The Invisible Toothbrush Written by Emmanuel Cheraskin, MD, DMD Friday, 30 March 200 0 !

"# 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 ust as important as brushing for the prevention of tooth decay. !is research also e"plains #hy primitive peoples on nutrient-dense diets have no tooth decay, in spite of the fact that they do not brush their teeth. $ lon% time a%o, &resident 'arry () Truman *as asked the +uestion, ,What-s ne*., 'is res/onse, ,I0 you never heard it be0ore, re%ardless o0 ho* old it is, it-s ne*1, 2tili3in% the Truman benchmark, several /oints are obvious) First, the /resent notion that dental accumulations44stu00 like /la+ue and scum that %ets on your teeth44contribute to dental diseases and that these collections can be mechanically removed is not only old but %enerally conceded) What is also not ne*, as 0ar as the /ublished literature is concerned, is that there are nonmechanical contributions to the common dental diseases) Many o0 the re/orts are 30 to "0 years old) (ome o0 them are +uite recent, /articularly the innovative discussions by 5i%el Clarke and his associate in $ustralia) 'o*ever, *hat is really ne* and em/hasi3ed in this re/ort, is that the accumulations in themselves may be due to the absence o0 an invisible toothbrush) The *hodunit may *ell be hy/oascorbemia44lo* levels o0 vitamin C1 6bviously this is a relatively ne* thou%ht and re+uires 0urther study) $nd, by the *ay, vitamin C serves many other 0unctions) It is *ell4documented as an electron donor and im/ressive scaven%er7 it /lays im/ortant roles in /rotectin% the ca/illaries 0rom 0ra%ility and /ermeability7 it is e8traordinary 0or *ound healin%, and much, much more) (o, /rovidin% the ascorbates may add a bonus to im/roved oral health) ) ) by contributin% to %eneral *ell4bein%1

Some Facts
9et-s start *ith three inesca/able 0acts! ) The /rinci/al site 0or chronic disease is the mouth, even in this day and a%e) 2) 5inety40ive /ercent o0 the civili3ed /o/ulation su00ers *ith tooth decay and:or /eriodontal disease) 3) ;ud%ed by our current successes and 0ailures, the /resent e8/lanations and solutions are 0illed *ith contradictions) For e8am/le, more brushin% and 0lossin% doesn-t necessarily %uarantee less disease) The 5ational Institutes o0 'ealth <5I'= and other authorities, as *e shall learn, ar%ue that oral /athosis is a multi0actorial /roblem) They identi0y three essential in%redients! < = a critical microbial /o/ulation, <2= a//ro/riate diet and <3= a susce/tible state, as sho*n in Fi%ure ) <These three 0actors a//ly e+ually to /eriodontal disease)= The 0i%ure im/lies that all three 0actors must be /resent 0or tooth decay to develo/ and that i0 even one o0 these three variables is absent, then /athosis does not occur) Figure 1

tooth decay=susceptible tooth+bacteria+sugar

2)() DE&$>TME5T 6F 'E$9T' ? '2M$5 (E>@ICE( &ublic 'ealth (ervice, 5ational Institutes o0 'ealth 5I' &ublication 5o) #04 "A Be that as it may, researchers have 0ocussed /rinci/ally on the role o0 diet and microor%anisms7 only scant attention has been accorded the resistance:susce/tibility 0actor) $nd, *hen researchers do consider the susce/tibility 0actor, they usually s/eak o0 susce/tibility and %enetics as synonymous) This re/ort *ill e8amine one as/ect o0 the susce/tibility 0actor, *ith em/hasis on the measurability o0 tissue tolerance in oral /athosis) (/eci0ically, *e shall devote our attention to the +uestion, ,Can you %et a*ay *ith brushin% your teeth less.,

