Nutritional deficiencies and dentofacial growth /certified fixed orthodontic courses by Indian dental academy

Nutritional deficiencies and dentofacial
growth.
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


Contents
-Introduction
-classes of nutrients
-disturbances in carbohydrates
-disturbances in lipids
-protein deficiencies
-mineral deficiencies
-vitamin deficiencies
-nutrition and growth and development

-nutrition and skeletal maturation
-nutrition and dental tissues
-nutrition and the oral mucosal tissues
-nutrition and craniofacial malformations
-nutritional status on tooth movement and tissue response
-conclusion


Introduction
- Nutrition is defined as the science of how the body utilizes
the food to meet requirements for development ,growth,
repair and maintenance.
-There are six classes of nutrients found in foods
Carbohydrates
Proteins
Fats
Vitamins
Minerals
Water

-These nutrients can be further divided into 2 types
essential –they are that which the body cannot manufacture in
sufficient amounts.
proteins ,fats,water soluble and fat soluble vitamins and
minerals.
non essential- they can be manufactured in the body from the
raw materials supplied by the food.
glucose,fructose,lecithin,cholesterol.


Energy producing nutrients –they provide calories and enable the
body to generate energy for carrying on it many functions.
carbohydrates,proteins, fats come under this category.
Vitamins ,minerals and water on the other hand do not provide
energy but facilitate a variety of activities in the body.
RECOMMENDED DIETARY ALLOWANCES have been used
as a standard for energy and nutrient intakes.RDA’S are
established for energy, proteins and many vitamins and
minerals.They are nutrient amounts in excess of what 98 pc of
the population requires to maintain health.They are not
minimum requirements or optimal intakes for all people.

Carbohydrates
-major source of energy within the human diet
-provide 4 kcal/gm
-also called ‘spare protein’as adequate amounts of carbohydrate
allows proteins to be used for tissue anabolism and not as an
energy source.
Simple sugars -monosaacharides (glucose,fructose,galactose)
- disaacharides (sucrose, lactose, maltose)
Complex sugars – polysaacharides
(starch, glycogen, cellulose)


Proteins
-They hold a central position in the architecture and functioning
of all living matter.Are the major components of bone , skin
hair ,muscle and also play a vital role in living processes.
-Used as an energy source in need ( 4kcal/ gm).
Essential amino acids- methionine,threonine,valine,trypthophan,

isoleucine,lysine,phenylalanine,histidine,leucine.
Non essential amino acids – glycine ,alanine ,serine ,aspartic acid
glutamic acid ,proline ,citrulline, tyrosine ,cystine,proline.

Lipids
-They are the energy store house of the human body providing
9 kcal/gm of energy
-They serve as adipose tissues in the body, serve to protect
internal organs, regulate temperature , carry fat soluble
vitamins .
-Lipids are divided into fats and oils.
-also classified as triglycerides, phospholipids and sterols.
-also into saturated and unsaturated fats
-unsaturated are further divided into mono and polyunsaturates


Polyunsaturated fats divided into Omega 3-fats
Omega 6-fats
-Omega 3 fats –they have their 1st double bond at the 3rd carbon
from the methyl end of the molecule.These fats include
Linolenic acid, may decrease cholesterol and reduce cardiac
disease risk by lowering BP and preventing blood clots.Hence
they are beneficial.
-Omega 6 fats – they are named so as their 1st double bond is at
the 6th carbon from the methyl end.They include essential
fatty acid Linoleic acid and are found mainly in vegetables and
meats.

 The polyunsturated fatty acids cannot be synthesized

in the body and are therefore considered essential
fatty acids . They include the linoleic acid ,linolenic
acid and arachidonic acid.

 Fats are important to oral health from the standpoint

that phospholipids are a structural component of cell
membranes , tooth enamel,dentine .They are involved
in the calcification and mineralization of teeth and
bones .In addition research indicates that high fat
foods tend to be inhibitory towards dental caries .

