By Allison G. James, DDS
Summary: A dentist warns that refined grain and sugar products are “the chief causative factor in dental caries [cavities] and paradentosis [gum disease].” The author also discusses the body’s important calcium-phosphorus ratio and warns against eating too much “heat-sterilized food.” The esteemed Dr. Francis M. Pottenger Jr., MD—author of the famous Pottenger’s Cats—comments at the end of the article. From Annals of Western Medicine and Surgery, 1947. Lee Foundation for Nutritional Research reprint 34.[The following is a transcription of the original Archives document. To view or download the original document, click here.]
Nutrition and Dental Disease
For many years pathologic lesions of the oral cavity have received a consideration from the medical and dental professions that is purely mechanistic—both as to cause and treatment. With knowledge of bacterial activity and later the introduction of theories regarding focal infection, the teeth and supporting structures, in their vulnerable position of accessibility to operative procedures, received an undue amount of attention. In many cases dental lesions may unquestionably have existed as primary foci, but in the enthusiasms engendered by that convenient hook focal infection—upon which to hang misunderstood body disabilities—undoubtedly countless unnecessary sacrifices were made.
As knowledge of degenerative diseases progressed, and with the recognition that degenerative diseases of many types were increasing, a more sane and logical attitude has developed. It is recognized by those practitioners in medicine and dentistry who have followed closely events of the last two decades that the oral structures, while possessing a remarkably high vitality and resistance, are but vital parts of the organism and subject to all of its fluctuations in health. Lesions of the oral structures are to be considered symptoms rather than primary diseases.
With the understanding that nutrition is the process by which growth is promoted and health maintained and that disease represents disturbed nutrition of the cell, part, or organism affected, dental pathologic lesions receive a more logical consideration than is possible from the mechanistic point of view.
Pathologic lesions of the oral cavity that the dentist is called upon to treat fall into three main groups:
- Lesions or degenerative changes of the supporting and investing structures of the teeth—paradentopathies
- Destructive lesions of the structure of the tooth itself—dental caries
- Malformation or maldevelopment of the facial bones and dental arches
Paradentosis (Periodontoclasia, Pyorrhea Alveolaris)
The relation of the tooth to the jaw—the dentoalveolar articulation—is similar to other joints of the body, having all the elements of other articulations, even including minute movement. Therefore, disturbances in this joint relationship may be interpretable as arthritic manifestations. Supporting this concept is the fact that chronic degenerative arthritis (hypertrophic) frequently shows typical changes of this character in the dentoalveolar articulation. The rationale of more than local treatment becomes evident.
The all-prevalent and increasing incidence of dental caries closely corresponds to the increased use of refined and concentrated carbohydrates in the national diet. Widespread clinical experience in successful control of dental caries through the restriction or elimination of the concentrated sugars has demonstrated this relationship.1,2,3 That high refined carbohydrate diets, with [their accompanying] avitaminosis, demineralize the skeleton has long been recognized by the medical profession, but frequently the degree of bone demineralization accompanying rampant dental caries has been overlooked.
Paradentosis and dental caries are postnatal diseases in that they are imposed upon the organism. The view that malformation and maldevelopment of the jaws and facial bones are the result of injuries to the germ plasm in the parents prior to conception has been well supported by animal experiment and clinical observation.4,5,6,7 The previously mentioned postnatal lesions imposed on the parents prior to conception are to be considered among the probable causes of germ plasm injury, with resultant need for orthodontic treatment in the succeeding generation. Today there are more dentists in the practice of orthodontics than ever before, and still they are unable to care for all children needing their services.
This increased requirement has often erroneously been attributed to better diagnostic methods and improved treatment possibilities. A [survey] of those young persons requiring treatment or who already received treatment with parents in the age bracket of forty or more will disclose the fact that in a great majority of the cases neither parent has required orthodontic treatment. Occasionally, one of the parents has required such treatment. Parents in the age bracket below forty, on the other hand, show increasing evidences of past orthodontic treatment or indications that such would have been beneficial. And in the still younger age bracket of those potential parents now entering adult life, an amazing universality of orthodontic treatment or its unfortunate omission is apparent.
Phosphorus-Calcium and Acid-Base Ratios
Seven-day dietary analyses made by one laboratory (American Foundation for Dental Science; complete biostatistical studies will be published shortly) of more than 10,000 dental patients in southern California over the past ten years have shown certain dietary faults to be constant in cases of paradentosis and dental caries. Frequently, the two are active together in the same person.
Patients displaying active paradentosis show an intake of phosphorus exceeding the desired one-and-one-half ratio to calcium (1 Ca: 1.5 P). Such excesses may appear as 1:1.8 and may range to such extremes as 1:3.5 in severe cases of vertical atrophy. The ratio is an important consideration. Both calcium and phosphorus may be grossly deficient. Rarely is the phosphorous found to exceed the recommended 1.5 grams daily. The ratio of acid-ash to base-ash foods is usually also unfavorable, but the important factor lies in the calcium-phosphorus ratio.
