Vitamin C Improves Tooth Cleanliness

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Vitamin C Improves Tooth Cleanliness

 

The Case of the Invisible Toothbrush: Why Some People

Can Brush Less

by E. Cheraskin, M.D., D.M.D.

 

Park Tower 904/906, 2717 Highland Avenue South,

Birmingham, AL 35205-1725.

(Reprinted with permission from the Journal of

Orthomolecular Medicine Vol. 8, No. 3, 1993)

 

Abstract

A long time ago, President Harry S. Truman was asked

the question, " What's new? " His response, " If you

never heard it before, regardless of how old it is,

it's new! " Utilizing the Truman benchmark, several

points are obvious. First, the present notion that

dental accumulations contribute to dental diseases and

that these collections can be mechanically removed is

not only old but generally conceded. What is also not

new, as far as the published literature is concerned,

is that there are nonmechanical contributions to the

common dental diseases. Many of the reports are 30 to

40 years old. Some of them are quite recent,

particularly the innovative discussions by Nigel

Clarke and his associate in Australia. However, what

is really new and emphasized in this report, is that

the accumulations in themselves may be due to the

absence of an invisible toothbrush. The whodunit may

well be hypoascorbemia! Obviously, this is a

relatively new thought and requires further study.

And, by the way, vitamin C serves many functions. It

is well-documented as an electron donor, impressive

scavenger, important in capillary fragility and

permeability, extraordinary for wound healing, and

much, much more. So, providing the ascorbates may add

a bonus to improved oral health ... by contributing to

general well-being!

 

Introduction

Apropos, there are three inescapable facts:

 

* The principal site for chronic disease is the mouth

.... even in this day an age, 95% of the civilized

population suffers with tooth decay and/or periodontal

disease.

 

* Judged by our current successes/failures, the

present explanations and solutions are filled with

contradictions (i.e. more brushing and flossing

doesn't necessarily guarantee less disease).

 

* Maybe ... just maybe ... this is all because we

haven't heeded the counsel of the experts.

 

The National Institutes of Health (NIH) (1) and other

authorities, as we shall learn, argue that oral

pathosis is a multifactorial problem. They identify

three essential ingredients: (1) a critical microbial

population, (2) an appropriate diet, and (3) a

susceptible state (Figure 1). (Incidentally, other

buzzwords are available such as resistance, tissue

tolerance, internal milieu, coping systems, immunity,

and homeostasis). And, by the way, this same chart is

just as applicable to the periodontal tissues by

simply substituting " periodontal disease " for " tooth

decay " . More importantly, in their pictorial

portrayal, they underline the product relationship. If

any of these three variables is absent, then oral

disease does not occur. Parenthetically, this has not

been translated into their arithmetic formula which

suggests that the phenomenon is additive!

 

(Figure 1 illustrates that it takes all three of these

factors ,not just one or two, for tooth decay to

occur. The source is U.S. DEPARTMENT OF HEALTH & HUMAN

SERVICES Public Health Service, National Institutes of

Health NIH Publication No. 80-1146)

 

Be that as it may, principal attention has been

devoted to the role of diet and microorganisms; only

scant attention has been accorded the

resistance/susceptibility factor. And, when it is

considered, susceptibility and genetics become

synonyms. This report is one in a series on Medical

Ignorance: Myths and Magics in Modern Medicine. It

will remind us of the role and emphasize the

measurability of tissue tolerance in oral pathosis.

Specifically, we shall devote our attention to the

question, " Can you get away with brushing your teeth

less? "

 

A Different Look at Mr. and Mrs. America

Two hundred presumably healthy middle income

Caucasians (with the usual mouth problems of dental

caries and/or periodontal disease) participated in

this study. (2) To quantitate tooth cleansing, we

choose the most simple measurable system. Each subject

was questioned regarding the frequency of

toothbrushing. It was convenient to divide the group

into those with less than twice (n 71), the 95 who

brushed twice per day, and the 34 more than two times

daily. To assess tooth cleanliness, a simple, popular,

and easy grading of foreign material, the debris

score, was utilized. Finally, as one measure of

susceptibility, the fasting plasma ascorbic acid

concentration was obtained in each of the subjects.

Our reason for using the ascorbates is based on the

observation that in some subsets of the general

population suboptimal vitamin C state is as high as

100%.(3) Additionally, we have studied vitamin C

deficiency in dental patients and discovered that up

to 72% may be hypoascorbemic. (4) By this trinity of

information, it was then possible to construct, and

hopefully respond, to three questions.

