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In an earlier report,1 it was shown that a significant decrease in sulcus depth scores followed a relatively low-refined-carbohydrate high-protein diet. However, the study provided no control group or dietary supervision, and two variables, refined-carbohydrate and protein, were operative.
The present investigation, a companion to one concerned with gingival state,2 is designed to study the effect of a known quantity of sucrose upon sulcus depth and, in a sense, is the converse of the experiment previously reported.
Method and Results
Seventy-six dental students participated in this experiment. Forty were instructed to consume a relatively low-refined-carbohydrate high-protein diet (Group I). Of the remaining 36, 22 students were supplied with sucrose drinks (Group IIa); 14 served as controls (Group IIb).
Sulcus depth was measured with a Starlite periodontal probe to the nearest millimeter on the buccal, lingual, mesial and distal of the lower central and lateral incisors. Of a possible 1216 measurements (four teeth per person times 76 subjects), 1200 measurements were made because four teeth (16 measurements) were missing (table 1). From these calculations, mean sulcus depth scores for each group were derived (table 1).
Table 1–Sulcus depth distribution
The 40 subjects in Group I were instructed to eliminate, as far as possible, refined-carbohydrate-foods from the diet. The recommendation was also made that protein intake be increased. Group II was randomly divided. Twenty-two subjects (Group IIa) were given, under supervision, one hundred grams of sucrose (C.P.) in solution daily. Specifically, each student received a fifty gram drink at 7:45 A.M. and 1:15 P.M. The remaining 16 subjects (Group IIb) served as the control series. Four days later, sulcus depth was regraded and mean scores recalculated (table 1) by the same examiner with no knowledge of the earlier findings or the nature of the dietary regimens.
An examination of Table 1 shows that, at the initial visit, the scores are surprisingly similar. For example, the percentage of two millimeter sulci was 66.9, 69.9, and 70.9 per cent in Groups I, Ila, and IIb. Similarly, three millimeter sulci were found to be 20.1, 20.5 and 20.9 per cent in Groups I, IIa and IIb, respectively. Further study of Table 1 reveals one millimeter sulci increased 15 per cent (11.2 to 26.1 per cent) in Group I; a decrease of 3 per cent (6.8 to 3.4 per cent) in Group IIa; essentially no change in Group IIb.
Tables 2a-c summarize the initial and final mean sulcus depth scores for the three groups. Attention is directed to the 13 per cent reduction in mean scores following the introduction of a relatively low-refined-carbohydrate high-protein regime (Table 2a). Conversely, it is noteworthy that there is a 5 per cent increase in the mean sulcus depth scores in the students given the sucrose drinks (Table 2b). Finally, Table 2c indicates that the control series (Group IIb) showed essentially no mean percentage change (1 per cent).
More importantly, it will be noted that the decrease in Group I and increase in Group IIa are statistically significant (P < 0.001); this is not true in the control group (P > 0.500).
Table 2a–Mean sulcus depth scores
Table 2b–Mean sulcus depth scores
Table 2c–Mean sulcus depth scores
The fact that, within the short interval of a few days, sulcus depth can be improved by eliminating refined-carbohydrate foods from the diet is pictorially emphasized (figure 1). The triangles, signifying the patients with the unsupervised reduction in dietary-refined-carbohydrate foods (Group I), are concentrated below the diagonal line indicating that the majority of mean sulcus depth scores decreased. This is underscored in figure 2. It will be noted, in the diet group, that the overwhelming percentage (85 per cent) of subjects showed a decrease in mean sulcus depth scores (stippled column). One in eight (12.5 per cent) demonstrated no change (diagonally-hatched column). Only 2.5 per cent (cross-hatched column) worsened. Parenthetic mention should be made of the fact that these findings with diet and sulcus depth are quite consistent with the results obtained with the same diet and gingival state.2
It should be recalled (table 2b) that, following sucrose drinks, mean sulcus depth increased. This qualitative analysis of sulcus depth following sucrose drinks is consistent with the earlier reported findings of sucrose ingestion and gingival state.2 Returning to figure 1, it will be found that the majority of dark circles (Group IIa) are above the diagonal line. This means that the mean sulcus depth scores worsened appreciably in the students taking the sucrose drinks. This is reemphasized in figure 2. Here it will be observed that 72.7 per cent (cross-hatched column) worsened; 22.7 per cent (diagonally-hatched column) remained the same; only 4.5 per cent improved (stippled column). Hence, in effect, Groups I and Ila are mirror images. These findings are consistent with those reported in connection with gingival state.2 Finally, the open circles (figure 1) constitute Group IIb (control series). Most of the open circles are on or very close to the diagonal line suggesting little change. This is borne out (figure 2) by the 21.4, 50.0 and 28.6 per cent for improvement, no change and worsening, respectively. These findings are also quite consistent with those noted in connection with the gingival study.2
These observations do not prove that sucrose is the causative factor. It may well be that, by deliberately adding the sucrose drinks, the subject’s diets are consciously or otherwise altered. This may be likened to the child who will not eat his dinner. (and possibly then not the protein) if he has consumed some candy shortly before mealtime. Obviously, this problem can best be resolved if the patients were studied in a metabolic ward. Secondly, the sugar effect may be mediated (figure 3) through the endocrine system.3 It is possible that the changes observed here may be hormonally inspired. Finally, it is conceivable that the increased sugar consumption may have set the stage for an increase in vitamin and mineral needs.4 Hence, the fundamental problem may be due to a vitamin and/or a trace mineral deficit (figure 4). Once again, the design of this experiment does not provide answers to these questions.
Fig. 3. The interrelationships of hormones, nutrition and metabolism
Fig. 4. Intermediary carbohydrate metabolism showing the relationships of several vitamin and mineral fractions to various metabolic stages.
Seventy-six dental students participated in an experiment to demonstrate the effects of refined-carbohydrate food and sucrose upon gingival state. The 40 subjects instructed to take, unsupervised, a relatively low-refined-carbohydrate high-protein diet showed a statistically significant (13 per cent) reduction in mean sulcus depth scores in four days. Twenty-two students, receiving 50 gram sucrose supplements twice daily for four days, demonstrated a statistically significant 5 per cent increase in mean sulcus depth. The 14 controls remained essentially the same.
The greater percentage of individuals in the diet group (85.0 per cent) demonstrated a decrease in sulcus depth. In contrast, the majority of the sucrose supplemented group (72.7 per cent) exhibited an increase in sulcus depth. The controls were almost equally divided in regard to improvement (21.4 per cent) and worsening (28.6 per cent).
- Ringsdorf, W. M., Jr., and Cheraskin, E.: “Periodontal pathosis in man: I. Effect of relatively high-protein low-refined-carbohydrate diet upon sulcus depth.” J. Period. 33: 341, 1962.
- Cheraskin, E., Ringsdorf, W. M., Jr., and Setyaadamadja, A. T. S. H.: “Periodontal pathosis in man: XII. Effect of sucrose drinks upon gingival state.” Pakistan Dent. Rev. (in press).
- Wohl, M. G., and Goodhart, R. S.: Modern Nutrition in Health and Disease. Lea and Febiger, Philadelphia, 1960.
- Soskin, S., and Levine, R.: Carbohydrate Metabolism, University of Chicago Press, Chicago, 1952.