Establishment of Dental Health

Establishment of Dental Health in People Afflicted with Dental Diseases

By Milton Theo. Hanke, Ph.D.

Chicago, III.

            Most people are, or have been, afflicted with some dental disease. The dental perfection, discussed in the first paper of this series, is an entirely feasible theoretical possibility; but life and people being what they are, it is something that we can hardly hope to attain en masse. I’ll health, either general or dental, is not entirely a matter of diet; but it is very generally recognized that food is highly important. We will not attempt to discuss the relation of diet to dental health in children, or in those adults who have not had a particularly auspicious start in life.

To the best of our present knowledge, no food constituent has a specific effect upon any oral disease. Its only function is to supply materials from which healthy body tissue can be produced; and these healthy tissues automatically liberate energy, destroy poisons (when possible) and overcome infection.

Numerous dietary suggestions have been made, and each author feels certain that his particular food regime is most valuable; yet a careful consideration of these various diets shows that they are essentially identical and differ only in detail. After prolonged experimentation with a diet, which will be outlined, we have become convinced that it is effective in combating or preventing certain dental disorders.

The Dietary Essentials

We have usually not made detailed dietary recommendations, except to insist upon the inclusion of certain foods that appear to contain the essential constituents for dental health. Other foods may be eaten, as a matter of course, and we have not restricted the diet, except as stated. The following foods are those suggested:

1 –Eight ounces of orange juice and the juice of ½ lemon once or twice daily, depending upon the age and the gingival condition of the patient. Pubescent children, pregnant women and all who have a marked tendency toward gingivitis should receive 16 ounces of orange juice (or its equivalent in ascorbic acid in some other food). Patients with an acute ulcerative gingivitis receive a quart of orange juice, the juice of 2 to 4 lemons and 3 eggnogs a day for ten days or until the cute condition has subsided.

2 –Eight to 32 ounces of milk. (Children take 32 ounces readily, while adults have usually to be persuaded to take as much as 8 ounces.)

3 –One or 2 eggs. Adolescent children and pregnant women receive 2 eggs.

4 -0.25 to 0.50 head of lettuce or its equivalent in leaf lettuce.

5 -0.5 lb. of fruit in addition to orange juice.

6 -0.8 to 1.0 lb. of vegetables. It is best to have 2 to 4 different vegetables each day.

7 –About 0.25 to 0.5 lb. meat once or twice a day (Cooked weight.) Children appear and act healthier whey they receive meat twice a day. The direct effect of meat upon dental conditions has not been determined.

8 –Specific recommendations are usually not made with regard to butter, but most Americans obtain from 1.5 to 2.0 ounces per day, which seems sufficient.

9 –Special products rich vitamins A and D, although they have usually not been recommended, have frequently been used. Such additions appear to be of some value, especially in children.

10 –Calcium phosphate (dibasic) has been used in the case of six pregnant women (3 grams per day). These are the only cases, out of 18 studied, in which the calcium and phosphorus content of the blood serum remained normal during the eight month of pregnancy. This would appear to be particularly valuable in such cases.

Results of Treatment

ACUTE ULCERATIVE GINGIVITIS : also called “trench mouth” or Vincent’s infection:

Sufferers will usually be found, when the history is obtained, to have been subjected to some devastating physical or nervous strain that has materially lowered their non-specific resistance to infection. In combination with this, they have also, invariably, been subsisting on a diet containing little or no antiscorbutic food. The administration of a quart of orange juice and 3 eggnogs a day, leads to some improvement in 3 days; the ulcers and the fetid breath have usually disappeared at the end of the fifth day; most of the swelling and redness are gone on the seventh day and the gingivae are at least as normal as they were before the attack, on the tenth day. Eggnogs are apparently not essential for the healing of the gingivae, but they aid in nourishment, thus hastening the general recovery. The eggnogs are of value as well, in that, by temporarily coating the sensitive oral tissues, they lessen the discomfort caused by the acid citrus fruit juice. Bouillon and a mush of finely hashed meat or of cooked cereals are also of value in restoring body strength. The condition responds to treatment quite as if it were a form of scurvy. None of our test cases have received any dental treatment during the acute period; but such treatment is undoubtedly of value.

GINGIVITIS. T he more common types of gingivitis are quite general and are to be found in 80-95% of Americans. Some source of local irritation, such as calculus, plaques, materia-alba, malocclusion of faulty dental restoration is usually present, and although the removal of the local irritant frequently leads to a disappearance of the gingivitis, there are cases in which the inflammation persists in spite of the most careful search for and removal of local irritants. There are others in which the inflammation can not be associated with any definite local irritant. The addition to the diet of a pint of orange juice (or the equivalent amount of certain other antiscorbutics such as tomatoes or cabbage) usually leads to a prompt disappearance of the gingivitis when local irritants are absent, or in those cases that do not respond otherwise. Administration of antiscorbutics is practically always of value in the treatment.