Vitamins
-They are a group of essential nutrients required in very minute
amounts to participate and regulate chemical reactions within
the body.
-not energy producing nutrients
-are available from foods and can be in an active or an inactive state
-They are of two types
FAT SOLUBLE - A ,D calciferol , E tocopherol , K menadione
WATER SOLUBLE – C , B (thiamine ,riboflavin , niacin , folate ,
pyridoxine ,vit B 12 , biotin , choline, inositol , pantothenic acid )


Minerals
-They provide structural components for the body.(bones ,teeth )
-They allow for nerve muscle function ,blood clotting ,tissue
growth ,repair,acid base balance of fluids .
-classified as major and trace minerals
- Major minerals –needed in amounts greater than 100mgs/ day
Ca ,Mg ,P ,K ,Na ,Cl ,S.
-Trace minerals -needed in lesser amounts –F ,Zn ,Se ,Cu ,I ,Mo
Mn.


Protein deficiencies
Protein calorie malnutrition among children is the most
important and widespread nutritional problem .It occurs in
children as two distinct clinical diseases.( PEM )
Kwashiorkar and Marasmus.
Kwashiorkar , a disease caused caused by protein deficiency
when the weaned child is given starchy and low protein food,
though the calorie intake may be sufficient. Mostly affects
children between 1 – 3 yrs whose diet are grossly deficient in
protein.


Many factors contribute to its rapid development ,the rapid
growth of the child and its high protein requirement
Clinical findings
- growth failure,height ,weight affected.
- wasting of muscles masked by edema.
- characteristic changes in skin –areas of depigmentation and
other areas of deeper pigmentation (flaky paint dermatosis)
- hair changes also characteristic.black hair loses its color and
becomes streaked with grey,red or blond color.(flag sign)
- liver is enlarged,lesions of mouth,tongue also seen.

Marasmus ,is a type of malnutrition caused primarily by a
deficiency of proteins and calories.It occurs in infants under 1
year of age.(overall lack of calories.)
Clinical findings
- growth failure
- extreme wasting of muscles,limbs are thin ,belly may be
protuberant , edema is absent.
- skin is dry ,atrophic, loose ,wrinkled.
- anemia ,hair changes ,vitamin deficiencies may be present.
- the mental status is unaffected in contrast to kwashiorkar where
the child is irritable or disinterested.

Kwashiorkar


Flag sign in kwashiorkar


Vitamin B -1 (Beri beri)
-Beriberi, which means weakness is a disease produced by the
deficiency of thiamine.
- Symptoms include fatigue, irritability, restlessness, loss of
appetite, and vague abdominal discomfort.
- Patients develop burning sensations, tingling in the extremities,
and changes in sensation such as numbness. Patients may
develop mental confusion and psychosis. Heart manifestations
include heart failure with shortness of breath (dyspnea) and
cyanosis (bluish tinged skin). Neurologic symptoms are caused
by degeneration of the nerve fiber and its insulation (myelin).










There are two kinds of beriberi: dry and wet.
Dry beriberi is associated with energy deprivation and
inactivity characterized by mental confusion, peripheral
neuropathy, muscular wasting with loss of function or
paralysis of the lower extremities. (neuromuscular symptoms)
Wet beriberi is resultant of high carbohydrate intake along
with strenuous exercise characterized by edema, tachycardia,
pulmonary congestion, and enlarged heart.(edema)
Cardiac beri beri – cardiac decompensation
Wernicke kosakoff syndrome in alcoholics.


Vitamin B 2 (riboflavin)
-Riboflavin deficiency is particularly common in children.
-The diagnostic lesions are usually limited to the mouth and
perioral regions.
-Mild form begins with glossitis .Filiform papillae become
atrophic while the fungiform papillae are normal.In severe
cases the tongue becomes glazed and smooth owing to the loss
of all papillae, assumes a purplish red colouration (magenta
coloured)
-maceration and fissuring of the angles of the mouth ( angular
cheilosis)
-lips are red and shiny due to desquamation.
-white moist maceration can be seen (perleche).

-Riboflavin deficiency also effects the nasolabial folds and alae
nasi ,which exhibit a scaly ,dermatitis.
-Ocular changes consisiting of corneal vascularization
photophobia are also seen.
-Prenatal riboflavin deficiency can cause the following postnatal
effects.
-shortness of the maxilla and mandible
-cleft palate and anomalies of incisor teeth.
-angle `s class II maloclusion

Niacin
-The deficiency of niacin leads to a condition called pellagra
which means rough skin.
-This syndrome is identified by the three D `s.
Dermatitis –bilaterally symmetrical scaly , red , thickened
keratotic areas of the skin.
Diaorrhea
Dementia
- Oral manifestations include- entire oral mucosa is fiery red and
painful. edema of the tongue. salivation is profuse.


