbic acid daily. This dramatically contrasts with the fact that of the twelve leg ulcers in the four Group II patients receiving placebo tablets, only four were partially healed in the same s-week period. Statistical analysis revealed a highly significant difference in these results (P < 0.01). Group II patients, however, duiing the succeeding 8 weeks of ascorbic acid supplementation, ended the period with nine of the twelve ulcers totally healed. It is interesting that, even though the patients were on the placebo during the second 8 weeks, four additional ulcers in Group
Vitamin C and human wound healing
235
I completely healed. This is obviously a carry-over of the improved ascorbic acid status reached during the previous period of supplementation. Thus, high doses of ascorbic acid were therapeutically effective even though these patients had an allegedly acceptable vitamin C intake. These favorable results provided evidence additional to that already cited that the addition of this vitamin to the currently prescribed healing regimens would accelerate the response and significantly shorten the recovery period. GENETIC IMPAIRMENT SYNTHESIS
IN COLLAGEN
In recent years increased knowledge concerning the synthesis of collagen has generated the description of several inherited disorders of its biosynthesis. Collectively, these diseases are clinically described as Ehlers-Danlos syndrome and subclassified into at least seven types. In many inherited disorders, knowledge of the cofactor requirements for the specifically impaired enzyme reactions and the subsequent administration of pharmacologic amounts of the vitamin precursors of these active cofactors have resulted in dramatic clinical improvement. Since Ehlers-Danlos syndrome, Type VI, involves a specifically impaired enzyme which uses vitamin C as its principal reducing agent, Elsas, Miller, and Pinnell’” elected to determine if pharmacologic doses of ascorbic acid could help reverse the collagen lysyl hydroxylase deficiency. These investigators selected an 8-year-old boy with Type VI Ehlers-Danlos syndrome who had hydroxylysine-deficient collagen in his body (10 percent of normal). Without sufficient quantities of lysyl hydroxylase (only 17 percent of normal in this patient), the amino acid lysine cannot be incorporated into collagen.2i The defective collagen in this patient produced muscle weakness, lax joints, friable skin, many hemorrhagic scars, a high-arched palate, and small corneas. Throughout his life, multiple lacerations had occurred after minor trauma and the poor wound-healing capacity resulted in abnormal scar formation. Most of the child’s joints could be extended greatly beyond their normal range, and he could actually touch the tips of both shoulders under his chin. The patient’s dietary history indicated an intake of approximately 50 mg. of ascorbic acid per day over the past year, and his urinary and plasma levels of vitamin C were within the normal range of 8 to 37 mg./per day/per gram of creatine and 0.2 to 2 mg. percent, respectively. Excretion studies after a single oral dose of 4,000 mg. of ascorbic acid were similar
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to that in three control subjects. Plasma levels of vitamin C after loading also rose, similar to those in the controls. From these tests. it was concluded “that ascorbate deficiency was not present.” Over a 2-year period the investigators administered 4,000 mg. of ascorbic acid daily. This produced a significant increase in the formation of hydroxylysine and clinical evidences of improvement-better wound healing, an increase in muscle strength, cornea1 growth, return of bleeding time to normal, and an increase in pulmonary residual volume. These results suggested that the quality of newly synthesized collagen had greatly improved. No clinical change in the loose joints and friable skin indicated that incorporation of hydroxylysine into preformed collagen did not occur. This was substantiated by measurements of this amino acid in the skin. CONCLUSIONS
Clinical studies provide evidence that wound healing in subjects judged not to be deficient in vitamin C can be significantly accelerated with supplements of this nutrient above the RDA. We administered daily dosages of 500 to 3,000 mg., which is roughly 8 to 50 times the RDA of 60 mg., to subjects recovering from surgery, other injuries. decubital ulcers, and leg ulcers due to hemolytic anemia. Genetic impairment of collagen synthesis has also been observed to be responsive to ascorbic acid supplementation in an 8-year-old boy with Type VI Ehlers-Danlos syndrome. Four grams of ascorbic acid daily produced a significant improvement in the quality of newly synthesized collagen but did not alter that formed prior to the supplementation of vitamin C. The combined evidence in this review provides a substantial base for further research. both clinical and experimental trials, concerning the interrelationships between vitamin C and the body’s healing potential.
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13 14. 15.
16. 17. 18. 19.
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22.
