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Local and Systemic Influences in Periodontal Disease: IV. Effect of Prophylaxis and Natural Versus Synthetic Vitamin C Upon Clinical Tooth Mobility
Published in International Journal of Vitamin Research, Vol. 34, No. 2, pp. 202-218, 1964.
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Introduction
In previous papers the effect of synthetic vitamin C with or without bioflavonoids and natural vitamin C concentrate plus bioflavonoids upon the gingival and sulcus depth scores were considered (El-Ashiry et al., 1963). Available reports in the literature indicate a possible effect of vitamin C deficiency upon tooth mobility, in both lower animals and in the human. Hence, it was thought advisable to study the effect of the various therapeutic regimes upon clinical tooth mobility.
Review of the Literature
Lower Animal Studies: Loosening of the teeth has been recognized for centuries as a cardinal scorbutic sign (Boyle, 1951). In experimental animals the long continued administration of diets containing minimal amounts of ascorbic acid but otherwise adequate has caused tooth mobility (Boyle, 1941). The loosening is believed to result from breaking of the collagen fibers in the periodontal membrane. With administration of vitamin C to the deficient animals, repair takes place rapidly so that, within about a week, the teeth become firm. Increased tooth mobility in monkeys has been produced with vitamin-C deficient diets (Waerhaug, 1960). Concomitant with the loosening of the teeth, the gingiva became flabby with ready bleeding. Apparently, the increased tooth mobility is facilitated by the generalized destruction of the collagen of the periodontal membrane and resorption of the inner surface of the alveolar wall.
Human Studies: Among the diverse manifestations of vitamin C deficiency, increased tooth mobility has been described (Harris, 1955; Chambers, 1959). The afflicted collagen of the periodontal fibers appears to cause widening of the periodontal space (as seen in the roentgenogram), unusual mobility and eventual loss of teeth (Tillman, 1961). In isolated reports, the increased mobility of the teeth has been associated with low plasma ascorbic acid levels (Weisberger 1938; Harris 1955).
Method of Investigation
One hundred and two subjects participated in this study. The selection was as random as possible from volunteers at the University of Alabama Medical and Extension Centers and from the Birmingham Fire Department. Table 1 shows the patient distribution in terms of age and sex.
All subjects reported to the Department of Oral Medicine following a 12 hour period without food. Upon admission, a fasting venous blood sample was drawn. The oral examination was conducted with the patient comfortably seated in a dental chair. The mouth was illuminated with a dental spotlight. In all cases the examination started in the maxillary right canine region and progressed across to the left cuspid. The same pattern was followed in the mandible. One examiner (G. M. A.) made all of the observations.
Calculus Scores: Although the quantity of calculus undoubtedly has a bearing upon the degree of pathosis, it was felt that the location of these deposits was of major importance. Hence, the evaluation was based upon whether there was an absence of calculus or whether supragingival, subgingival, or both supra- and subgingival calculus was present on each tooth examined. The inspection was done with an explorer and mirror. Compressed air was used to retract the gingiva for better detection of subgingival calculus. The legend for scoring calculus is shown in Table 2. In the individual with all 12 anterior teeth, 12 calculus scores were recorded. The individual scores were then added and divided by the number of teeth to obtain a mean value for each side of the mouth.
Tooth Mobility Scores: The clinical mobility of the 12 anterior teeth was measured with digital pressure. Table 3 outlines the tooth mobility scoring system. The individual scores were then summated and divided by the number of teeth to obtain a mean value for each side.
Measurement of Vitamin C State: The method of Mindlin and Butler (1938) was used for the determination of plasma ascorbic acid levels. The test was always done twice from equal aliquots of the same blood sample. These duplicate determinations served as a check on the accuracy of the procedure (r=+0.988, P<0.001). For the determination of tissue ascorbic acid status, the lingual vitamin C test was employed (Ringsdorf et al., 1962; 1963; El-Ashiry et al., 1963; Cheraskin et al., 1964). This is a simple procedure which involves the timing (in seconds) of the decolorization of one minim of N/300 dichlorophenolindophenol dye deposited upon the dorsum of the dried tongue. In order to evaluate the reproducibility of the test, the procedure was always performed twice. The correlation between the first and second lingual time readings was found to be highly significant (r=+0.989, P<0.001). Bioflavonoid state was not ascertained since there are no known laboratory tests.
