Oral Medicine

EXCESSIVE CITRUS JUICE CONSUMPTION. II. CLINICAL OBSERVATIONS OF ITS EFFECT ON SUPERFICIAL

AND DEEP TISSUES OF THE ORAL CAVITY

HENRY HICKS, D.D.H., GREENWCEI, (“OSX.

M Y SUBJECT, one of the most confused and abused of the past two decades, has been of special interest to me for the past fifteen years. Excessive

citrus juice consumption and its effect on the superficial and deep tissues of the oral cavity has been overlooked by professional and lay groups alike because citrus fruit juice has been oversold to the public. It, has become the standard, highly nationalized, and most advertised health food in America, its vitamin C factor a cure-all! Citrus fruit and vitamin C have become synonymous in the minds of most people. While we cannot, deny that citrus fruit is one of the best sources rich in vitamin C and that vitamin C is essential for normal connective tissue and bones and for normal metabolism,l we overlook the fact that other substances which are also present in citrus fruits may do more harm than the good that is derived from the vitamin C when taken in excess.

Since the exact requirements of vitamins are not, definitely known, the quantity of citrus fruit to be consumed to provide the normal amount of vitamin C also is not known. There are individual variations of need among people in normal health. Any figure suggested must include a, substant,ial factor of safety to afford protection. The amount of vitamin C necessary to prevent. scurvy is about 30 mg. daily,2 whereas the basic requirement is about 50 to 60 mg., and as much as 100 mg. or more is suggested for optimum nutrition and buoyant) health. Since so much emphasis has been laid on obta.ining the vitamin (1 from citrus sources alone, it would be necessary to consume from one to three, possibly four oranges per day to supply 100 mg. This number 01’ oranges will sllppl~ from two to eight ounces of juicat.

It would be uncommon for one to consume three to -four whole oranges at one time, but it, is common for one to consume the equivalent, of this in the form of juice. Those who consume a large glass of citrus juice for breakfast, usually do not stop with that but eat or drink some other similar fruit containing citrates, tartrate, or malate with other meals during the day. I-Ience, over a period of time an excess of these substances must. be handled by t,he body and in my opinion may be the cause of the detrimental effects I am about to describe.

That this is a most confused subject is evidenced by the fact that during the last two decades all sorts of professional and lay persons have written that ingestion of large quantities of citrus fruit juice is healthful and have advised its use.

Read before the monthly conference of the New York Institute of Clinical 01’al Pathology. Dec. 18, 1950.

EXCESSIVE CITRUS JUICE CONSUMPTION. II 859

To illustrate, I quote from one of the leading lay magazines. As a recom- mendation for a prettier skin the article states breakfast should include “fruit juice, large glass (choose from orange, grapefruit, pineapple, apricot or other nectars)-Lunch :-Stewed fruit (such as figs, prunes, pears, apricots, peaches) or gelatin dessert and fruit or tomato juice, large glass.-Dinner-Clear soup or fruit cup-stewed fruit or gelatin dessert.“3

A standard obstetrical text recommends the daily consumption of 200 C.C. of orange juice,4 and the substitution of a variety of fruits including “i/z grape- fruit twice daily-to take the place of the ordinary rich pastries and desserts.“’

These are only two examples of* the numerous diets which contain quantities of citrus juices and that are being followed for other purposes such as weight reducing, treatment of hypertension, and treatment of common colds. These diets may or may not have merits. However, there is the question of whether in an attempt to meet adequately the requirements of vitamin C, citrus fruit, juice, as the sole source, is not overemphasized. Many other fruits and vege- tables are fairly good sources. Green peppers, for instance, are extremely rich in vitamin C but no one would think of eating three or four peppers at a time.

I have discussed this aspect of the subject in detail because it is not my purpose to disagree with the findings of investigators regarding the beneficial effects of moderate quantities of citrus fruits upon connective tissue, but “moderate quantities” should be strongly emphasized. As professional individ- uals we have learned to recognize the results of an overdose of drugs, food, and drink. It is rather shortsighted on our part not to conceive that serious effect,s might result from this innocent food drink, the citrus juice.