A Different Look at Mr. And Mrs. America

We conducted a study that involved t*o hundred /resumably healthy middle income Caucasians <*ith the usual mouth /roblems o0 dental caries and:or /eriodontal disease=)2 To +uantitate tooth cleansin%, *e chose the most sim/le arbitrary measurable system) Each subCect *as +uestioned re%ardin% the 0re+uency o0 toothbrushin%) It *as convenient to divide the /artici/ants into three %rou/s, those *ith less than t*ice <nDE =, those *ho brushed t*ice /er day <nDFG=, and those *ho brushed more than t*o times daily <nD3"=) To assess tooth cleanliness *e utili3ed a sim/le, /o/ular and easy %radin% o0 0orei%n material called the Debris (core) In this study, *e looked at only one measure o0 susce/tibility, the 0astin% /lasma ascorbic acid concentration) 6ur reason 0or 0ocussin% on the ascorbates is the 0act that in some subsets o0 the %eneral /o/ulation subo/timal vitamin C state is as hi%h as 00 /ercent)3 $dditionally, *e have studied vitamin C de0iciency in dental /atients and discovered that u/ to E2 /ercent may be hy/oascorbemic)"

he raditional !onfirmation

The most o0ten asked +uestion is, ,'o* e00ective is toothbrushin%., In other *ords, ,What-s the connection bet*een debris <oral cleanliness= and toothbrushin% habits.,

Fi%ure 2 sho*s the 0re+uency o0 daily toothbrushin% by study /artici/ants on the hori3ontal a8is and the mean debris scores on the vertical) 5ot sur/risin%ly, those brushin% least had the %reatest accumulations o0 debris *hile the %rou/ that did the most toothbrushin% had the least amount o0 debris) Thus, to ans*er the 0irst +uestion, there does indeed a//ear to be a convincin% relationshi/ bet*een tooth cleansin% <toothbrushin% 0re+uency= and tooth cleanliness <debris score=) These observations su//ort the current dental /hiloso/hy o0 the im/ortance o0 local and mechanical 0actors in /eriodontal health and sickness) 'o*ever, althou%h the correlation coe00icient *as statistically si%ni0icant <rD40)2AG, /H0)0 = it *as not /er0ect) This su%%ests the /ossibility that other 0actors may be o/erative)

A Second "pinion
Turn on the television and *ithin minutes, you are likely to hear about a ne*0an%led vitamin4stu00ed cereal) Tune in the radio and discover that *e no* have 0iber in convenience 0oods) $ll o0 this stems 0rom the *ell4established 0act that vitamins and minerals in0luence every cell, tissue, or%an and site in the human system) It 0i%ures, there0ore, that the mouth should also be /art o0 the story) What is the connection bet*een nutrition and susce/tibility to oral disease. In other *ords, the +uery no* to be /osed is, ,Can *e alter oral debris by chan%in% vitamin state., 6ur /ersonal e8/erience has been +uite e8tensive *ith ascorbic acid)G4E (o, 0or /ur/oses o0 this e8/eriment, *e /ose the +uestion thus! ,What is the correlation o0 vitamin4C status and oral cleanliness *ithout alterin% the usual oral cleansin% habits.,

Fi%ure 3 /ictorially /ortrays the /lasma ascorbic acid levels in the study /artici/ants on the 84a8is) The 200 subCects *ere arbitrarily divided into three near4e+ual subsets) There *ere A# *ith the /oorest ascorbate levels, ran%in% 0rom 0)0 to 0)") (i8ty4seven sho*ed the best vitamin C levels <0)# to )3= and AG had avera%e vitamin C levels <0)"40)E=) The avera%e debris scores are sho*n on the y4a8is) 5ote that those *ith the /oorest ascorbic acid levels had the most debris *hile the %rou/ *ith the best ascorbate state had the least accumulations) The correlation is statistically si%ni0icant <rD40)2 0, /H0)0 =, very much like that sho*n in Fi%ure 2, and also not /er0ect) There0ore, *ithin the limits o0 these data, there a//ears to be a very real correlation bet*een vitamin C state <as a /ossible nonmechanical contributor= and debris, irres/ective o0 tooth cleansin% habits)

he !urrent #cologic hinking

What *e have sho*n thus 0ar <Fi%ures 2 and 3= is actually an analysis o0 a series o0 surreal events) In the real *orld, /eo/le *ho do or do not clean their mouth also do or do not in%est ascorbates) Thus *e need to determine *hether the accumulations are the result o0 ho* much one brushes or ho* much vitamin C is in%ested)

