Why was the Vipeholm Study done and why have
this symposium?
BO KRASSE
Department of Cariology, Faculty of Odontology. Unimrsitj of Gothenburg, Gothenburg, Sweden
In the 193O's it had been elearly documented
that the dental health in Scandinavia was
extremely poor. This led, in Sweden, to some
important decisions. The first of these was
the resolution in the Swedish Parliament in
1938 that a Publie Dental Service be orga-
nized. When the service was planned, it was
found that the costs would be very hea\'y as
the need of dental care was tremendous. This
finding resulted in a proposal to the Parlia-
ment about the need for research on preven-
tion, and the Swedish government requested
the Medical Board "to perform in collabora-
tion with the Board of the Dental School a
general investigation concerning what mea-
sures should be taken to decrease the fre-
quency of the most common dental diseases
in Sweden."
Comprehensive committee work started
which gradually resulted in the decision to
perform a clinical study on diet and dental
caries at Vipeholm Hospital, a hospital for
the mentally deficient outside Lund. It was
thought that an institution of this type with
a large number of practically permanent pa-
tients would provide an opportunity to per-
form long-term nutritional studies under
well controlled conditions. In the introduc-
tion (1) it was stated: "Studies hitherto avail-
able had not provided a definite answer to
sueh basic questions as to whether dental
caries should be regarded as the expression
of a disturbance of the general condition
of the patient, e.g. a deficieney disease, or
whether it was due to loeal oral factors relat-
ed to the diet."
Today this statement may seem strange but
it was made just a few years after DEAN had
shown that fluoride in the drinking water
could have a caries protective effect. Further-
more, SoGNNAES (2) had just suggested tlie
hypothesis that a high sogar intake could af-
fect the metabolism ofthe tooth during its de-
velopment. He pointed out that the caries
eun'e during World War II first reached a
minimum several years after the deepest drop
in the consumption of sugar. It also should be
stressed that reliable animal models had not
yet been developed and that results from
studies on humans were contradictory. The
situation at the time ofthe study has been re-
viewed by GnsTAFSsoN (3) and this paper
should be read by those who, on the basis of
our present knowledge and ethical require-
ments, criticize the Vipeholm study.
In this connection it ought to be empha-
sized that before the invesdgation started the
plan was presented to the government and
to the parliament and that the Medical
Board in Sweden was responsible for the
study. The physicians at the hospital checked
the general health of the patients at regular
intervals and dentists regularly examined
their teeth.
100 KRASSE
Studies and organization
The studies at Vipeholm started in 1945 and
ended in 1954. They can be divided in three:
I. The clinical experimental studies ofthe
relationship between diet and dental
caries (4)
II. Supplementary studies
III. Special studies
The clinical experimental studies started
with a preparatory period in 1945, during
which the padents were selected and the
recording methods were developed. After
that followed the Vitamin Study (1946-47),
during which the effect of different supple-
ments on caries activity was examined.
The purpose of the Carbohydrate Study
was to examine how the caries activity, as
studied under controlled conditions, is influ-
enced by the ingestion of earbohydrates-
During Carbohydrate Study I, extreme con-
ditions were applied with regard to the car-
bohydrate consumption. During Carbohy-
drate Study II the basic diet was roughly
representative of Swedish standards. The
type of sweets was, with exception of toffees,
the same as consumed outside the institution.
The daily amount was similar to that con-
sumed by some ehildren in Lund.
The results are well known and will be
discussed in detail by NEWBRUN. Here only
the main diagram (Fig. 1) is shown. It has
often been reproduced and shows that sugar
in sticky form can inerease caries activity. It
should be noted that the main conclusion is
based on intragroup comparisons, i.e. the
effect of variations in the sugar intake was
examined under controlled conditions.
A finding which did not attract as much
attention was that about 20% ofthe patients
did not develop any new carious lesions at
all, although they had a frequent intake of
sweets between meals for long periods. This
is illustrated in the lower part ofthe diagram
in Fig. 2.
Another observation which has been dis-
cussed very little was that carious lesions
continued to appear despite the avoidance
of refmed sugar and maximum restriction of
natural sugars and other earbohydrates.
In addition to the medical examination
of the patients, a number of supplementary
studies were performed. The most important
of these was on the reliability of the method
(5). Biochemical studies included examina-
tions ofthe sugar content of blood and urine
as well as pH, viscosity, buffer capacity, calci-
um, and phosphate concentration in saliva.