 

The Traditional Confirmation

The most often asked question is, " How effective is

toothbrushing? " In other words, " What's the connection

between debris (oral cleanliness) and toothbrushing

habits? "

 

Figure 2 shows the frequency of daily toothbrushing on

the horizontal axis and the mean debris scores on the

vertical. Three points warrant special emphasis.

First, those brushing least (black column) represent

the greatest accumulations. Second, in the group with

the most toothbrushing (white column), there is the

least amount of debris. Finally, while the correlation

coefficient is statistically significant (r = -0.265,

p <0.01), it is not perfect. This suggests the

possibility that other factors may be operative.

 

Hence, in answer to the first question, there does

indeed appear to be a convincing relationship between

tooth cleansing (tooth-brushing frequency) and tooth

cleanliness (debris score). These observations are not

surprising and support the current dental philosophy

of the importance of local and mechanical factors in

periodontal health and sickness.

 

(Comparing Figure 2 “Relationship of daily

toothbrushing frequency and debris index” with Figure

3 “Relationship of plasma ascorbic acid and debris

index” shows that vitamin C reduces tooth debris to a

similar extent that brushing does.)

 

A Second Opinion

Turn on the television and we will guarantee within

minutes news about a new-fangled vitamin-stuffed

cereal. Tune in the radio and discover that we now

have fiber in finger foods. All of this stems from the

well-established fact that vitamins and minerals

influence every cell, tissue, organ and site in the

human system. It figures, therefore, that the mouth

should also be part of the story. What is the

connection between diet/nutrition and susceptibility

to oral disease?

 

In other words, the query now to be posed is, " Can we

alter oral debris by changing vitamin state? " Our

personal experience has been quite extensive with

ascorbic acid (“AA”).(5-7). So, for purposes of this

experiment, " What is the correlation of the ascorbates

and oral cleanliness without altering the usual oral

cleansing habits? "

 

Figure 3 pictorially portrays the plasma ascorbic acid

levels on the x-axis. The 200 subjects were divided

into three near equal subsets. There were 68 with the

poorest ascorbate levels (black column) ranging from

0.0 to 0.4. Sixty-seven showed the best (white column)

vitamin C levels (0.8 to 1.3). The average debris

scores are shown on the ordinate. Three items deserve

special note. First, those with the poorest AA

demonstrate the most debris (black column). Second,

the group with the best ascorbate level (white column)

is characterized by the least accumulations. Finally,

the correlation is statistically significant (r

-0.210, p <0.01), very much like that shown in Figure

2 and also not perfect.

 

Therefore, within the limits of these data, there

appears to be a very real correlation between vitamin

C state (as a possible nonmechanical contributor) and

debris irrespective of tooth cleansing habits.

 

The Current Ecologic Thinking

What we have witnessed thus far (Figures 2 and 3) is

actually an analysis of a series of surreal events. In

the real world, people who do or don't clean their

mouth also do or don't ingest ascorbates. And so, are

the accumulations totally the result of how much one

brushes or how much vitamin C is ingested?

 

Figure 4 depicts the frequency of daily toothbrushing

on the abscissa and the average debris scores on the

y-axis. Additionally, the 200 subjects were divided

into two equal subgroups. The 100 with the relatively

poorer plasma ascorbic acid levels (less than 0.6 mg%)

are shown by the black columns; the other 100 with the

better vitamin C state (0.6+ mg%) by the white

columns. Several points warrant elaboration. In those

showing the lower (poorer) plasma ascorbic acid

scores, there's an obvious inverse relationship. In

other words, and not surprisingly, the greater the

toothbrushing frequency, the less the debris (0.87).

This has already been demonstrated (Figure 2). It is

also statistically confirmed (r = -0.337, p < 0.01).

On the other hand, it is interesting that the data

suggest that in those with relatively good AA state

(the white columns), it is not too critical how

frequently one brushes one's teeth. This is

underscored by the lack of statistical significance (r

= -0.164, p > 0.05).

 

(Figure 4. “Relationship of debris index, plasma

vitamin C and toothbrushing” shows that toothbrushing

plus high plasma ascorbic acid reduces tooth debris

more than brushing alone.)

 

Here is probably part of the explanation for the

well-known fact why some of us need brush our teeth

less than others.

 

Comments

Surely by act if not by word, the centerpiece for

stomatology is cleanness. And so, we are told that

good oral hygiene (cleansing habits) will cause good

oral hygiene (cleanliness); bad oral hygiene (poor

cleansing) will net poor cleanliness.