Fi%ure " de/icts the 0re+uency o0 daily toothbrushin% on the 84a8is and the avera%e debris scores on the y4a8is) This time the 200 subCects *ere divided into t*o e+ual sub%rou/s) The 00 subCects *ith the relatively /oorer /lasma ascorbic acid levels <less than 0)A m%I= are sho*n by the black columns7 the other 00 *ith the better vitamin C status <%reater than 0)A m%I= are sho*n by the %ray columns)

5ote that in those sho*in% the lo*er </oorer= /lasma ascorbic acid scores, there-s an obvious inverse relationshi/) In other *ords, and not sur/risin%ly, the %reater the toothbrushin% 0re+uency, the less the debris <0)#E=) This has already been demonstrated <Fi%ure 2=) It is also statistically con0irmed <rD40)33E, /0)0G=) 'ere is /art o0 the e8/lanation 0or the *ell4kno*n 0act that some o0 us need to brush our teeth less than others)

Summary and !onclusions

The center/iece 0or stomatolo%y44the medical study o0 the /hysiolo%y and /atholo%y o0 the mouth44is cleanness) Thus, *e are told that %ood cleansin% habits *ill result in %ood oral hy%iene <cleanliness= and /oor cleansin% habits *ill result in /oor cleanliness) It is evident that /la+ue material may be removed 0rom the tooth sur0ace *ith e00ective mechanical cleansin% techni+ues as sho*n in the literature# and earlier in this re/ort <Fi%ure 2=) 'ence, the inter0ace structures, that is the teeth, may, *ith /ro/er instruction, be altered throu%h a chan%e in the e8ternal *orld <toothbrushin%, 0lossin%, irri%ation=) Much less clearly understood is the im/ortance o0 the inner *orld, namely %in%ival tissue metabolism, to 0orei%n and e8ternal accumulations) In the /ast, /la+ue has been re%arded as inert matter) 5o* it is reco%ni3ed that this so4called debris is a microcosm containin% myriads o0 livin% neutro/hils and other 0ormed elements) Its environs are remarkably similar to human blood and tissue 0luid)F $s such, it should44and does44 re0lect metabolic chan%es *ithin the host tissues) @ie*ed in this /ers/ective, the role o0 the or%anism-s metabolic status as a /ossible contributor to /la+ue 0ormation becomes more understandable) The 0indin%s o0 this investi%ation, as re/resented in Fi%ure 3, su%%est that /la+ue is indeed also related to the internal milieu as Cud%ed by vitamin C metabolism) In other *ords, this can be vie*ed as a demonstration o0 nonmechanical brushin%44an invisible toothbrush) These 0indin%s are consistent *ith other /ublished re/orts o0 nutrient4debris relationshi/s) For e8am/le, Coven 0 has re/orted a si%ni0icant connection bet*een %in%ival ascorbic acid and debris score in children) $nother study 0ound marked di00erences in 0orei%n accumulations bet*een $dventist and non4$dventist teena%ers) The authors concluded that they *ere related to diet and not to di00erences in brushin% 0re+uency) It has also been con0irmed by Mandel that the /la+ue re/resents the initial /hase in calculus 0ormation) 2 6bviously, cause and e00ect can be more convincin%ly im/uted 0rom clinical trials) 6ne such study 3 re/orted a resolution o0 materia alba, calculus and stain *hen G00 m% o0 ascorbic acid *as daily administered 0or F0 days to 3G mentally retarded boys) Duster*inkel, et al " and 9ane and his associates G re/orted reducin% debris scores si%ni0icantly *ith multivitamin and mineral su//lementation) 5ot*ithstandin%, even in this day and a%e, it is still materially held that the only solution to /la+ue control is to remove it mechanically) A4 E I0 nutrients are determinants o0 /la+ue, as the /resent investi%ation and other studies su%%est, this conce/t may be