Microbiologie studies were concentrated oo
the lactobacilli.
A number of special studies were also un-
dertaken by members ofthe group, for exam-
ple studies on consumption of sweets and
earies activity in schoolchildren and in
Hungarian farmworkers, genetic studies on
earies free military recruits, fluoride in drink-
ing water and caries prevalence in ehildren,
inhibition of acid production by substances
isolated from the chocolate bean. Altogether,
around 25 studies were published frotn the
research station at Vipeholm.
The study was carried out under the di-
rection of the Medical Board and the gene-
ral director J. A. HojER had meetings with
the staff several times a year. The sugar
and confectionary industry supported the
studies. A scientific committee was appoint-
ed for the management of the donations
and in this committee were experts from
both the Medieal Board and the industries.
The work at the research station was led
by BENGT E. GUSTAFSSON, later professor of
medical microbial ecology at the Karolin-
ska Institute in Stockholm. GUSTAFSSON was
a top flight scientist and served for several
years as head of the Swedish Medieal Re-
search Council. It was very mueh thanks
to him that the Vipeholm study became a
solid scientific contribution. Another im-
portant member of the team was the statis-
tician Professor C. E. QPENSEL. The rest of
us were ntainly young enthusiasts in train-
ing. Altogether, around 15 persons worked
at the research station.
 WHY WAS THE VIPEHOLM STUDY DONE?
Fig.].
Why this symposium?
The Vipehoim investigation proper (1) can
be regarded as a classical study in the litera-
ture ofdental caries. It is therefore of interest
to review some of the main findings on the
basis of newer knowledge. This seems all the
more important as the caries prevalence has
dropped considerably at the same time as
the consumption of sugar and sweets has
increased. This contradictory situation,
which can generally be explained by the
protective effect offluorides,will be discussed
by NEWBRUN,
The result^ will also be discussed in rela-
tion to the extensive new knowledge which
has been gained about the microbiolog)' of
dental caries. We have learnt that sucrose
101
g- 2-
plays a key role in the establishment of
mutans streptococci on teeth and that high
sugar concentrations might favor these mi-
croorganisms. The reason for this, as well as
the metabolic activity of cariogenic bacteria,
will be discussed by J, CARLSSON and G,
ROLLA,
In different parts of the world,, the caries
prevalence varies widely, Mutans streptococ-
ci are found in large numbers in populations
with low sugar intake and low caries acdwty
as well, and P, CARLSSON will discuss this
finding on the basis of some microbiological
observations made in connection with the
Vipehoim Study, Finally, D. BIRKHED will
talk about the development and practical
use of sugar substitutes with the knowledge
of the Vipehoim study as a base.
102 KRASSE
A completely different reason for arrang-
ing this symposium is that the Vipehoim
Study has become a classical reference in
the dental literature and that it could be of
interest to discuss why. In my opinion the
main explanations are: 1) a relevant problem
was examined under controlled conditions;
2) it was shown with convincing evidence
that consumption of sugar can increase caries
activity in man; 3) supplementary studies
completed the picture and supported the re-
sults of the main study.
Reference
1. HojER JA, MAUNSBACH AB, The Vtpehoim
Dental Caries Study. Purposes and organisa-
tion, Acta Odontol Scand 1954; 11: 195-206.
2, SoGNNAES RF, Analysis of wartime caries re-
duction in European children, with special
regard to observations from Norway, Am J Dis
Child 1948; 75: 792 (only),
3, GUSTAFSSON BE. The Vipehoim Dental Caries
Study. Survey of the literature on carbohy-
drates and dental caries. Ada Odontal Scand
1954; 11: 207-31.
4, GUSTAFSSON BE, QUEKSEL C-E,, SWENANDES-
LANKE L, et al. The Vipehoim Dental Caries
Study. The effe,ct of different levels of carbohy-
drate intake on earies activity in 436 indivi-
duals observed for five years. Acta Odontol Scani
1954; 11: 232-64,
5, QuENSEL C-E, CusTAFssoN BE, GRAHNEN H.
The Vipehoim Dental Caries Study. Reliabili-
ty ofthe method in the determination of caries
activity. Ada Odontol Scmd 1954; 11: 365-88.