After fifteen years of clinical observations (and three more in retrospect) on the patients who have come to my office for treatment, I find that there is definitely an element of harm from the ingestion of large quantities of citrus fruit on the deep and superficial tissues of the oral cavity. These effects include hyperemic gum tissue, easy and excessive bleeding, marked mobility of teeth, loss of alveolar process, hypersensitiveness of the oral tissue. Incidentally, many complaints referable to other systemic conditions have been noted by many of these patients. These include headaches, constant physical exhaustion, and stomach pains following ingestion of citrus juice, dizziness, prolonged common colds, and joint pains. Several patients showed various allergic manifestations.

Starting in 1932, I kept very close observation of all patients who came to see me for treatment, actually doing all the prophylaxis and periodontal treat- ment. This is essential to detect the changes that are diminished or modified by prophylaxis. All patients were questioned regarding their citrus fruit intake, and in addition complete dietary histories were also carefully taken. All those who were found to have hyperemic gum tissue and hypersensitive teeth were instructed either to eliminate temporarily all citrus juices, substituting ascorbic acid, 50 mg. daily, or to reduce the juice intake to an equivalent of three oranges per week. Vitamin B and calcium were prescribed where diets were found to be deficient in these substances.

The case reports illustrated by x-rays are of patients who have habitually taken large quantities of citrus fruits, of those who have taken and stopped, and of those who have always taken normal quantities of whole fruit.

860 IHENRY ~mxs

Case Reports Case l--This patient may bc (*l;lssified as an h;ll)itual drinker ot’ large

quantities of citrus juice.

One Feb. 10, 1934, a white female schoolteacher, 21 years of age, came to this office for dental care with the complaint of an aching tooth on the lower right side. X-rays (Fig. 1, A) revealed an apical abscess on the lower right first molar, the second having been lost a few years previously. The patient was found to have a complement of 28 teeth with all wisdom teeth missing except the lower right. There were seven fillings, five occlusal on first and second lower left molars and first and second upper right molars and first upper left molar, 2 proximals, a distoclusal on upper left second premolar, and a lower right distoclusal on first molar. The x-rays also disclosed 10 proximal cavities with penetration into the dentine. The alveola-r process appeared normal. Gum tissue appeared to be fairly normal but had a slightly reddish tone. There was a minimum amount of calculus deposit. The patient, had lIeen consuming I’rom six to eight ounces of orange juice daily for breakfast For about a year.

I’r&ment.-The lower right first molar was remo~,~~l using novocain anes- thesia on Feb. 12, 1934. First prophylaxis was given on April 4, 1934, and the patient was advised to reduce intake of cit,rus juices. Between Feb. 10. 1934, and July 31, 1934, all cavities were filled with inlays; second prophylaxis was given on Feb. 13, 1935. Lower right bridge was set on Narch 18, 1935; third prophylaxis was given on Dec. 12, 1935, the fourth on July 22, 1936. No addi- tional dentistry was found necessary during these two visits. The fifth prophy- laxis was given on March 2, 193’7 (F ig. 1, B), at which time several new cavities appeared, particularly cervical ones. Some were filled with inlays and some coated over with silver nitrate. Again the patient was advised to reduce the intake of citrus juices. During the ensuing years, many more proximal cavities appeared and anterior teeth were beginning to become carious in 1939. The patient began developing sinusitis during 1.940, making it almost impossible to ho any dental operative work. During all these intervening years the patient continued to consume large quantities of citrus juice. Between the period of 1939 and 1944 several more cervical decalcifications developed. Marked mobilit,y began to develop in 1939 until 1944 (Fig. 1, C) ; t,he teeth showed definite separation and open contacts. On Oct. 29, 1943, large buccal cervical decalcifica- tions were seen on lower right third molar supporting bridge. On Feb. 2, 1945, periodontal abscess developed on the lower right t,hird molar and the bridge had to be removed (Fig. 1, U). Other teeth began to be hypersensitive to air and touch and the gum showed marked hyperemia with much more marked mobility of teeth. On Jan. 12, 1949, a new bridge was made for the lower right posterior teeth (Fig. 1, E) . During the early part of 1949 the patient began developing other physical symptoms-exhaustion, nausea, stomach pains, and loss of weight. For the first time since she became my patient in 1934 she became convinced, at my insistence, that she should reduce, or temporarily eliminate, the citrus intake. Periodontal treatment was given Feb. 17, 1949, Feb. 18, 1949, Feb. 21, 1949, and March 10, 1949. All citrus juices were

