The Invisible Toothbrush

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One of the many risk factors for heart disease is poor dental health. The root cause for both diseases is probably the same–nutritional deficiencies, including deficiency of vitamin C. In this article, Dr. Emmanuel Cheraskin presents evidence that serum vitamin C levels are just as important as brushing for the prevention of tooth decay. His research also explains why primitive peoples on nutrient-dense diets have no tooth decay, in spite of the fact that they do not brush their teeth.

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–stuff like plaque and scum that gets on your teeth–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–low levels of vitamin C! Obviously this is a relatively new thought and requires further study. And, by the way, vitamin C serves many other functions. It is well-documented as an electron donor and impressive scavenger; it plays important roles in protecting the capillaries from fragility and permeability; it is 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!

Some Facts

Let’s start with three inescapable facts:

1. The principal site for chronic disease is the mouth, even in this day and age.
2. Ninety-five percent of the civilized population suffers with tooth decay and/or periodontal disease.
3. Judged by our current successes and failures, the present explanations and solutions are filled with contradictions. For example, more brushing and flossing doesn’t necessarily guarantee less disease.

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) appropriate diet and (3) a susceptible state, as shown in Figure 1. (These three factors apply equally to periodontal disease.) The figure implies that all three factors must be present for tooth decay to develop and that if even one of these three variables is absent, then pathosis does not occur.

Figure 1
tooth decay=susceptible tooth+bacteria+sugar

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES
Public Health Service, National Institutes of Health
NIH Publication No. 80-1146

Be that as it may, researchers have focussed principally on the role of diet and microorganisms; only scant attention has been accorded the resistance/susceptibility factor. And, when researchers do consider the susceptibility factor, they usually speak of susceptibility and genetics as synonymous.

This report will examine one aspect of the susceptibility factor, with emphasis on 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

We conducted a study that involved two hundred presumably healthy middle income Caucasians (with the usual mouth problems of dental caries and/or periodontal disease).² To quantitate tooth cleansing, we chose the most simple arbitrary measurable system. Each subject was questioned regarding the frequency of toothbrushing. It was convenient to divide the participants into three groups, those with less than twice (n=71), those who brushed twice per day (n=95), and those who brushed more than two times daily (n=34).

To assess tooth cleanliness we utilized a simple, popular and easy grading of foreign material called the Debris Score.

In this study, we looked at only one measure of susceptibility, the fasting plasma ascorbic acid concentration. Our reason for focussing on the ascorbates is the fact that in some subsets of the general population suboptimal vitamin C state is as high as 100 percent.³ Additionally, we have studied vitamin C deficiency in dental patients and discovered that up to 72 percent may be hypoascorbemic.⁴

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 by study participants on the horizontal axis and the mean debris scores on the vertical. Not surprisingly, those brushing least had the greatest accumulations of debris while the group that did the most toothbrushing had the least amount of debris. Thus, to answer the first question, there does indeed appear to be a convincing relationship between tooth cleansing (toothbrushing frequency) and tooth cleanliness (debris score). These observations support the current dental philosophy of the importance of local and mechanical factors in periodontal health and sickness.

However, although the correlation coefficient was statistically significant (r=-0.265, p<0.01) it was not perfect. This suggests the possibility that other factors may be operative.

A Second Opinion

Turn on the television and within minutes, you are likely to hear about a newfangled vitamin-stuffed cereal. Tune in the radio and discover that we now have fiber in convenience 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 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.^5-7 So, for purposes of this experiment, we pose the question thus: “What is the correlation of vitamin-C status and oral cleanliness without altering the usual oral cleansing habits?”

Figure 3 pictorially portrays the plasma ascorbic acid levels in the study participants on the x-axis. The 200 subjects were arbitrarily divided into three near-equal subsets. There were 68 with the poorest ascorbate levels, ranging from 0.0 to 0.4. Sixty-seven showed the best vitamin C levels (0.8 to 1.3) and 65 had average vitamin C levels (0.4-0.7).

The average debris scores are shown on the y-axis. Note that those with the poorest ascorbic acid levels had the most debris while the group with the best ascorbate state had the least accumulations. 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 shown thus far (Figures 2 and 3) is actually an analysis of a series of surreal events. In the real world, people who do or do not clean their mouth also do or do not ingest ascorbates. Thus we need to determine whether the accumulations are the result of how much one brushes or how much vitamin C is ingested.

Figure 4 depicts the frequency of daily toothbrushing on the x-axis and the average debris scores on the y-axis. This time the 200 subjects were divided into two equal subgroups. The 100 subjects 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 status (greater than 0.6 mg%) are shown by the gray columns. Note that 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, p0.05).

Here is part of the explanation for the well-known fact that some of us need to brush our teeth less than others.

Summary and Conclusions

The centerpiece for stomatology–the medical study of the physiology and pathology of the mouth–is cleanness. Thus, we are told that good cleansing habits will result in good oral hygiene (cleanliness) and poor cleansing habits will result in poor cleanliness.

It is evident that plaque material may be removed from the tooth surface with effective mechanical cleansing techniques as shown in the literature⁸ and earlier in this report (Figure 2). Hence, the interface structures, that is the teeth, 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, namely 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–and does–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–an invisible toothbrush.

These findings are consistent with other published reports of nutrient-debris relationships. For example, Coven¹⁰ has reported a significant connection between gingival ascorbic acid and debris score in children. Another study¹¹ found marked differences in foreign accumulations between Adventist and non-Adventist 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 study¹³ 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 al¹⁴ and Lane and his associates¹⁵ reported reducing debris scores significantly with multivitamin and mineral supplementation.