By means of a table of random numbers the patients were arranged into two groups: (1) those to be scaled on the right side, and (2) those to receive prophylaxis on the left. Also, the patients were randomized to receive one of the systemic regimes. Thus, in terms of systemic therapy, four groups were developed. Table 4 shows the composition of the materials which were administered.
All capsules looked exactly alike. Thus, neither the patient nor the examiner was aware at any time during the experimental period which preparation was employed.
At the first visit, each patient received thorough scaling of the teeth on one side of the mouth. Jaquette and McCall scalers were employed to remove the calcareous deposits. Moistened flower of pumice was applied with a revolving rubber cup in a contra-angle handpiece to polish the accessible crown and root surfaces. Finally, dental tape and pumice were utilized to polish the interproximal surfaces of the teeth.
At the completion of the first visit each patient was instructed to take by mouth three capsules per day for three weeks. Thus, 25 subjects received a placebo, 25 were given 300 mgm. synthetic vitamin C daily, 25 were administered 300 mgm. synthetic vitamin C plus 300 mgm. citrus bioflavonoids per day, and the remaining 27 were supplemented with 300 mgm. of a natural vitamin C concentrate with 300 mgm. bioflavonoids each day.
Approximately 21 days later each of the patients returned. All participants were re-examined clinically and biochemically without reference to the earlier records or the nature of the supplementation.
Results
Pretherapy Findings: Table 5 summarizes the initial calculus scores. It is clear that about one-half of the examined areas are without calculus. The initial tooth mobility scores are also shown (Table 6). About three-fourths of the teeth examined showed no signs of clinical tooth mobility. Table 7 outlines the patient distribution in terms of the initial plasma ascorbic acid levels. It was found that the scores ranged from 0-1.38 mgm. per cent. The distribution of the initial lingual times is included (Table 8). The values ranged from 12 to 60 seconds.
A comparison of calculus and tooth mobility is pictorially portrayed (Figure 1). The overall relationship is heightened by a coefficient of correlation of +0.235 and P<0.001. Though this correlation is significant, it does not, of course, prove a cause-and-effect relationship. For example, it was noticed that some subjects with minimal calculus scores still had high tooth mobility values.
Figure 2 illustrates graphically the correlation of plasma ascorbic acid and mean tooth mobility values at the initial visit. This correlation was found not significant by statistical analysis (r=-0.101 and P>0.100). The only significant relationship of vitamin C state and tooth mobility (r=+0.241 and P<0.001) was found between the lingual times and the mean tooth mobility ratings. Figure 3 demonstrates clearly that subjects with the highest mean tooth mobility scores are associated with the longest lingual times. Quite in order, participants with the lowest mean tooth mobility ratings have the shortest lingual times. Special mention should be made that the correlation between the vitamin C status (as indicated by the lingual times) and mean tooth mobility values, irrespective of calculus state, are significant. This is what was observed earlier between calculus and mean tooth mobility (irrespective of vitamin C state).
Table 9 illustrates the pretherapy relationship of both calculus scores and vitamin C state to tooth mobility values. The chart demonstrates very clearly that the participants with the lower calculus values (0.0-0.5) and higher vitamin C levels (0.60-1.40) have the least tooth mobility ratings (0.2±0.2). Following the same pattern, those subjects with the higher calculus values (>0.5) and lower vitamin C levels (0.00-0.59) are associated with the highest tooth mobility scores (0.4±0.2). The table shows clearly that as one moves from left to right (irrespective of plasma ascorbic acid levels) the tooth mobility increases with increase in calculus values. Once again, as one proceeds from top to bottom (irrespective of calculus grade), in either column, the tooth mobility increases with the decrease in the vitamin C levels.