EXCESSIVE CITRUS JUICE CONSUMPTION. II 861

eliminated substituting 100 mg. vitamin C. Also 12 tablets of 6.8 gr. of Brewer’s yeast were given, together with 151/2 gr. of calcium gluconate and 400 units of vitamin D daily. On May 2, 1949, the teeth were spot scaled and the gum tissue showed much improvement with less redness and less bleeding. There was less movement of teeth but the cervical surfaces were still quite sensi- tive in the posterior region.

A.

B.

c.

D.

E.

Fig. 1.-A, 1934, patient aged 21: B, 1937, aged 24; C, 1944, a.ged 31, showing open con- tacts in premolar regions; D, 1948, aged 34, bridge removed from lower third molar, periodontal abscess; E, 1949, aged 35, shows resorption of alveolar process imolving more than one-half.

To date the patient, aged 35, is once again in good health with all teeth firm in spite of the resorbed alveolar processes-no hyperemia,, no bleeding, no addi- tional caries, and no fillings since Jan. 3, 1949. Incidentally, the sinusitis disap- peared.

Case 2.-On Oct. 17, 1931, a white woman, aged 28, came to my office for dental care. X-ray examination (Fig. 2, A) revealed three missing teeth: lower left first molar, lower right first molar, and upper right third molar. There

862 HEXRT HICKS

were seven amalgam fillings; occlusal on the upper left second molar, distoclusal on the upper left first molar, distoclusal on the upper left first premolar, disto- clusal on the upper right first molar, occl~~sal on the upper right second molar, occlusal on the lower left second molar, and occlusal on the lower right, second molar. Three cavities were found: distal upper left. first molar, mcsial iippcr right second premolar, distal lower right second molar. The mout,h was very immaculately kept. Lower posterior teeth had drifted forward due to early loss of left and right first molars.

Teeth showed considerable movement and definit,e signs of resorption of the alveolar process, particularly between the upper second premolar and the first molars. There was slight redness and bleeding on touch. The patient was con- suming six to eight ounces of citrus juice daily, alternating with whole fruit in season. The habit of taking citrus juice and fruits was formed four years previously.

Treatment and Results.-Interestingly enough, at this time I did not yet realize the significance of the bleeding and the marked movement of teeth. As you will recall, the citrus fruit theory as a health-giving fruit was introduced in 1930 when the Florida Cit,rus Fruit Commission published the booklet. on the benefim of citrus fruit, Citrus Fruits and HeaZth. This booklet sold citrus fruit to the nation. I was also the victim of the propoganda at that time; hence t,he routine treatment for this patient was fillin g t,he cavities and prophylaxis. The space was retained by a yd crown inlay placed on the lower right second molar on March 15, 1932 (Fig. 2, R). Between the first visit on Oct. 17, 1931. and March 15, 1932, three gold and two porcelain inlays were inserted. Between March 15, 1932, and July 13, 1937, a t,otal of six inlays, six synthetics, one amalgam, and one gold foil were inserted and one root. canal was treated and filled with gutt,a-percha. The lower left space retainer was placed on June 20, 1933. The patient continued drinking cit,rus juice in large quantit,ies in spite of t,he fact that she was advised t,o reduce the citrus intake as early as l!l35. The teeth showed increased movement in spite of the sgacc rela.iner. About 1936, anemia developed. The number of cavities developed during t,hosc years was very significant (Fig. 2, C and 1)).