- Epithelium of the tongue desquamates
-Tongue is beefy red in chronic states and scarlet red in acute
conditions.
-Tenderness ,pain ,redness and ulcerations begin at the
interdental gingiva and spread rapidly.
- Superimposed ANUG infection can be present.


Casals necklace in pellagra


Bilaterally symmetrical lesions


Vitamin B- 6(pyridoxine)
-Pyridoxine is involved in a variety of metabolic processes, major
role in amino acid metabolism.
-The features of its deficiency include dermatitis , glossitis
angular stomatitis , peripheral neuropathy.
-The oral lesions bear a striking resemblance to pellagrous
stomatitis.


Vitamin B-12 and Folic acid

-Deficiency leads to megaloblastic anemia symptoms of which include
pallor ,weight loss ,glossitis ,degeneration of spinal cord.


Biotin deficiency

-scaly changes in the skin ,muscle pains ,glossitis and
mental depression

Vitamin A




Vitamin A, made from carotene exists as retinol, retinal,
retinoic acid, ( formerly called "prealbumin" or
"transthyretin"). It is responsible for maintaining the
differentiation of certain special kinds of epithelium and in
deficiency states, epithelial surfaces of all kinds tend to
undergo squamous metaplasia and hyper-keratinize.
The best known symptoms of deficiency are xerophthalmia
(from loss of differentiation of the mucus cells of the cornea),
Bitot's spots (masses of desquamated keratin on the cornea or
conjunctiva), keratomalacia (excess keratin on the cornea,
which gets macerated and infected ) resulting in blindness.

-Deficiency of this can lead to night blindness (nyctalopia)
-Due to keratinization of the epithelial tissues ,there is increased
susceptibility to infections of all membranes protected by
mucus.
-Follicular keratosis –skin change ( goose flesh )
-Dental changes include -retarded erruption rate
-hyperplastic giniva
-retarded alveolar bone formation
-pdl disease and microabscesses
-disturbed enamel and dentine formation
- enamel hypoplasia

Vitamin C
-it is involved in the formation of collagenous intercellular
substance,found in cartilage ,bone ,dentine ,vascular
epithelium,it helps maintain body structure.
-other functions include synthesis of steroid hormones ,release of
iron, formation of folinic acid, antioxidant property.
-deficiency results in the condition called SCURVY
-joint pains ,poor growth , poor wound healing and susceptibility
to infections.
-easy bruising – ecchymoses
-petechial hemorhhages ,bleeding gums , loose teeth

-tenderness associated with the joints.
-the hair of the body assume a corkscrew form and pinpoint
bleeding around the hair follicles can confirm the diagnosis.
-the osteoblasts fail to form osteoid and the calcified matrix
material is not destroyed with a wide zone of nonossified
matrix called the scorbutic lattice.
-there is fracturing of the calcified matrix material leading to the
characteristic Trummerfeld zone.
-the area between this zone is free of hematopoietic cells and is
made of connective tissue cells –so called Gerustmark.

Corkscrew hair in scurvy


Peringual hemorrhages


Oral manifestations of scurvy


Scorbutic rosary


Vitamin D
- It occurs in two forms , vit D2-ergocalciferol and vit D3cholecalciferol.
-It is not a dietary essential when there is adequate exposure to
sunlight and it is the only vitamin known to be converted to a
hormonal form.
-Plays a key role in regulation of calcium and phosphorus
effecting bone mineralization.
-Deficiency results in faulty mineralization , resulting in
RICKETS in children and OSTEOMALACIA in adults.

