Vitamin D, Calcium and Phosphorus in the Prenatal Diet (Part II)

By S. M. WENGER, B. S., and R. L. HOESLY, B. A. of The Wisconsin Alumni Research Foundation

“For Every Child a Tooth” –that was the adage of our grandmothers and our mothers! To them the loss of teeth following the birth of their children was the natural course of events. Every woman when she assumed the responsibility of bearing children took upon herself the added burden of knowing that her teeth would suffer.

What a revelation it is to the modern mother to know that she can, despite hereditary factors, influence to some extent at least, the soundness and health of her child’s teeth and help to protect her own as well.

Our grandmother’s pregnancy was a secret between herself and her physician. The modern mother, who is “infanticipating” calls upon her Dentist’s aid as well as that of her Physician.

Increased attention to this problem is justified when one learns that the incidence of Dental Caries among school children of this country, according to a report of the White House Conference, is 95 per cent. Thus the care and preservation of children’s teeth becomes the responsibility of not only the Dentist, but also of the Obstetrician and the Pediatrician.

This responsibility becomes a definitely marked one since today the diet theory is accepted as of major importance in the building of sound teeth. As recently as a decade and a half ago, this problem was just becoming important. This is evidenced by McCollum when he stated, “It is said that the alarming prevalence of dental malformation and decay in American children is due to faulty nutrition before birth and during infancy and childhood”.

Eating for Two

Our grandmothers struggled under the false idea that a mother-to-be must eat for two-literally. Modern mothers eat for two-not in quantity-but rather in quality. They, unlike their ancestors, will not have their bones and teeth ruthlessly robbed by nature for the benefit of the youngster.

It would have been a fallacy of asinine proportions for our mothers even, to believe that the teeth of their unborn children were beginning to form approximately six weeks after conception and that they would continue to develop for about twenty year.

Modern mothers know, without having to see the actual visible proof that every normal child is born with a complete set of baby teeth. These teeth can’t be seen, it is true, but they are there, formed from the materials made available, and ready to force their way through the gums. Hence the increasing attention paid to prenatal care.

Importance of Oral Cavity to Health

Earnshaw says that “of all the organs in the body, none is so frequently the subject of disease as the organ of mastication.” He further states that dental decay is almost wholly dietetic in origin. This theory is true to an extent since we have shown in our preceding article that the nutritional element is one of the most important of all factors responsible for dental caries.

Earnshaw believes that diet influences dental disease in two ways, first in a general way by providing or failing to provide all the building materials in satisfactory amounts, and secondly by the local action of food in a direct attack upon the structure of a tooth or due to too little mastication with resulting decay from disuse. These factors were also discussed in our preceding article.

In another instance Earnshaw cites the examination of infants whose teeth have decayed almost as soon as they erupted. That is long before any local action of the diet could have brought about decay. In these cases, he concludes that it is the mother’s diet which is defective since the influences favoring the formation of good teeth must operate during intrauterine life.

Roberts believes that it is agreed by all that during the developmental period, nutrition is of paramount importance in building well-formed teeth and jaws and likewise their supporting tissues. She thinks it obvious that the mineral salts, especially calcium and phosphorus, must be supplied during this period in ample amounts together with an abundance of the calcifying factor, Vitamin D.

Queensland School Survey

Haenke shows this influence very definitely in a survey made in a Queensland, Australia, school in 1929. Among the entrants at this school the percentage of sound mouths increased over a period of years from 3-8 per cent to 10-18 per cent following prenatal diet instructions to mothers.

In their experiments on rats, Sontag, Munson and Huff found that a deficiency of calcium and phosphorus, the tooth and bone building minerals, in rats is capable of producing a deficiency of these substances in the young born of them. Abnormalities of the Vitamin D content –the third factor most important in building sound teeth –in the same effect on the offspring of these rats as such a diet would have if administered directly to young rats. In other words their experiment indicated that fetal mineralization is not independent of mineral metabolism of the rat mother.

Osteomalacia in China

In view of the fact that teeth are formed of the same materials as bones, it is interesting to note the studies of osteomalacia and to see its close relationship to dental caries.

Osteomalacia is best described as a disease resulting in the softening of the bone from lose of its earthy constituents. It occurs chiefly in adults, especially in pregnancy.

It is therefore definitely a deficiency disease, the principle lack, according to Maxwell et al, being in a shortage of mineral content and the activator for calcium metabolism.

Maxwell and Miles, after a thorough study of osteomalacia in China, found that there were definite changes in the skeletal system of two out of three fetuses born, by Caesarian section, from mothers who were suffering from this disease.

According to their report, the bones of these fetuses showed curious changes about the ends of some of the bones. The main change was indicated in the apparent cupping of the ends of long bones which appeared decidedly rachitic.

Sweet-Sour Spare Ribs for Calcium

It is interesting to note in this connection that an old established and highly esteemed oriental custom consists in providing pregnant and nursing mothers with a special dish called Sweet-Sour Spare Ribs. It is prepared by breaking the rib bones into small pieces and cooking them with more or less of the adherent meat in sweetened vinegar. An analysis of this dish has indicated that a single serving supplies as much calcium as the estimate of an American’s daily needs.