incom/lete) The need 0or 0urther investi%ation o0 nutritional a//roaches to oral hy%iene <tooth cleanliness= *ould thus seem to be a//ro/riate) @ie*in% brushin% 0re+uency4debris score relationshi/s, as in0luenced by ascorbic acid status <Fi%ure "=, /rovides additional insi%hts into /la+ue /revention and control) $t all levels o0 brushin% 0re+uency, those *ith the better /lasma ascorbic acid levels e8hibit cleaner teeth) In 0act, the avera%e debris score <0)F2= 0or those *ho brush less than t*ice daily but have better vitamin C levels com/ares 0avorably *ith that o0 the /oorer C subCects *ho brush t*ice or more daily <0)F0 and 0)#E=) The key 0act underscored in this investi%ation is not the e8istence o0 one /articular nutrient4/la+ue relationshi/, but the need to com/letely reevaluate e8istin% conce/ts o0 oral hy%iene <tooth cleanliness=) The /hiloso/hic considerations and the /ractical im/lications o0 the ecolo%y o0 oral health and sickness not only continues but seems to intensi0y) This is su/erbly borne out in the citations by 5i%el Clarke and his co4*orker! F ,(ome individuals e8/erience severe in0lammation to minimal /la+ue, *hereas others have minimal in0lammation to heavy /la+ue))))Whether these variations occur as a result o0 di00erences in host res/onse or in virulence o0 the microbes is undetermined7 ho*ever, the /robabilities /oint to host 0actors rather than to microbes))))&eriodontal disease has lon% been reco%ni3ed as a chronic disease, but the literature describes a disease that is derived entirely 0rom the e00ects o0 a microbial coloni3ation o0 the %in%ival crevice) I0 this *ere so, it *ould mean that /eriodontal disease is uni+ue amon% chronic diseases, all o0 *hich re/resent the lon%4term cumulative e00ects o0 interaction bet*een a host biolo%ic system and the surroundin% environment))))&erha/s dentistry has lost the /ers/ective bet*een the oral tissues and the entire or%anism))), $dditionally, *e note the interest o0 these $ustralian investi%ators in the relationshi/ o0 ecolo%ical /rinci/les to the s/eci0ics o0 oral disease) This is em/hasi3ed in the 0ollo*in% +uotation! ,JThere is a /ossibleK causal role 0or the host 0actors and Jthere is the su%%estionK that the ty/e and severity o0 /eriodontal disease<s= are re0lections o0 the com/etence o0 the host de0ense rather than o0 the virulence o0 commensal oral or%anisms) ) ) JIt can beK /ostulated that chronic /eriodontal disease results *hen environmental 0actors, s/eci0ically those that com/romise the /eri/heral blood su//ly, disturb the delicate balance bet*een host and /arasite in 0avor o0 the /arasite))), Finally, the im/ortance o0 ascorbates is also em/hasi3ed as one o0 a number o0 contributin% 0actors to the %enesis o0 /eriodontal /athosis! ,)))It has been established that 20 /ercent o0 %in%ival colla%en is turned over daily))))Fibroblasts re+uire ascorbate to /roduce colla%en) 'ence, the hi%h turnover o0 %in%ival colla%en /robably renders %in%ival remodelin% and re/air /articularly vulnerable to ascorbate de0iciency) @itamin C is also re+uired by /olymor/hs in their vital de0ense role)