Rickets


-Dental manifestations include
disturbed calcifications of enamel and dentine.
delayed erruption of deciduous and permanent teeth
jaw bones are thickened
maxilla is narrow and palate is high,mandible is short
misalignment of teeth in the jaws.
higher caries index
enamel hypoplasia


Osteomalacia
-it is also called as Adult rickets.
-characterized by poor calcification of bones and resulting
deformities.
-it differs in etiology as it is a degenerative change –a
decalcification of bone already formed rather than faulty
growth.
-its common in women during pregnancy.
-softening and distortion of the skeleton with increased tendency
towards fracture. (brittle bones)
-pelvic deformities are common.

Vitamin E
-It has also been given the name –tocopherol which means ,the
alcohol which brings forth offspring.
- its mainly known for its antioxidant properties.
- also prevents the peroxidation of polyunsaturated fatty acids.
- its deficiency can have the following effects
- increased fragility of the red blood cells ( hemolysis ,anemia)
fat malabsorption , cystic fibrosis .
- vit E has gained a great deal of public and scientific attention
due to its anti aging effect ( antioxidant property prevents the
accumulation of free radicals causing cell damage in aging )

Vitamin K
-it exists in three forms K1 –phylloquinone
K2 - menaquinone
K3 – menadione
-it is necessary for synthesis of prothrombin and other blood
clotting factors by the liver.
-also helps in growth.
-deficiency rare in adults but can be seen in new born infants
resulting in hypoprothrombinemia.
-most common oral mainfestation is gingival bleeding.

Menke`s kinky hair syndrome

-Depigmentation of the skin and hair ,hypotheria ,seizures ,cerebral
degeneration ( impaired activity of cu containing enzyme )

Wilson`s disease
-This disease is characterized by markedly reduced serum copper
and cerucoplasmin levels,not due to a deficiency but rather due
to abnormal hepatic copper storage.
-most of the copper remains loosely bound to albumin and can be
transferred more readily to the tissues.
-the liver and the lenticular nucleus of the brain contain
abnormally large amounts of copper.
-Kayser-Fleischer rings - eye signs.


Wilson`s disease


Iron deficiency anemia


Fluorine deficiency


Disturbances in carbohydrates
-Since carbohydrates form a large part of our diet , nothing is
known of the effects of carbohydrate deficient diets.There is
an important group of diseases representing disturbances of
mucopolysaacharide metabolism.
-The Hurler syndrome is their prototype and is the most common
with the following manifestations.
-begins in first two years of life and terminates in death before
puberty.
-Prominent forehead ,broad saddle nose ,hypertelorism,thick lips
coarse tongue ,open mouth , nasal congestion.

-short neck , spinal abnormalities , flexion contractures result in
claw hand
-oral manifestations include
- short broad mandible,wide intergonial distance
- spacing of teeth
- localized areas of bone destruction with represent hyperplastic
dental follicles with large pools of mucopolysaccharides.
- gingival enlargements, enlarged tongue.


In the skull, changes of Hurler syndrome consist of premature
closure of the sagittal and metopic sutures, resulting in
scaphocephaly. The sphenoid bone is hypoplastic, resulting in a
shoe" shaped sella. The skull itself is typically thick with frontal
bossing and small facial bones.


Disturbances in lipids
-disturbances of lipid metabolism though rare do occur and result
in a particular group of diseases –the lipid storage diseases.
-these include the following
Hand Schuller Christian disease
Eosinophilic Granuloma
Letterer –Siwe disease
-Oral manifestations
Ulcerative lesions,gingival hyperplasia,diffuse destruction of
the maxilla and mandible causing loosening of teeth and
premature loss.

Hand Schuller Christian disease

Skin lesions

Osteolytic lesions of frontal, parietal
Bone.


Nutrition and dentofacial growth
-Growth is defined as an increase in size resulting from the
multiplication and enlargement of cells and comprises of three
phases.
first phase – hyperplasia
second phase --- hyperplasia and hypertrophy
third phase ---hypertrophy
-Growth and development are affected by nutritional
environment
-The diet can affect the process of cell replication and
enlargement thus influencing tissue and organ growth
- Many nutrients affect the enzymatic processes of the body
and thus enzymatic regulation is also influenced by diet.

- The points at which a nutrient deficit occurs during the growth
can have just as important an impact as the type of nutrition
deficit involved .These are often referred to as the ‘critical
period of growth .
-For ex- permanent damage from decreased cell numbers of a
particular tissue or organ may be the result of inadequate
nutrition during the hyperplastic phase of growth.If the same
deficit occurred during a hypertrophic phase , however, then it
may be compensated for later, in the way of catch up growth
when nutrition is adequate.