If the tissues fail to improve in 30 days, it usually signifies that some undiscovered local irritant is still present. In other cases the inflammation may disappear even though local irritants are obviously present, and are not removed. There are still other cases in which the gingivitis persists regardless of the diet; some antiscorbutic foods are actually conducive to gum inflammation in patients who are allergic to their proteins. Recent observations on a few people indicate that fish oil concentrates, rich in vitamin A, are of considerable value in combating gingivitis.

Diet in Healing

An important contributions to our knowledge of the role of diet in healing has recently been made by Molt (1). He cites cases of osteomyelitis and bone fractures in which the ultimate healing was perceptibly stimulated by ingestion of a diet similar to that outlines above. He particularly stresses the value of vitamin C as an aid in preventing or overcoming the dry socket which sometimes follows an extraction. He says “The susceptibility of certain patients to the occurrence in the same patients, no matter how long the interval between operations, called for questioning as to diet. The frequency with which these patients reported that because of some ailment, real or imaginary, they could not or would not take orange juice or eat any fresh fruits or vegetables was striking. Determination of blood phosphates and calcium showed a normal level. On my own responsibility or with the physicians sanction these patients were given a diet excessive in vitamin C, but otherwise balanced, with immediate and eminently satisfactory healing results. It has routine, therefore, to suggest the addition of from a pint to a quart of orange juice daily as a post extraction measure and dry sockets are a very infrequent occurrence.”

PYORRHEA OR SUPPURATIVE PERIODONTITIS. Success in the treatment of this disease depends largely upon the skill of the dental in removing the deposits and sources of trauma and in establishing drainage. Although no single dietary constituent has been shown to be most important in combating this disease, the ingestion of a liberal diversified diet containing the “essentials” listed above had led to an apparent cure in some cases, that without this dietary help, had become slowly worse over a period of years.

The most discouraging cases are those in which there is a slow, progressive destruction of absorption of the alveolar crest with a progressive loosening of the teeth. These may be cases in which the alveolar bone is imperfectly calcified, due possibly to faulty diet during the growing period, yet in view of the fact that May Mellanby (2) observed the absorption of imperfectly calcified alveolar crests and the development of pyorrhea in dogs even though the diet, in later life, was adequate, it would seem that diet can be of little value in this condition. Studies on humans have shown, however, that it is possible (at least in some cases) to arrest the progressive bone absorption, to overcome the infection in the periodontal membrane and to tighten the teeth sufficiently so they become serviceable by using the diet listed above as an adjunct to capable dental care. The gum tissue becomes quite healthy, and the patient may go on for years. With no apparent distress. However, there is nothing positive about this apparent cure, and any condition that tends to undermine the person’s general health, may re-establish the pyorrhea in spite of diet and dental care. The action of diet, in this condition, appears to be indirect. Diet is effective, if and when it tends to improve the general health of the patient. It appears never to accomplish a regeneration of the alveolar crest (which also checks perfectly with May Mellanby’s studies in dogs). The improvement is in the health of the soft tissues.

DENTAL CARIES. There is no good evidence, up to the present time, that any one dietary constituent is most important in combating this disease, although it is generally conceded, by those who have conducted studies in this field, that diet is of some value. The diet listed above gives as satisfactory results as any other. Even though reports regarding the effectiveness of diet in arresting caries vary considerably, it is probably safe to say that not over 50% of people will be benefited. This is a proportion worthy of respect, yet observation has  shown that factors other than diet operate in this disease.

Dental caries is a simple disease, the essential characteristics of which were discovered at least 50 years ago. It consists of a decalcification of enamel or dentine and the decalcifying agent is present in the oral cavity. Decalcification of the teeth occurs only in regions of stagnation.

It is rather important, therefore, that we know the nature of the decalcifying agent. This is usually said to be an organic acid which is produced by the action of bacteria on carbohydrate. The only other decalcifying agent with which we are now familiar and which could occur in the oral cavity is the enzyme phosphatase. There is no evidence that phosphatase occurs in the saliva in significant amounts or that it is operative at the normal salivary pH. There is no abundant evidence that the oral cavity always contains microorganisms that are able to produce acids from carbohydrate; but the actual existence of destructive amounts of acid in a cavity or on a tooth has not been demonstrated. This is surprising in view of the fact that the inorganic in the tooth neutralize the acid quite promptly. It will probably not be possible, for this reason, to actually demonstrate the presence of more than traces of acidity in a cavity or, in fact, in most of the regions of stagnation.