Rickets is of course closely allied with osteomalacia in that these two diseases are both the result of a diet deficient in calcium, phosphorus and Vitamin D. It seems quite apparent that, while one of these factors –Calcium-Phosphorus-Vitamin D- may each ahve some specific effect on osteomalacia, rickets or dental caries individually, sufficient amount of all three are necessary in order to build strong bones and sound teeth. They each represent one side of a triangle which cannot be geometrically complete unless all three sides are present.

During pregnancy a woman requires extra supplies of calcium, phosphorus, iron and the different vitamins in order to meet the needs of the fetus. If she has a generous diet, all is well, but it happens too frequently that the diet she is taking is not sufficient for her own daily needs and those of the fetus too. Then nature is obliged to call upon the mother’s reserves and when these are depleted, then symptoms show themselves.

Netherland Maternal Mortality Lowest

In study of mothers in lower economic strata in England, Balfour found many living on bread and tea and saving pennies to buy cakes and meats for the rest of the family. Most of these cases upon nearing the end of pregnancy showed septic mouths full of carious teeth. He noted likewise that in certain sections of the United Kingdom where maternal nutrition is lowest, maternal mortality is most marked. Comparing the situation in England and Wales with that in France, the Netherlands and other European countries, Balfour concludes that “It appears that the Netherlands, the national diet of which is rich in Vitamins A and D, has a definitely lower maternal mortality than the United Kingdom.”

Quigley contends that something has happened to food within the last 50 years and that with this happening has come an increase in tooth pathology, diabetes, heart disease and obstetrical mortality.

And well formed is his opinion when he cites that in 15 years, Caesarian section in New York City alone has risen from 0.2 per cent to 2 per cent –an increase of 1000 per cent –due primarily to obstetrical difficulties resulting from rickets which led to the lack of normal bone development. This problem is of course one which must be dealt with in infancy and before birth. A narrow-pelvised female will never become normal. Hence the proper care of growing girls will result in better mothers 20 to 30 years hence.

In discussing the harm which will come to both mother and child due to a deficient diet, McLester states that the “Vitamin shortage in the diet of the mother will bring disaster to the offspring.” He maintains that an adequate supply of vitamins and mineral matter in the food of the mother is the best insurance for good teeth in the offspring.

It is a recognized fact that Vitamin D influences calcium and phosphorus metabolism. In optimum amounts it allows for greater absorption of calcium.

A deficiency of Vitamin D creates a negative calcium balance with decalcification of bone and, according to Conn et al, is no doubt a definite factor in the later mal development of primary and permanent teeth.

Vitamin D Needed as Calcium-Phosphorus Activator

Reed ably states the same idea when he says, “From the data thus far presented, it does not seem unwarranted to assume that dental caries is due primarily to a deficiency in the blood of calcium or phosphorus or both, or to an inadequate utilization thereof owing to the absence of Vitamin D which leaves the teeth unprotected.” He concluded from numerous investigations that dental caries, whether associated with pregnancy or not, is due to dietary conditions wherein a deficiency of Vitamin D and calcium is the most conspicuous factor.

It is Stone’s definite feeling, after several studies, that since a considerable degree of calcification of the teeth takes place before birth, it seems that the mother’s diet and health would have a definite effect on their structure and their later resistance to decay.

According to Sherman, Vitamin D seems to have an important relation both to the development of the teeth and the maintenance of their soundness in later years.

It is a well known fact that supplying calcium in cases where a deficiency is known does no good without the addition of Vitamin D as well. Without the Vitamin D as an activator the calcium passes through the body unused. Chapman expresses this idea when he says, “The lack of Vitamin D causes rickets, bowlegs, knock knees, decayed teeth, etc… It is no use drinking milk to get lime if you have not enough Vitamin D intake to fix it.”

Danforth likewise states that a lack of Vitamin D results in deficient calcification causing the production of soft fragile bony structure. He says Vitamin D exerts a definite effect upon calcium and phosphorus absorption and for this reason he recommends an adequate supply for the pregnant woman.

Studies in Calcium-Phosphorus Storage

The adequacy of calcium storage, according to Dutta, depends on a sufficient supply first of calcium and phosphorus and second of Vitamin D. He considers the latter essential for the absorption of the two minerals calcium and phosphorus from the bowel and hence normal calcification of the bones. Dutta further maintains that a deficiency of Vitamin D will interfere with the calcium phosphorus storage by the mother and its utilization by the fetus. He consequently says, “The foetus is a parasite and if it does not get its share, it will rob the host to get its own and consequently calcium will be depleted from the system of the mother and the latter will suffer from decalcification, the effects depending upon the degree of depletion.”

In experiments on rats in which large doses of Vitamin D were given in a deficient mineral diet during gestation, the calcium-phosphorus content of the offspring was raised over that of rats born of mothers on the same diet without Vitamin C.

A group of pregnant women who participated in a study by Toverud and Toverud at the University of Norway Medical and Dental Clinic showed increases in the retention of calcium following the addition of Vitamin D in the form of cod liver oil to their diets.

Examination of children from mothers who had lived on a minimum amount of milk (below