-The critical period concept reveals the importance of nutrition in
allowing the body to attain its full growth and development
potential.Oral tissues are no less susceptible to nutritional
stresses that may affect a person`s oral health and wellness
througout life.
LAW OF MINIMUM (formulated by Justus von Liebig 1843)
…. Among the nutrients essential for growth , the one which is
furnished in minimum amount (relative to the need for growth
at normal rate ) will thereby determine the rate of growth ,the
organism growing only to extent that it can increase in size .


- The law of minimum is applicable to proteins but not to
minerals since the body may grow to adult size although poor
in calcium and other minerals. Children with poor bone
structure may still grow to average or normal size.


Nutrition and craniofacial malformations
-Animal experiments show that maternal dietary deficiency even
when experienced for a brief time during a critical period
results in some biochemical alterations followed by
morphologic changes.This is true when vitamins are disturbed
and nucleic acid synthesis suffers.Maternal diet affects the
later part of antenatal life rather than during the early weeks of
organogenesis.
-Suboptimal levels of these nutrients may potentiate other
terratogenic factors .The possibility of vitamins and trace
minerals being suboptimal during pregnancy is great.The use
of alcohol and other drugs may increase the requirement for
certain nutrients.

-The administration of riboflavin or pyridoxine to mice reduced
the incidence of cortisone induced cleft palate.
-Zinc provides an example of a nutrient for which even a short
term dietary deficiency could be terratogenic.No mobilizable
store exists for zinc necessitating that it regularly be present in
diet.
-A large variety of malformations have been found in the new
born of mothers with severe vit A deficiency
-Deficiency of riboflavin - results in shortening of mandible
cleft palate and other skeletal malformations.

- Cleft lip and palate is one craniofacial anomaly of particular
interest.This condition can be induced in animals by
nutritional deficiencies such as those of folic acid , riboflavin
and zinc .
- Retrospective studies of the histories of pregnancies resulting
in clefts suggest that vitamin and trace metal levels have an
influence.


Nutrition and the teeth
-As tooth development begins in utero and extends into adult life
nutrition exerts a pre erruptive and a post erruptive effect.
-Hence teeth are affected in 2 distinct ways
Local effect –depends on the intra oral chemical or physical
action on the external surfaces of the teeth and oral tissues due
to the products of masticatory and bacterial action on various
food stuffs.
Systemic effect –is important during the period of tooth
development. Nutritional deficiencies during tooth
development affect the tooth size ,formation ,erruption time
and caries attack

- Protein deficiency – poor bone calcifications ,retarded centres
of calcifications ,delayed tooth erruption ,retarded jaw growth
crowded dentitions.
- Calcium ,Vit D,P deficiency –result in retarded jaw ,tooth and
condyle development ,defective enamel and dentine,loss of Pdl
and bone resorptions.
- Vit C deficiency – loss of connective tissue ,gingival bleeding
tooth mobility ,incresed pdl disease .As it is vital to collagen
production for formation of teeth and bones .Also important in
healing of oral tissues due to its anti oxidant property.

-Vit A is indispensable for the proper growth and development
of the periodontium ,teeth ,salivary glands and oral epithelium.
Deficiency can lead to the following
-changes in the ameloblasts –loss of physiologic ability and
anatomical changes resulting in defective and decreased
matrix formation. Enamel hypoplasia.
-endochondral or replacement bone growth is retarded.
-arrest in compact bone formation
-eventually all skeletal growth development dependent upon
replacement of endochondral bone formation ceases.

Nutritional effect on tooth movement and tissue
response to appliances
-Tooth movement relies on the biologic response of the pdl and
alveolar bone to applied forces and this tissue response is
analogus to healing
-And as the orthodontic patient is selectively treated during the
adolescent growth spurt which provides an additional
challenge to his nutritional status.
-During this healing some nutrients which are nonessential
become essential or are required in higher levels.
Aspargine which although is categorized as a non essential amino
acid has been shown when deficient to inhibit growth and
healing in demineralized bone matrix implants in rats.