Though interesting, the preceding relationships do not necessarily demonstrate cause-and-effect. These correlations simply indicate that variables co-exist. To try and pinpoint possible cause-and-effect, it was felt advisable to study the tooth mobility pattern after both local (prophylaxis) and systemic therapy (synthetic with and without bioflavonoids and natural vitamin C concentrate with bioflavonoids).
Posttherapy Findings: The nature of the experimental design provided the opportunity to study the changes in tooth mobility after both local and/or systemic therapy.
Effect of Scaling: In each subject one half of the teeth was scaled at the first visit. Thus, in the placebo group, it was possible to examine the effect of the removal of calculus upon the periodontium on one side versus the untouched (nonscaled) other side of the mouth. Table 10 shows the original and mean initial and final tooth mobility scores for the scaled and nonscaled sides in those persons without systemic treatment (placebo group). There appears to be no change on the nonscaled side. However, there seems to be as approximately 5 per cent worsening in the mean tooth mobility scores following scaling. Neither of the groups was found significant by statistical analysis.
Effect of Systemic Therapy: It was also possible to evaluate the effect of altering the host without local treatment (no scaling). Table 11 includes the initial and final original and mean tooth mobility ratings of those subjects receiving systemic therapy versus placebo supplementation. There appears to be approximately a 63 per cent reduction in the mean tooth mobility values (P<0.001) in the group which was administered natural vitamin C and bioflavonoids. Those receiving synthetic vitamin C and bioflavonoids showed an improvement of 40 per cent in their tooth mobility scores (P<0001). Quite in order, the synthetic vitamin C group followed with approximately 33 per cent improvement in their mean tooth mobility values (P<0.001). Finally, the placebo group showed no improvement at all (zero per cent).
Effect of Local and Systemic Therapy: Table 12 emphasizes that the greatest improvement on a mean basis (100 per cent) occurred in those individuals subjected to prophylaxis with natural vitamin C and bioflavonoids. The same amount of reduction in the tooth mobility ratings was noticed in the scaled group with synthetic vitamin C and bioflavonoids. The next improvement (67 per cent) was shown in those participants with prophylaxis and synthetic vitamin C. Finally, those patients who were subjected to local treatment only (placebo group) showed a slight loosening of the teeth (5 per cent) on a mean basis. By statistical analysis, all individuals who were subjected to both local and systemic therapy showed a significant reduction in tooth mobility scores. In contrast, those who received only local therapy (placebo group) demonstrated slight loosening in some cases and the overall change was found insignificant statistically.
Discussion
It should be recalled that two possible factors were studied in terms of their relationship to tooth mobility. These variables were calculus representing the local problem, and vitamin C state on the systemic side. A significant relationship was found between calculus and tooth mobility (r=+0.235 and P<0.001). A slightly higher correlation (r=+0.241 and P<0.001) was found between the lingual time and tooth mobility. On the other hand, the relationship of plasma ascorbic acid level to tooth mobility was insignificant. The lack of significance between the last two variables may be due to the fact that the plasma ascorbic acid is regarded as more a function of the diet than an indication of tissue level.
More noteworthy is the relationship of the combination of local (calculus) and systemic factors (plasma ascorbic acid) to tooth mobility. Those subjects with the lower plasma ascorbic acid levels and the higher calculus values were associated with the highest tooth mobility scores (0.4±0.2). Conversely, those participants with the higher plasma ascorbic acid levels and lower calculus values showed the lowest tooth mobility ratings (0.2±0.2).
It is true that one cannot draw any cause-and-effect conclusions from these observations. These values only show that variables co-exist. However, these observations are consistent with the gingival and sulcus depth findings previously reported (El-Ashiry et al., 1963).
Figure 4 graphically depicts the percentage change in tooth mobility with the eight different forms of therapy. Table 13 summarizes the intergroup statistical significance. It is noteworthy that all nonscaled vitamin treated groups were statistically significantly different from the placebo group. However, none of the intergroup differences were significant. Table 13 also illustrates that all scaled groups were significantly different except for the change in tooth mobility in the participants supplemented with natural vitamin C concentrate versus synthetic vitamin C with bioflavonoids (100 per cent). It is clear that all groups were significantly different in terms of scaling versus nonscaling except for the change in tooth mobility in the placebo group.