Notwithstanding, even in this day and age, it is still materially held that the only solution to plaque control is to remove it mechanically.^16-17 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.

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 ascorbic acid 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 one particular nutrient-plaque relationship, but the need to completely reevaluate existing concepts of oral hygiene (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 the interest of these Australian investigators in the relationship of ecological 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 percent 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…”

It should be emphasized that we have lots of data about vitamin C because we have studied the ascorbates extensively. What the results would be depending upon other vitamins, as well as other dosages in terms of host resistance and susceptibility, is an unanswered question. Nevertheless, the fact of the matter is that vitamin C can serve as an invisible toothbrush.

Sources of Vitamin C In milligrams (mg) per 100 grams
Acerola berries	1300
Peppers, red chile	369
Guavas	242
Peppers, red sweet	204
Leafy green vegetables	50-180
Parsley	172
Peppers, green sweet	128
Broccoli	113
Brussels Sprouts	102
Watercress	79
Cauliflower	78
Persimmons	66
Cabbage, red	61
Strawberies	59
Papayas	56
Oranges & juice	50
Cabbage, green	24
Lemon juice	23
Liver, calf	36
Note: Hunter-gatherers obtained vitamin C from certain organ meats, such as adrenal glands and parts of the stomach. Many wild fruits and vegetables have much higher levels of vitamin C than those that are cultivated.

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Sidebar

NATURAL VERSUS SYNTHETIC VITAMIN C

By Thomas Cowan, MD

It is common these days to use the terms vitamin C interchangeably with ascorbic acid. In fact, there are numerous differences between these two very distinct biological entities. Vitamin C, found in numerous plant and animal foods, is a necessary nutrient for humans in that we make none of our own vitamin C. Natural vitamin C is a complex mixture of at least 9 or 10 distinct molecular entities. These include ascorbic acid (the preservative part of the complex), tyrosinase (an enzyme), rutin, bioflavenoids, copper, manganese, and other enzymes and minerals. Each of these compounds has a synergistic effect with the other substances, the end result being a potent and complicated compound that has far-reaching biological effects. Some of these effects include reducing capillary fragility (thus reducing the tendency to bruising or bleeding), improving the integrity of the collagen fibers, binding and thereby neutralizing histamine (lessening allergies), and many other vital functions. Ascorbic acid has only one effect, that is anti-oxidation. While many nutritionists and physicians sing the praises of anti-oxidants in our diet, the fact is that excessive anti-oxidation inhibits our cellular mechanisms from digesting and disposing of unwanted tissue. This is perhaps why the latest studies on excessive use of ascorbic acid show that it may contribute to the development of coronary artery disease. This situation would never arise from the use of the whole vitamin C complex as found in natural foods.

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References

1. National Institutes of Health Brochure No. 80-1146, Bethesda, U. S. Department of Health and Human Services.
2. Clark, J.W., Cheraskin, E. and Ringsdorf, W.M., Jr. An Ecologic Study of Oral Hygiene. Journal of Periodontology/Periodontics 40: #8, 476-480, August 1969.
3. Schorah, C. J.Vitamin C Status in Population Groups. IN: Counsell, J.N. and Hornig, D.H. Vitamin C (Ascorbic Acid)1981.Englewood, Applied Science Publishers.
4. Cheraskin, E. and Ringsdorf, W.M., Jr.Vitamin C State in a Dental School Patient Population. Journal of the Southern California State Dental Association 32: #10,375-378, October 1964.
5. Cheraskin, E., Ringsdorf, W.M. Jr. and Sisley, E.L. 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, S.S.Thoughts Concerning Cause, Pathogenesis, Treatment and Prevention of Periodontal Disease. Journal of Periodontology 29: #3, 217-223. July 1958.
9. Arnim, S.S.Microcosms of the Mouth – Role in Periodontal Disease. Texas Dental Journal 82: #3, 4-10, March 1964.
10. Coven, E.M.Relationship of Vitamin C State and Oral Health of a Pedodontic Group in a Prepayment Program. Industrial Medicine and Surgery 24: #5, 410-412, May 1965.
11. Holmes, C.B. and Collier, D.Periodontal Disease, Dental Caries, Oral Hygiene and Diet in Adventist and Other Teenagers. Journal of Periodontology 37: #2, 100- 107, March-April 1966.
12. Mandel I.D.Histochemical and Biochemical Aspects of Calculus Formation. Periodontics 1: #2, 43-52, March-April 1963.
13. Cohen, M.M.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, W.M., Jr. Tissue Tolerance to Orthodontic Banding: A Study in Multivitamin-Trace Mineral Supplementation. Journal of Periodontology 37: #2, 132-145, March-April 1966.
15. Lane, W.B., 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, J.C.Oral Health Care for the Prevention and Control of Periodontal Disease-Review of the Literature. World Workshop in Periodontics 1966. Ann Arbor, University of Michigan Press, pp. 397-455.
18. Waerhaug, J.Epidemiology of Periodontal Disease – Review of the Literature.World Workshop in Periodontics 1966. Ann Arbor, University of Michigan Press, pp.181-222.
19. Clarke, N.G. and Carey, S.E.Etiology of Chronic Periodontal Disease: An alternative Perspective. Journal of the American Dental Association 110: #5, 689–691, May 1985.

This article appeared in Wise Traditions in Food, Farming and the Healing Arts, the quarterly magazine of the Weston A. Price Foundation, Spring 2001.

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