The citrus habit continued until Oct. 13, 1941, during which time anemia continued, and acne and the complaints of physical exhaustion and stomach pains developed. The patient was again advised to eliminate citrus fruit for two weeks and reluctantly she conceded. On Oct. 22, 1941, the patient was again advised to discontinue citrus fruit, for one month. Thr mouth began to improve, bleeding stopped, and hypersensitiveness decreased. I-Iowever, the stomach pains still persisted and the physician in charge, accepting my opinion, advised the patient to discontinue the citrus intake indefinitely. On Aug. 1, 1942, the patient returned for prophylaxis. The oral cavity approached normal. The teeth were more firmly imbedded and physically the patient showed remark- able improvement. Between Aug. 1, 1942, and Nov. S-5, 1945, only two new in- lays were inserted (Fig. 2, E). Between Nov. 15, 1945, and June 10, 1950, no new cavities occurred. To date all the teeth are very firm with no movement, gum

EXCESSIVE CITRUS JUICE CONSUMPTION. II 863

tissue firm, no bleeding on touching or scaling, and no progressive resorption. Acne disappeared as did the complaints of physical exhaustion and stomach pains. The latter, however, recur whenever acid food is consumed. This patient no longer consumes citrus juices ; 50 mg. of ascorbic acid daily has been sub- stituted and 0.3 Gm. calcium gluconate with the morning meal prescribed.

A.

l3

c.

u.

E.

Fig. 2.-A, 1931, patient aged 28 ; B, 1932, aged 29 ; C, 1936, aged 33, anemia developed; D, 1938, aged 35, anemia continued, facial acne, physical exhaustion, stomach pains developed: E, 1949, aged 46. After citrus intake habit was stopped in 1941, all hypersensitiveness and facial acne disappeared, bleeding stopped. Anemia condition improved, physical exhaustion tias not as acute. stomach pains still existed when acid juice was consumed,

Case 3.-On March 11, 1925, a white woman, aged 33, schoolteacher, came to my office for routine dental treatment. X-ray examination showed lower left and right first molars missing; also upper left and right third molars ‘(Fig. 3, ,4 and B). Three devitalized teeth and several inlays and amalgam fillings were found in both the upper and lower teeth. Teeth and gums were found to be in

864 HENRY HICKS

excellent normal condition. There were no signs of boric resorption nor tooth movement. There was no recession. Diet was found 1 o be normal, cit,rus int,ake also normal, three whole oranges per week, alterne,tin, u tlaily me orange with one helping of other fresh, canned, dried fruits.

Treatment c~cl Results.-Outside of routine dentistry, fillings and bridgc- work, nothing was done. No attempt was made to interfere with the well- established good diet nor the citrus intake which had been three whole oranges per week. On Feb. 14, 1944, the upper left second premolar was removed be- cause the tooth was fractured by an accident (Fig. 3, (2 and D). From 1925 1 o 1950 the oral cavity appeared normal; there has been no change in the gingivae and no signs of resorption. Prophylaxes were given at normal intervals during the twenty-five year period. This excellent condition, in my opinion, is attribu- table to good diet and care.

A.

8

c.

Fig. 3.-A, 1935, patient aged 44 ; R, 1938, aged 47 ; C, 1944, aged 53, upper second pm- molar accidentally fractured and removed; D, 1950, aged 59, no change in normal oral tissue. no sign of alveolar resorption.