Patients with active dental caries show a marked deviation toward parity from the desired intake of acid-ash and base-ash foods in the ratio of 1:3, with this deviation due to the inclusion of large proportions of refined grain and sugar products. Such cases may show a ratio of 1 acid to 0.8 base. Patients with lesser susceptibilities may show a ratio such as 1:2. The calcium-phosphorus ratio is frequently correct or nearly so. Fortunately, a very accurate check method on these cases is possessed in the Lactobacillus acidophilus index determinations.
Some analyses will reveal both calcium-phosphorus imbalance and acid-base imbalance, and if the latter is caused by acid-ash, refined grain and sugar products in the diet, then we may be confident that both dental diseases are active. As stated above, the caries susceptibility may easily be verified.
Occasionally in very high-protein, high-fat diets with no refined carbohydrates, a marked acid-base imbalance exists. In such cases active dental caries is not found. The dental symptoms, if any, appear to be in the dentoalveolar articulation, with a sensation of looseness in one or more teeth. The patients is apt to be conscious of the teeth in walking or other jarring and may note stiffness or soreness in other joints. (The writer believes this form of arthritis may explain the sudden death of the dental pulp, with acute sequelae, that has been observed in such circumstances of acid-base imbalance and in the absence of either vertical atrophy or dental caries.)
The accompanying tables shows the important dietary relationships in fifty patients in the author’s practice of general dentistry.
Table: Averages of Fifty-Five Diets of Dental Patients
|Lesion||Number of Cases||Ca:P Ratio||Acid:Base Ratio||Total|
|Percent Total Calories from Refined Grain and Sugar Products|
|Caries and Vertical Atrophy||17||1:1.85||1:1.14||1752||36%|
|Horizontal Atrophy and Osteoporosis||4||1:1.52||1:1.05||1762||27.2%|
Active Dental Caries—Twenty-Four Cases
It will be noted that the calcium-phosphorus ratio of 1:1.64 was not extreme. That ratio of acid-ash foods to base-ash foods was 1:1.3, but of the total food intake, 31.6 percent of the calories were derived from refined grain and sugar products. These patients displayed varying degrees of osteoporosis in the alveolar processes. In many of them, Lactobacillus acidophilus index determinations have been made over a period of months.
Vertical Atrophy—Five Cases
These patients with vertical atrophy—that is, with deep pockets, true paradentosis but uncomplicated by dental caries—showed an average calcium-phosphorus ratio of 1:2.26. The acid-base ratio of 1:1.62 was slightly improved, but 24 percent of the total caloric intake was derived from refined grain and sugar products.
Active Dental Caries and Vertical Atrophy—Seventeen Cases
These patients displayed both active dental caries and vertical atrophy (pocket formation of paradentosis). In these patients the average calcium-phosphorus ratio was 1:1.85, with an acid-base ratio of 1:1.4. Thirty-six percent of the total caloric intake was derived from refined grain and sugar products.
Horizontal Atrophy and Osteoporosis—Four Cases
These patients with horizontal atrophy and osteoporosis—without either dental caries or pocket formation—showed an average calcium-phosphorus ratio very nearly correct, 1:1.52, but the acid-base ratio was down to 1:1.05. Of the total caloric intake, 27.2 percent was derived from refined products of grain and sugar.
These four patients showed marked signs of vitamin B complex deficiency, and in the light of investigations into the buffer capacity of saliva made at the Spies Clinic, Hillman Hospital, Birmingham, Alabama, should be investigated in this phase. The Birmingham studies showed that the malnourished patients relatively free from dental caries had the highest buffer capacity in the saliva.8,9
Controlled (Rechecks)—Five Cases
The five controlled cases are rechecks, made from a group in which there has been total arrest of destructive dental changes for a period of six months to several years.
One of the patients, who had rampant dental caries, has been under observation since April 1942, a total of sixty-three months. Through the cooperation of the Department of Dental Medicine, College of Dentistry, University of California, San Francisco, forty-nine Lactobacillus acidophilus index determinations have been made in this period. In April 1942 the patient presented with forty-six tooth surfaces affected by dental caries, fourteen of which were active at that time. During the period of observation—five years and three months—new dental caries have not occurred.
In this series of controlled cases, the calcium-phosphorus intake ratio of 1:1.26 is to be noted, as is the relationship of acid-ash foods to base-ash, 1:1.98. It will also be seen that these five, following the prescribed diet rather closely, have increased the average daily caloric intake to 2148 calories, with only 6 percent of that amount derived from refined grain and sugar products.
[Comment on Refined Carbohydrates and Dental Disease]
The recapitulations of the fifty cases here presented are in agreement with the substance of the vast number of analyses collected over the past ten years through the cooperation of many practitioners in California. They represent the utilization of diagnostic and corrective methods available in the clinical practice of dentistry and are not offered as part of a research program.
I believe that refined carbohydrates, to which Moose10 refers to as “diluting agents,” cannot be estimated in their deleterious effects by quantitative measurements but must be considered in direct relationship to the total caloric intake, its quality, and, very importantly, the patient’s metabolic capacity or efficiency. In a diet averaging 2000 calories daily, there appears no displacement possible by inadequate refined carbohydrates without deleterious dental changes.