,The /ha%ocytic and chemotactic 0unctions o0 the *hite cells re+uire vitamin C concentration *ithin the cell)))$lthou%h debate continues concernin% the re+uired /lasma ascorbate levels, it a//ears likely that the demand 0or ascorbates and essential metabolites 0or de0ense and re/air o0 %in%ival tissue may be met in the /resence o0 chronic in0lammation, smokin%, stress, inade+uate diet, a%in%, or any other vaso4 constrictive 0actors))), It should be em/hasi3ed that *e have lots o0 data about vitamin C because *e have studied the ascorbates e8tensively) What the results *ould be de/endin% u/on other vitamins, as *ell as other dosa%es in terms o0 host resistance and susce/tibility, is an unans*ered +uestion) 5evertheless, the 0act o0 the matter is that vitamin C can serve as an invisible toothbrush)

Sources of $itamin ! %n milligrams &mg' per 1(( grams $cerola berries &e//ers, red chile Luavas &e//ers, red s*eet 9ea0y %reen ve%etables &arsley &e//ers, %reen s*eet Broccoli Brussels (/routs Watercress Cauli0lo*er &ersimmons Cabba%e, red (tra*beries 300 3AF 2"2 20" G04 #0 E2 2# 3 02 EF E# AA A GF

&a/ayas 6ran%es ? Cuice Cabba%e, %reen 9emon Cuice 9iver, cal0

GA G0 2" 23 3A

5ote! 'unter4%atherers obtained vitamin C 0rom certain or%an meats, such as adrenal %lands and /arts o0 the stomach) Many *ild 0ruits and ve%etables have much hi%her levels o0 vitamin C than those that are cultivated) Sidebar

NATURAL VERSUS SYNTHETIC VITAMIN C

)y homas !o*an+ MD It is common these days to use the terms vitamin C interchan%eably *ith ascorbic acid) In 0act, there are numerous di00erences bet*een these t*o very distinct biolo%ical entities) @itamin C, 0ound in numerous /lant and animal 0oods, is a necessary nutrient 0or humans in that *e make none o0 our o*n vitamin C) 5atural vitamin C is a com/le8 mi8ture o0 at least F or 0 distinct molecular entities) These include ascorbic acid <the /reservative /art o0 the com/le8=, tyrosinase <an en3yme=, rutin, bio0lavenoids, co//er, man%anese, and other en3ymes and minerals) Each o0 these com/ounds has a syner%istic e00ect *ith the other substances, the end result bein% a /otent and com/licated com/ound that has 0ar4reachin% biolo%ical e00ects) (ome o0 these e00ects include reducin% ca/illary 0ra%ility <thus reducin% the tendency to bruisin% or bleedin%=, im/rovin% the inte%rity o0 the colla%en 0ibers, bindin% and thereby neutrali3in% histamine <lessenin% aller%ies=, and many other vital 0unctions) $scorbic acid has only one e00ect, that is anti4o8idation) While many nutritionists and /hysicians sin% the /raises o0 anti4o8idants in our diet, the 0act is that e8cessive anti4o8idation inhibits our cellular mechanisms 0rom di%estin% and dis/osin% o0 un*anted tissue) This is /erha/s *hy the latest studies on e8cessive use o0 ascorbic acid sho* that it may contribute to the develo/ment o0 coronary artery disease) This situation *ould never arise 0rom the use o0 the *hole vitamin C com/le8 as 0ound in natural 0oods)

,eferences ) $ational Institutes of !ealth %rochure $o. &'-(()*, Bethesda, 2) () De/artment o0 'ealth and 'uman (ervices)