Within the limits of this study, it appears that synthetic or natural vitamin C exerted a significant beneficial effect in reducing tooth mobility and this effect can be increased by adding prophylaxis and bioflavonoids.
It should be recalled that vitamin therapy was administered on a random basis. Obviously, by this technique, some of the vitamin supplemented subjects actually had satisfactory vitamin C levels at the start and therefore did not require vitamin therapy. Hence, it was thought proper to restudy the tooth mobility patterns in the subjects with the lowest plasma ascorbic acid levels and highest lingual times. For this phase of the study, the ten patients in each group with the poorest scores were selected. Figure 5 outlines the findings for the entire group (white columns) and those with the poorer vitamin C findings (black columns). The pattern of reduction in tooth mobility scores in those subjects with the poorest ascorbic acid findings followed the same pattern noticed for the entire groups. In each case there was more improvement in the relatively sicker group compared with the whole group. However, in the synthetic vitamin C-bioflavonoids and natural vitamin C concentrate-bioflavonoids (scaled) categories, there were no more reductions in tooth mobility noticed due to the obvious fact that even the entire group improved 100 per cent.
The question arises as to whether the biochemical patterns followed the clinical change. No significant change in plasma ascorbic acid levels and lingual times followed placebo therapy (P=0.504 and >0.100 respectively). On the other hand, there were significant increases in the plasma vitamin C levels following natural vitamin C concentrate with bioflavonoids (P <0.005), and synthetic vitamin C with and without bioflavonoids (P<0.001). Also all vitamin-treated groups showed significant reduction in their lingual times (P<0.001). Finally, all the three supplemented groups significantly differed from the placebo-treated subjects. All of these findings parallel the clinical findings. However, there were no other intergroup biochemical differences. It appears that the reported reduction in tooth mobility scores are in part (in terms of vitamin C state) reflected in the biochemical findings as measured by the plasma ascorbic acid levels and lingual times.
It should be recalled that the effect of these same eight different therapeutic regimes upon gingivitis and sulcus depth was discussed in earlier papers (El-Ashiry et al., 1963). Parenthetic mention should be made that there was a significant initial relationship (r=+0.448 and P<0.001) between gingivitis and tooth mobility. Also there was a significant initial correlation (r=+0.247 and P<0.001) between sulcus depth,and tooth mobility. Hence, it was advisable to compare the therapeutic effect of the eight regimes upon gingivitis, sulcus depth, and tooth mobility (Figure 6). Two points warrant particular attention. Firstly, there was more improvement in gingivitis, sulcus depth, and tooth mobility in the scaled versus the nonscaled side in those groups who received both local and systemic therapy. Secondly, the overall improvement in tooth mobility followed the same pattern that was noticed in the analysis of the gingiva and sulcus depth.
Summary and Conclusions
This study was intended to evaluate the relative effects of altering a local factor (calculus) and systemic factors (natural vitamin C concentrate versus synthetic vitamin C with and without bioflavonoids) upon periodontal pathosis (tooth mobility).
An attempt was first made to correlate tooth mobility with calculus and ascorbic acid status. The findings indicate a significant correlation between calculus and tooth mobility. Also a significant relationship was found between the lingual time and tooth mobility. A correlation was also obtained in the study of the combination of local and systemic influences. Though these relationships were all statistically significant, one cannot ascribe from these data any cause-and-effect.
To attempt possible cause-and-effect relationships, the latter phase of the study involved the appraisal of tooth mobility after the subjects received one of eight different therapeutic regimes. The treatment involved placebo versus synthetic vitamin C with and without bioflavonoids versus natural vitamin C concentrate with bioflavonoids with and without scaling of one half of the mouth.
Re-examination three weeks later showed a significant reduction in tooth mobility in those individuals subjected to both local and/or systemic therapy. However, combined therapy netted the greatest decrease in tooth mobility.
We wish to take this opportunity to thank Dr. Michael J. Walsh for supplying the placebo and vitamin C and bioflavonoid preparations.
References Cited:
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