Summary and Conclusions
1. Inclusion of a proportion of refined grain and sugar products in the diet beyond the tolerance of the patient appears as the chief causative factor in dental caries and paradentosis.
2. Proportionately as the phosphorus intake increases beyond the one and one-half ratio to calcium, the vertical atrophy of paradentosis increases.
3. For prevention and control of dental disease, diets of 2,000 calories may not safely be diluted by refined grain and sugar products. As the total caloric intake increases, a possible inclusion of 6 to 10 percent of these products may have no harmful effect.
By Allison G. James, DDS, 409 North Camden Drive, Beverly Hills. Reprinted from Annals of Western Medicine and Surgery, September 1947, by the Lee Foundation for Nutritional Research.
1. Jay, Phillip. “Lactobacillus Acidophilus and Dental Caries.” Am. J. Pub. Health, 28:759–761, June 1938.
2. Collins, R.O., Jensen, A.L., and Becks, H. “Study of Caries-free Individuals II. Is Optimum Diet or Reduced Carbohydrate Intake Required To Arrest Dental Caries.” J. Am. Dent. A., 29:1169–1178, July 1, 1942.
3. Becks, H., Jensen, A.L., and Millar, C.B. “Rampant Dental Caries; Prevention and Prognosis: 5 Year Clinical Survey.” J. Am. Dent. A., 31:1189–1200, September 1, 1944.
4. Pottenger, F.M., Jr. “The Effect of Heat Processed Foods and Metabolized Vitamin D Milk on the Dentofacial Structures of Experimental Animals.” Am. J. Orthodontics and Oral Surg., 32:467, August 1946.
5. Price, W.A. Nutrition and Physical Degeneration. Paul B. Hoeber, Inc., New York, 1939.
6. McCarrison, Robert. Studies in Deficiency Diseases. Oxford University Press, London, 1921.
7. Wrench, G.T. The Wheel of Health. C.W. Daniel Co., Ltd., London, 1938.
8. Dreizen, S., Mann, A.W., Cline, J.K., and Spies, T.D. “The Buffer Capacity of Saliva as a Measure of Dental Caries Activity.” J. Dent. Research, 25:213, August 1946.
9. Mann, A.W., Dreizen, S., Spies, T.D., and Hunt, F.M. “Comparison of Dental Caries Activity in Malnourished and Well Nourished Patients.” J. Am. Dent. A., 34:244, February 15, 1947.
10. Moose, R.M. “Sugar—A ‘Diluting’ Agent.” J.A.M.A. 125:738–739, July 8, 1944.
Discussion [by Dr. Francis Pottenger Jr.:]
Dr. James is to be commended for his clear cut statements with reference to the importance of nutrition in the maintenance of oral health, and also for bringing out the fact that disturbances in the oral cavity are indicative of general systemic disease. Although the internist may not always be able to determine the correlation between the evidences found in the mouth and his patient’s systemic problems, a closer study of the oral structures, however, will give him diagnostic aids that will prove of utmost value.
It has been my experience, as Dr. James brings out so clearly, that malformations of the facial structures, which also include the paranasal sinuses and all other structures beneath the brain case, usually result from disturbed nutrition in the parentage. Caries, on the other hand, is much more likely to represent a highly refined dietary intake on the part of the individual. Many cardiologists have pointed out that there seems to be a close relationship between dental caries and heart disease. As a rule, the consumption of refined carbohydrates in excess is attended by the development of water-bearing tissue of diminished tone throughout the body.
Although Dr. James stresses the calcium-phosphorus ratio in relation to paradentosis—predicated on the dietary analyses of Mr. Walsh—it has been my experience that there are other important factors as well. Not the least of these is the extensive sterilization by high heat that is practiced by modern civilization, thereby destroying important enzymes necessary for the utilization of the foods we consume.
It has also been my experience that rarely do my dental confreres give me a report of horizontal atrophy or osteoporosis in oral structures, but that I find evidence, upon careful study of other bony structures of the body, of either developmental failure or skeletal inadequacy. This may take the form of a true loss of bone density from the skeleton, a disturbance of its internal structural pattern, or a definite change in the articular surfaces.
There has been too great a tendency on the part of the physician to minimize the importance of the reports of his dental colleagues. Close cooperation between the medical and dental practitioner should enable the internist to make much earlier diagnosis of impending skeletal failure, with its concomitant organic and structural changes in other parts of the body. The dental radiologist obtains a very clear roentgenogram [X-ray] of the oral structures by the close proximity at which he takes his pictures. Hence he may be the first to observe a serious change in bony structure.
The physician who has interested himself in the importance of less refined food in the dietary is well aware of the therapeutic implications of the statements that Dr. James has made. The interesting correlations that he reports in the analysis of Mr. Walsh will be appreciated by practitioners interested in the long range health program of their patients.
By Francis M. Pottenger Jr., MD, North Canyon Blvd., Monrovia, California.
Reprint No. 34
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