 

It is evident that plaque material may be removed from

the tooth surface with effective mechanical cleansing

techniques as shown in the literature (8) and earlier

in this report (Figure 2). Hence, this interface

structure may, with proper instruction, be altered

through a change in the external world (toothbrushing,

flossing, irrigation).

 

Much less clearly understood is the importance of the

inner world (gingival tissue metabolism) to foreign

and external accumulations. In the past, plaque has

been regarded as inert matter. Now it is recognized

that this so called debris is a microcosm containing

myriads of living neutrophils and other formed

elements. Its environs are remarkably similar to human

blood and tissue fluid. (9) As such, it should reflect

metabolic changes within the host tissues.

 

Viewed in this perspective, the role of the organism's

metabolic status as a possible contributor to plaque

formation becomes more understandable. The findings of

this investigation, as represented in Figure 3,

suggest that plaque is indeed also related to the

internal milieu as judged by vitamin C metabolism. In

other words, this can be viewed as a demonstration of

nonmechanical brushing.

 

These findings are consistent with other published

reports of nutrient-debris (plaque) relationships. For

example, Coven (10) has reported a significant

connection between gingival AA and debris score in

children. Another study (11) found marked differences

in foreign accumulations between Adventist and

nonAdventist teenagers. The authors concluded that

they were related to diet and not to differences in

brushing frequency. It has also been confirmed by

Mandel that the plaque represents the initial phase in

calculus formation.' (12)

 

Obviously, cause and effect can be more convincingly

imputed from clinical trials. One such study (13)

reported a resolution of materia alba, calculus, and

stain when 500 mg of ascorbic acid was daily

administered for 90 days to 35 mentally retarded boys.

Dusterwinkel et al (14) and Lane. and his associates

(15) reported reducing debris scores significantly

with multivitamin and mineral supplementation.

 

Notwithstanding, even in this day and age, it is still

generally held that the only way plaque can be

prevented from causing damage to the periodontium is

to remove it mechanically.'(16) If nutrients are

determinants of plaque, as the present investigation

and other studies suggest, this concept may be

incomplete. The need for further investigation of

nutritional approaches to oral hygiene (tooth

cleanliness) would thus seem to be appropriate.

 

A second implication arises when an attempt is made to

study the role of nutrients in the genesis of

periodontal pathosis. It is customary in evaluating

nutrients as potential etiologic factors to do so only

in subgroups having the same oral hygiene (tooth

cleanliness) and age. (18) Obviously, if oral hygiene

(cleanliness) is to some extent a function of diet, it

should not be held constant when evaluating a nutrient

as a potential etiologic factor.

 

Viewing brushing frequency-debris score relationships

as influenced by ascorbic acid status (Figure 4)

provides additional insights into plaque prevention

and control. At all levels of brushing frequency,

those with the better plasma AA levels exhibit cleaner

teeth. In fact, the average debris score (0.92) for

those who brush less than twice daily but have better

vitamin C levels compares favorably with that of the

poorer C subjects who brush twice or more daily (0.90

and 0.87).

 

The key fact underscored in this investigation is not

the existence of a particular nutrient-plaque

relationship, but the need to completely reevaluate

existing concepts of oral hygience (tooth

cleanliness).

 

The philosophic considerations and the practical

implications of the ecology of oral health and

sickness not only continues but seems to intensify.

This is superbly borne out in the citations by Nigel

Clarke and his co-worker. (19) “... Some individuals

experience severe inflammation to minimal plaque,

whereas others have minimal inflammation to heavy

plaque ... Whether these variations occur as a result

of differences in host response or in virulence of the

microbes is undetermined; however, the probabilities

point to host factors rather than to microbes ...

Periodontal disease has long been recognized as a

chronic disease, but the literature describes a

disease that is derived entirely from the effects of a

microbial colonization of the gingival crevice. If

this were so, it would mean that periodontal disease

is unique among chronic diseases, all of which

represent the long-term cumulative effects of

interaction between a host biologic system and the

surrounding environment ... Perhaps dentistry has lost

the perspective between the oral tissues and the

entire organism ... "

 

Additionally, we note from the work of these

Australian investigators of their interest in the

relationship of ecologic principles to the specifics

of oral disease. This is emphasized in the following

quotation:

 

" ... (There is a possible) causal role for the host

factors and (there is the suggestion) that the type

and severity of periodontal disease(s) are reflections

of the competence of the host defense rather than of

the virulence of commensal oral organisms ... (It can

be) postulated that chronic periodontal disease

results when environmental factors, specifically those

that compromise the peripheral blood supply, disturb

the delicate balance between host and parasite in

favor of the parasite ... "

 

Finally, the importance of ascorbates is also

emphasized as one of a number of contributing factors

to the genesis of periodontal pathosis.