2) Clark, ;)W), Cheraskin, E) and >in%sdor0, W)M), ;r) $n Ecolo%ic (tudy o0 6ral 'y%iene) +ournal of ,eriodontology-,eriodontics "0! M#, "EA4"#0, $u%ust FAF) 3) (chorah, C) ;)@itamin C (tatus in &o/ulation Lrou/s) I5! Counsell, ;)5) and 'orni%, D)') @itamin C <.scorbic .cid= F# )En%le*ood, $//lied (cience &ublishers) ") Cheraskin, E) and >in%sdor0, W)M), ;r)@itamin C (tate in a Dental (chool &atient &o/ulation) +ournal of the /outhern California /tate Dental .ssociation 32! M 0,3EG43E#, 6ctober FA") G) Cheraskin, E), >in%sdor0, W)M) ;r) and (isley, E)9) The 0itamin C Connection F#3)5e* Nork, 'ar/er and >o* &ublishers, Inc) <hardback= F#") 5e* Nork, Bantam Books, Inc) </a/erback=) A) Cheraskin, E)The 0itamin C Controversy1 2uestions and .ns#ers) F##)Wichita, BioCommunications &ress) E) Cheraskin, E)@itamin COWho 5eeds It. FF3)Birmin%ham, $rlin%ton &ress #) $rnim, ()()Thou%hts Concernin% Cause, &atho%enesis, Treatment and &revention o0 &eriodontal Disease) +ournal of ,eriodontology 2F! M3, 2 E4223) ;uly FG#) F) $rnim, ()()Microcosms o0 the Mouth P >ole in &eriodontal Disease) Te"as Dental +ournal #2! M3, "4 0, March FA") 0) Coven, E)M)>elationshi/ o0 @itamin C (tate and 6ral 'ealth o0 a &edodontic Lrou/ in a &re/ayment &ro%ram) Industrial 3edicine and /urgery 2"! MG, " 04 " 2, May FAG) ) 'olmes, C)B) and Collier, D)&eriodontal Disease, Dental Caries, 6ral 'y%iene and Diet in $dventist and 6ther Teena%ers) ;ournal o0 &eriodontolo%y 3E! M2, 004 0E, March4$/ril FAA) 2) Mandel I)D)'istochemical and Biochemical $s/ects o0 Calculus Formation) ,eriodontics ! M2, "34G2, March4$/ril FA3) 3) Cohen, M)M)The E00ect o0 9ar%e Doses o0 $scorbic $cid on Lin%ival Tissues at &uberty) +ournal of Dental 4esearch 3"! MG, EG04EG , 6ctober FGG) ") Duster*inkle, (), Cheraskin, E) and >in%sdor0, W)M), ;r) Tissue Tolerance to 6rthodontic Bandin%! $ (tudy in Multivitamin4Trace Mineral (u//lementation) +ournal of ,eriodontology 3E! M2, 324 "G, March4$/ril FAA) G) 9ane, W)B), 5utrition and 6ral >es/onse to 6rthodontic Bandin%) 5niversity of .labama /chool of Dentistry Thesis, $u%ust FA#) A) Waerhau%, ;)Current Basis 0or &revention o0 &eriodontal Disease) International Dental +ournal E! M2, 2AE42# , ;une FAE) E) Lreene, ;)C)6ral 'ealth Care 0or the &revention and Control o0 &eriodontal Disease4>evie* o0 the 9iterature) 6orld 6orkshop in ,eriodontics FAA) $nn $rbor, 2niversity o0 Michi%an &ress, //) 3FE4"GG) #) Waerhau%, ;)E/idemiolo%y o0 &eriodontal Disease P >evie* o0 the 9iterature)6orld 6orkshop in ,eriodontics FAA) $nn $rbor, 2niversity o0 Michi%an &ress, //) # 4222) F) Clarke, 5)L) and Carey, ()E)Etiolo%y o0 Chronic &eriodontal Disease! $n alternative &ers/ective) +ournal of the .merican Dental .ssociation 0! MG, A#FPAF , May F#G) This article a//eared in 6ise Traditions in 7ood, 7arming and the !ealing .rts, the +uarterly ma%a3ine o0 the Weston $) &rice Foundation, (/rin% 200 ) About the Author