Case 4.-On Dec. ‘7, 1936, a white male patient, aged 37, came to my office for treatment of a toothache on the lower right third molar which was found to have a very large cervical cavity with the nerve almost exposed. The tooth had a large amalgam filling which was removed (Fig. 4, A). Examination re- vealed eleven other fillings, two occlusal amalgams on lower right second and third molars, mesiodistal inlay on lower right first molar, distoclusal on lower

EXCESSIVE CITRUS JUICE CONSUMPTION. II 865

left first molar, ocelnaal amalgam on second and third molars, left lower. The upper showed pit amalgam filling on the second right molar, and mesioclusal and distal pit amalgams on occlusal of first molar. The left upper showed disto- clusal amalgam filling on first premolar and pit amalgam filling on first, second, and third molars. The patient had normal full complement of 32 teeth with perfect occlusion. The patient was drinking six to eight ounces of citrus juice daily. The gum was red with profuse bleeding when touched, particularly during prophylaxis. There were symptoms of stomach and digestive disorder.

A.

B.

c.

D.

Rig. 4.--A, 1936, patient aged 37, citrus intake habit stopped here: B, 1942, aged 43, all Oral tissue normal; C, 1946, aged 47; D, 1950, aged 51, ora1 tissue still normal, no sign of alveolar resorption.

Treutment and Results.-Upper and lower x-rays were taken. The tooth- ache was treated with Ward’s Wondrpak and left that way until Aug. 23, 1938, at which time Wondrpak was removed and filled with copper cement. On May 10, 1942, an amalgam filling was placed over the copper cement. The first prophylaxis was given Dec. 23, 1936, at which time the patient was advised to discontinue drinking the citrus juice but to substitute three whole oranges per week alternating every other day with either fresh, canned, stewed, or dried fruits, No attempt was made to disrupt the diet routine. All cavities found were filled with inlays in the proximals, amalgam fillings on the occlusals and cervicals between Dec. 7, 1936, and April 23, 1947 (.Fig. 4, B and C). On Aug. 23, 1938, patient returned for further check-up, prophylaxis was given Aug. 29, 1938, and one additional cavity was found in the nature of an occlusal

866 HENRY HICKS

marginal repair on the lower right first molar. The condition of the oral cavity appeared normal. The gum was found t,o be in normal healthy condition and there was no bleeding. Then the patient did not return for anot,her prophylaxis and check-up until March 10, 1942, at which time the lower right third molar was veneered with amalgam filling over the old copper cement. Full mout,h x-rays showed no additional cavities and the alveolar process appeared normal. On Nov. 29, 1944, the patient returned for prophylaxis with no additional work. The mouth has been immaculately kept,. On Jan. 2, -1946, Oct. 5, 1948, and March 29, 1950, the patient was again treated for prophylaxis. The upper and lower x-ray films were taken on Oct. 7, 1950, and they revealed no change in the alveolar process and also there had been no additional cavity since Aug. 29, 1938 (Fig. 4, D). This patient has not taken citrus juirc since 1936, and the condition of the oral cavity is excellent and at t,he same t.ime he is enjoying nor- mal good health. It, is very interesting to not,e that this patient rcturnetl for* prophylactic treatment but, once every two years.

Case 5.-On Nov. 11, 1949, a white female, married, no childyen, aged :G, came t’o my office for consultation regarding periodonloc,lasia, iLilt poGhle complete extraction of upper and lower complement. oE twenty-seven teet,h. Previous to her arrival she had been to three other dcntixts who had recom- mended that all her upper and lower teeth be removed and dentures be slob- stituted.

Oral examination showed very heavy acetone odor from her breath. The gum tissue was very blue in color, bled profusely on touching, and exuded enormous quantities of pus. The t,eeth were all loose; SOIIW appeared to be so loose that one wonld have no difficnlt,y in cst,racting them without. forceps.