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25. I. Cannon, W. B.: The Wisdom of the Bodv, New York, 1932. W. W. Norton Company. 2. Gentile. A.: Phvsician Visits. Volume and Interval Since Last Visit, United Siates, 1975, Vital and Health Statistics, Series 10, Data from the National Health Survey: No. 128, DHEW publication (PHS) 79-1556, U. S. Government Printing Office. 3. Givens, J. D.: Current Estimates from the Health Interview Survey. United States, 1978, Vital and Health Statistics. Series 10, Data from the National Health Survey: No. 130. DHEW publication (PHS) 80-1551. U. S. Government Printing Office. 4. Haupt, B. J.: Utilization of Short-Stay Hospitals. United States, 1978, Vital and Health Statistics, Series 13, Data from
National Health Survey: No. 46, DHEW publication (PHS) 80-1797. U. S. Government Printing Office. Bartlett. M.. Jones, C. M., and Ryan, A. E.: Vitamin C and Wound Healing. II. Ascorbic Acid Content and Tensile Strength of Healing wounds in Human Beings. N Engl J Med. 226: 474-481, 1942. Boume. G. H.: The Effect of Vitamin C on the Healing ofWounds. Proc. Nutr. Sot. 4:204-216. 1946. Schwartz. P. L.: Ascorbic Acid in Wound Healing-A Review. J. Am. Diet. Assoc. 56:497-503, 1970. Wolfer. J. A.. Farmer, C. .I.. Carroll, W. W., and Manshardt. D. 0.: An Experimental Study in Wound Healing in Vitamin C Depleted Human Subjects, Surg. Cinecol. Obstet. 8&l-15. 1947. Collins, C. K., Lewis. A. E.. Ringsdorf. W. M.. Jr., and Cheraskin. E: EfTect of Ascorbic Acid on Oral Healing in Guinea Pigs, Int. J. Vitam Nutr. Res. 37:492-495, 1967. Pfister. R. R.. and Paterson, C. A.: Additional Clinical and Morphological Observations on the Favorable Effect of Ascorbate in Experimental Ocular Alkali Burns, Invest. Ophthalmol. Vis. Sci. 16:478-487. 1977. Pfister. R. R.. Paterson. C. A., and Hayes, S. A.: Topical Ascorbate Decreases the Incidence of Cornea1 Ulceration After Experimental Alkali Burns. Invest. Ophthalmol. Vis. Sci 17:1019-1024. 1978. Levinson. R. A.. Paterson. C. A.. and Pfister. R. R.: Ascorbic Acid Prevents Cornea1 Ulceration and Perforation Following Experimental Alkali Burns, Invest. Ophthalmol. Vis. Sci. 15:986-993. 1976. Medical News: Vitamin C May Enhance Healing of Caustic Comeal Burns. J.A.M.A. 243:623, 1980. Shukla. S. P.: Plasma and Urinary Ascorbic Acid Levels in the Postoperative Period, Experientia 25:704. 1969. Irvin, T. T.. Chattopadhyay, D. K.. and Smythe. A.: Ascorbic Acid Requirements in Postoperative Patients. Surg. Ciynecol. Obstet. 147:49-55. 1978. Hunt. A. H.: The Role of Vitamin C in Wound Healing, Br. J. Surg. 28:436-461. 1941. Holmes, H. N.: Shock. Science %:384-386. 1942. Holmes. H. N.: The Use of Vitamin C in Traumatic Shock. Ohio State Med. J. 42:1261-1264. 1946. Cheraskin, E.: The Ecology of Periodontal Disease, Report, of Proceedings, Workshop on Diet, Nutrition and Periodontal Disease. American Society of Preventive Dentisty, 7-27. 4-7 August, 1974. Ringsdorf. W. M.. Jr.: Unpublished data. Khosla. V. M.. and Gough, J. E.: Evaluation of Three Techniques for the Management of Postextraction Third Molar Sockets. Oral Surg. 31:189-198. 1971. Hunter. T., and Rajan, K. T.: The Role of Ascorbic Acid in the Pathogenesis and Treatment of Pressure Sores. Paraplegia 8:211-216, 1971. Burr. R. G.. and Rajan, K. T.: Leucocyte Ascorbic Acid and Pressure Sores in Paraplegia, Br. J. Nutr. 28~275-281, 1972. Taylor. T. V.. Rimmer, S.. Day, B.. Butcher. J., and Dymock. 1. W.: Ascorbic Acid Supplementation in the Treatment of Pressure Sores. Lancet 2:544-546, 1974. Afiti. A. M.. Ellis. L.. Huntsman, R. G.. and Said. M. 1.: High Dose Ascorbic Acid in the Management of Thalassaemia Leg Ulcers-A Pilot Study. Br. J. Dermatol. 92: 339-341. 1975. Elsas. L. J.. Miller. R. L., and Pinnell, S. R.: Inherited Human Collagen Lysyl Hydroxylase Deficiency: Ascorbic Acid Response. J. Pediatr. 92:378-384, 1978. Passmore. R.: How Vitamin C Deficiency Injures the Body. Nutr. Today 12:6-l I. 27-31, 1977. the
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Reprint requests to: Dr. W. M. Ringsdorf, Jr. Department of Oral Diagnosis University of Alabama School University Station Birmingham, Ala. 35294
of Dentistry