 

“... It has been established that 20% of gingival

collagen is turned over daily Fibroblasts require

ascorbate to produce collagen. Hence, the high

turnover of gingival collagen probably renders

gingival remodeling and repair particularly vulnerable

to ascorbate deficiency. Vitamin C is also required by

polymorphs in their vital defense role. The phagocytic

and chemotactic functions of the white cells require

vitamin C concentration within the cell ... Although

debate continues concerning the required plasma

ascorbate levels, it appears likely that the demand

for ascorbates and essential metabolites for defense

and repair of gingival tissue may be met in the

presence of chronic inflammation, smoking, stress,

inadequate diet, aging, or any other vaso-constrictive

factors ... "

 

References

1. National Institutes of Health. Brochure No.

80-1146, Bethesda, U.S. Department of Health and Human

Services.

 

2. Clark JW, Cheraskin E and Ringsdorf WM Jr: An

Ecologic Study of Oral Hygiene. Journal of

Periodontalogy/Periodon tics 40: #8, 476-480, August

1969.

 

3. Schorah CJ: Vitamin C Status in Population Groups.

In: Counsell JN and Hornig DH. Vitamin C (Ascorbic

Acid), 1981. Englewood, Applied Science Publishers.

 

4. Cheraskin E and Ringsdorf WM Jr: Vitamin C State in

a Dental School Patient Population. Journal of the

Southern California State Dental Association 32: #10,

375378, October 1964.

 

5. Cheraskin E, RingsdorfWM Jr and Sisley EL: The

Vitamin C Connection. 1983, New York, Harper and Row

Publishers, Inc. (hardback). 1984, New York, Bantam

Books, Inc. (paperback).

 

6. Cheraskin E: The Vitamin C Controversy: Questions

and Answers, 1988. Wichita, BioCommunications Press.

 

7. Cheraskin E: Vitamin C... Who Needs It?, 1993.

Birmingham, Arlington Press.

 

8. Arnim SS: Thoughts Concerning Cause, Pathogenesis,

Treatment and Prevention of Periodontal Disease.

Journal of Periodontalogy 29: #3, 217-223, July 1958.

 

9. Amim SS: Microcosms of the Mouth - Role in

Periodontal Disease. Texas Dental Journal 82: #3,

4-10, March 1964.

 

10. Coven EM: Relationship of Vitamin C State and Oral

Health of a Pedodontic Group in a Prepayment Program.

Industrial Medicine and Surgery 24: #5, 410-4 12, May

1965.

 

11. Holmes CB and Collier D: Periodontal Disease,

Dental Caries, Oral Hygiene and Diet in Adventist and

Other Teenagers. Journal of Periodontalogy 37: #2,

100-107, March-April 1966.

 

12. Mandel ID: Histochemical and Biochemical Aspects

of Calculus Formation. Periodontics 1: #2, 43-52,

March-April 1963.

 

13. Cohen MM: The Effect of Large Doses of Ascorbic

Acid on Gingival Tissues at Puberty. Journal of Dental

Research 34: #5, 750-751,October 1955.

 

14.Dusterwinkle S, Cheraskin E and Ringsdorf WM Jr:

Tissue Tolerance to Orthodontic Banding: A Study in

Multivitamin-Trace Mineral Supplementation. Journal of

Periodontalogy 37: #2, 132-145, March-April 1966.

 

15.Lane WB: Nutrition and Oral Response to Orthodontic

Banding. University of Alabama School of Dentistry

Thesis, August 1968.

 

16. Waerhaug J: Current Basis for Prevention of

Periodontal Disease. International Dental Journal 17:

#2, 267-281, June 1967.

 

17. Greene JC: Oral Health Care for the Prevention and

Control of Periodontal Disease - Review of the

Literature. World Workshop in Periodontics 1966. Ann

Arbor, University ofMichigan Press, pp. 397-455.

 

18. Waerhaug, J: Epidemiology of Periodonal Disease -

Review of the Literature. World Workshop in

Periodontics 1966. Ann Arbor, University of Michigan

Press, pp. 181-222.

 

19. Clarke NG and Carey SE: Etiology of Chronic

Periodontal Disease: An Alternative Perspective.

Journal of the American Dental Association 110: #5,

689-691, May 1985.