On questioning, the patient, revealed that she had been a diabetic all her life and was under constant care of a physician. Her physical condition was very poor and she was in a state of exhaustion. The complexion was yellowish. She was unable to do but a very minimum amount, of housework and found it necessary to take a nap every afternoon. She smoked approsimately two packs of cigarettes daily. In order to accomplish any housework at all she found it necessary to consume five oranges per day to supply a sufficient amount of quick energy. Twenty-three units of U-10 of ~qdar insulin were used before break- fast and twenty-one units before dinner at night daily. -I-rinalysis was done t,wire daily before taking insulin. Only standard diabetic foods were used,

X-ray examination (Fig. 5) revealed marked Class 1II pyonahea with a.11 teeth involved. Some pockets extended to the apices. Only five small occlusal pit amalgam fillings were found. The following teeth were missing: upper right and left third molars, lower right first molar and lower left first and second molars. Upon reviewing the s-rays I fully appreciated the three previous recommendation for complete extraction. With her depressed mental condition any procedure suggested by me would have been acceptable. With trepidation I suggested that all but twelve teeth might be temporarily saved if she wrould be willing, and also as far as her physical condition would permit, to try the follow- ing course of treatment. The physician in charge was contacted and with his cooperation the following treatment was followed.

EXCESSIVE CITRUS JUICE CONSUMPTtON. fI $67

Treatment and Results.-First step, the teet,h were all thoroughly scaled, eight one-hour treatments using Novocain anesthesia. Surgical interference was contraindicated in this instance as it was found necessary to preserve all tissue possible. During instrumentation, Paig solution was used (Paig solution con- tains phenol, aconite, iodine, and glycerin, 1, 2, 3, 4 parts by volume) as the only medicament and 50 per cent hydrogen peroxide was used as a mouthwash. The following three teeth were removed, in addition to the five that were previously removed : upper right second molar, upper right lateral incisor, and upper left second premolar. No teeth were ground and no attempt has been made to date to brace the remaining teeth.

Fig. 5.---Nov. 11. 1949, patient aged 45.

From the dietary standpoint nothing has been altered except the following: The consumption of five oranges daily was reduced to three oranges weekly, alternating with other unsweetened stewed fruits; three teaspoons calcium lac- tate with water, two teaspoons of natural cod liver oil, 50 mg. of vitamin C, three tablets of 6.8 gr. Brewer’s yeast, were consumed daily. The whole orange intake was reduced from three per week to two per week after the first three months from Nov. 11, 1949, to Feb. 13, 1950. A tablespoon of wheat germ was added at the end of six months and yeast was eliminated. The patient was found to be able to tolerate all changes without affecting the diabetic condition or any changes in the insulin intake. The average daily diet is as follows.

868 HENRY HICKS

Breakfast: 75 Gm. orange twice a week (one orange weighed aft,er pealing) , other days 75 Cm. apple sauce (s/ cup) ; 1 tablespoonful of wheat germ with milk to cover? 1 egg, I slice white brcatl toast (white. less sugar than whole wheat,), caoffec, black.

Lunch: 250 Gm. 5 per cent vegetables (sample: 2 cups strained spinach and one tomato), 1 slice white bread, 100 Gm. fresh 10 per cent fruit (one pear), tea or coffee, black.

Dinner: 90 Gm. cooked meat (j/d lb. steak cooked) 250 Gm. 5 per cent vegetable (cabbage, cauliflower, kale, Brussels sprouts) 90 Grn. potalo (1 medium potato baked with skin), 75 Gm. 5 per cent fruit (5 per cent fruit., 1 dish canned peaches, no sugar) coffee, black.

In three months from Nov. 11, 1949, to Feb. 17, 1950, all bleeding and pus disappeared and all teeth started to tighten. On Feb. 17, 1950, the occlusal surfaces of seven teeth were judiciously ground. The acetone breath also was no longer present,. At the end of six months, May 9, 1950, all the superficial oral tissue appeared normal and the teeth were very firm. The periodontal tissue reat,tached to roots; also, the patient found it unnecessary to take after- noon naps. Physical condition improved to the extent that t,he patient was doing all her routine housework and was painting the interior of her home ; in addition she was walking t,wo miles two or three times weekly without becoming exhausted.