Caries Associated with Plaques

Since the tissue of Williams and Black, dental caries has been definitely associated with a deposit on the teeth that is commonly called a plaque. The nature of this deposit and ways for removing it we will discuss elsewhere; but the important fact in this connection is that the plaque may contain considerable free acid. A solution of dichlorophenol red promptly turns yellow when applied to most plaques and this is especially true in the regions bordering on the interproximal spaces. This proves that the plaque may be acid in reaction (pH below 6.0) and serves as an added support to the chemico-bacterial theory of dental caries.

A property of the plaque which has, apparently, been overlooked is its ability to absorb and retain large amounts of sugar. Plaque material removed from the carious teeth of children 15 to 30 minutes after a piece of hard candy has been removed from the mouth, was so impregnated with sugar that it could not be dried on a glass slide until after it had been washed with water. The material, in one of these cases, had a rancid odor and a pH below 5.0 (estimated colorimetrically with methyl red). In this way it has been possible to demonstrate the persistent presence of carbohydrate, and the presence of sufficient acidity, in plaques on human teeth to decalcify enamel.

Since the decalcifying agent responsible for dental caries appears, then, to be acidity, we have next to consider why some people are immune and other are susceptible to dental caries.

People who are immune to dental caries must either have mouths free from regions of stagnation teeth free from plaques or some unusually efficient mechanism for neutralizing acidity. The teeth of immunes are, as a general rule, very regularly spaced and the occlusion approaches the ideal. The regions of stagnation are less numerous than in the case of mouths with a faulty occlusion and irregular dentition. Plaques, however, occur quite as frequently and readily on the uncared for teeth of immunes as of any others, so the opportunity for acid production on the surfaces of such teeth is good. The difference between immunes and susceptible must, therefore, be chiefly a difference in the ability of these two types to neutralize dangerous amounts of acidity.

A recent study by our group (3) shows that people who are immune or temporarily not susceptible to dental caries, secret an alkaline, well buffered saliva that can neutralize considerable acid before the hydrogen ion concentration becomes sufficiently great to dissolve dental enamel. The pre-breakfast or early morning saliva from people who are susceptible to dental caries is poorly buffered. Comparatively little acid is required to raise the hydrogen ion concentration of such saliva to a value that will attack dental enamel. Persons immune to dental caries therefore secrete a good quality saliva that neutralizes acidity produced in plaques and in other regions of stagnation before a sufficient concentration of hydrogen ions can develop to decalcify enamel.

The possible role of diet in arresting dental caries can now be rationalized. The diet will lead to an arrest of caries if it produces a metabolic change such that the saliva becomes highly buffered; which suggests immediately that the alkalinizing foods should be most effective. This is, indeed, the contention of Martha Jones (4) and others; and it may be true. We must remember, however, that metabolism can be affected by many substances and should come to no definite conclusions until further studies have been made.

It is also a fact that a strongly alkalinizing, highly vitaminized diet does not lead to an arrest of dental caries in all cases. One such refractory person has continued to secret an acid, poorly buffered, pre-breakfast saliva in spite of the fact that he has eaten the above prescribed diet for eight years and has, for nine months, been also ingesting 18,000 units of vitamin A and 3,000 of vitamin D. No dietary regime will prevent or arrest dental early in all cases; but the possibility of benefiting 50% or our American children makes it desirable that this information be given out. Other methods for controlling dental caries in people who do not respond favorably to diet are now available and will be discussed elsewhere.

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BIBLIOGRAPHY

1 –Molt, Frederick F. “Diet as a Factor in Healing Jour. Am, Dent. Assoc. 23 (1442-6) 1936.

2 –Mellanby, May, “Diet and Teeth”, An experiment study, Parts I and II, Special Report Series No. 140 (1929) and No. 153 (1930), Medical Research Council, London.

3 –Hanke Milton T. and The Chicago Dental Research Club, “The Buffer Value of the Saliva and its Relation to Dental Caries”, Dental Digest -1937.

Note to editor –This paper is supposed to appear in the May, 1937, issue. Kindly till in the page numbers and the volume number when the article appears.

4 –Jones, Martha R. “Our Changing Concept of an Adequate Diet in Relation to Dental Diseases”. Dental Cosmos LXXVII, 538-49, 651-63 (1935).

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