At the time of writ,ing, Oct. 14, 1950, at the end of one year, the patient had lost the yellowish complexion and physically appeared to he a normal 36- year-old person with plenty of energy and vit,ality to carry on t,he same as any individual without her affliction. There had been no change in the insulin in- take, and no necessity for any quick energy food. From all outward indications, the patient was leading a perfect.ly normal life.

Conclusion

During these fifteen years it has been found that three oranges or three grapefruit halves or one orange and two grapefruit halves per week, inter- spacing with one normal helping daily of other whole, fresh, canned, stewed, or dried fruits, together with good dental care and adequate diet, will maintain absolutely normal oral health.

The .following conditions are traceable to t,he habitual ingestion of large quantities of tit rus fruit juices regardless of other diet factors. In occasional cases about six months are required for the development of hyperemia.

1. Hyperemia with profuse and easy bleeding of the gingivae. Between one and three years are required in the majority with otherwise adequate diets.

2. Hypersensitiveness of teeth will usually occur in about six months to one year.

3. Mobility of the teeth will be apparent in from three to seven years. 4. Contacts will begin to separate in from seven to ten years. 5. Resorption of bone will occur in about ten to fifteen years.

EXCESSIVE CITRUS JUICE CONSUMPTION. II 869

The general quality of the diet influences the speed of change caused by ingestion of excessive amounts of citrus juices. For example, it was found that those taking diets deficient in vitamin B and minerals, together with excessive amounts of citrus juice, had more rapid alveolar resorption and were more easily susceptible to pyorrhea, while those with good adequate diets and exces- sive citrus juice intake had less rapid resorption and hyperemia at a given time. In contrast, those with poor diet factors without excess citrus juice intake had less or no resorption.

However, with good diet factors after the excess of citrus juice is eliminated, all superficial and deep tissues of the oral cavity returned to normal more rapidly and remained so.

The usual age at which the marked mobility of teeth and definite bone re- sorption becomes evident is about 32 to 35 (Fig. 6). Periodontal pockets with apical involvement occur about the age of 50 to 55 and often as early as 45. Systemic complaints such as exhaustion, headaches, digestive complaints, and joint pains are usually in evidence from the age of 35 to 45.

Fig. B.-Shows approximate rate of resorption, loss of alveolar bone, and formation Of periodontal pockets.

Again, I wish to emphasize that citrus fruit is an excellent source of vitamin C which is necessary for connective tissue repair, but other substances present in this source seem to be the detrimental factor. In all cases where the excessive juice was eliminated and pure vitamin C substituted, the patient improved both generally and orally. When calcium, vitamins D and B were added, the result appeared to be more rapid and the recovery positive.

The current popular belief that ingestion of large quantities of citrus fruit juice is healthful should be carefully appraised. Citrus fruit in moderate amounts as a source of vitamin C in the diet is not to be condemned; it would seem that more than two to three oranges or one grapefruit per week is excessive in view of the fact that vitamin C is obtainable from other sonrces.6

870 HENRY IlICKS

References 1. Bodansky, Meyer: Introduction to Physiological Chemistry, ed. 4, Now York, 1938,

John Wiley & Sons, Inc., p. 594. 2. Council on Jlental Therapeutics, American Dental Association, Accepted Dental Remedies,

ed. 14, Chicago, 1950, American Dental Association. 3. Ladies’ Home Journal, p. 160, September, 1950. 4. Beck, A. C.: Obstetrmal Practice, ed. 3, Baltimore, 1942, Williams & Wilkins Company,

I). 173. 5. Ibid., Ip. 174. 6. Hicks, Henry: Excessive Citrus Juice Consumption. Clinical Observations of Its Effect

on Superficial and Deep Tissues of the Oral Cavity, J. Am. Dent. A. 41: X-44, 1950.

5 GLEP: COURT.