Ascorbic acid is a classical example of a nutrient that may
influence the biologic response to forces.It has been reported
that 17 to 72 pc of orthodontic patients may have suboptimal
levels of ascorbic acid. The rationale for its effect is based in
part on the fact that a lack of it interferes with collagen
synthesis by preventing hydroxylation of proline to
hydroxyproline, affecting the pdl and formation of osteoid.
Ascorbic acid may also influence Retention. In a study using
separation of guinea pig incisors the group that was deficient
showed a more rapid relapse.

-Nutritional status may also play a role in the gingival response
to orthodontic bands and brackets. Since bands and brackets
present a stress to the periodontium, especially in regard to
increased exposure to retained debris, tissue tolerance needs to
be maximized.
-Dusterwinkle et al. (J .Periodontology 1966) studied the tissue
tolerance to orthodontic banding.He concluded that oral health
and disease is a function of the product of the degree of host
resistance and the magnitude of the environmental challenge.A
nutritional status adequate to support a healthy pdl in a non
banded situation may provide suboptimal host resistance in a
banded situation.

Nutrition and skeletal maturation
-

-

-

Prolonged nutritive failure in growing children shows a
retarding influence on each of the 28 bone centres in the hand
and the wrist which are used as indicators of skeletal
maturation.
Correction of dietary deficiencies brings an acceleration in the
overall rate of skeletal maturation but does not equally affect
all the bone centres.
The fastest growing centres generally show the greatest
relative response to dietary correction,whereas the slowest
growing centres do not demonstrate a preferential utilization
of nutrients.

Nutrition and the oral mucosal tissues
-The nutritional state of a person is often manifested in oral
tissues due to the rapid turnover of cells in this area and the
bacterial onslaught the area receives .The soft oral tissues are
sensitive to nutritional and dietary deficiencies.
-Healthy oral epithelium experiences a 3 day to 7 day cell
turnover and acts as an effective barrier to toxins.Inadequate
nutrition may cause the tissues to breakdown ,become infected
and develop lesions.
Vit B complex deficiency – magenta , raw, fissures ,smooth or
swollen tongue.Angular chelitis ,itchy eyes and scaly
dermatitis may also occur.

-Patients with iron deficiency may present with pallor ,spoon
shaped nails ,pale ,atrophic tongue ,pale conjuctivae and
sensitivity to cold.
-Routine periodical examination of the mucosa ,the tongue ,lips
and the saliva is helpful in determining the nutritional status.


Conclusion
-In the past ,the extent of a dentist `s nutritional counselling
involved advising patients to reduce consumption of sweets
and frequency of snacks.However much more is required
today.
-Dentists must be aware of how nutrition impacts general and
oral health and how dental treatment affects the nutritional
status .Compared with other other health care workers the
dentists reach a large number of people per year and as the
dental visit is of longer duration than the medical visit ,better
opportunities for motivational interventions are present.


-Patients should be assessed for signs of nutrient imbalances and
if they are suspected then appropriate referrals should be
made.
-Incremental increases in height and weight as compared with
standards are one of the best measures of satisfied nutritional
needs ,although they are not diagnostic for borderline
states.Thus the orthodontist who usually uses these data for
growth prediction is able to estimate past nutritional status
.Additionally the presence of bands and brackets should alert
the orthodontist to the cariogenecity of the diet.Perhaps the
best method for patient education is the diet history.

While orthodontists will rarely see the frank manifestations of
nutritional deficiencies ,it should be recognized that
suboptimal levels of certain nutrients are common and have an
effect on the biologic responses of the tissues influenced by
orthodontic treatment.
Additionally the age group typically involved in orthodontic
treatment has particularly high nutritional demands and
particularly poor dietary behaviour.


References
- Nutrition and oral health.Laura M Romite . Dent Clin N Am
47,2003, 187-207.
- Nutritional considerations in orthodontics.Wayne Hickory ,
Ravindra Nanda .Dent Clin N Am 25 ,1981 ,195-201.
- Principles of nutrition and diet therapy .Barbara Luke.
- Nutrition in health and disease .Lenna Copper.
- Textbook of oral pathology .Shafer.
- Severe oral manifestation in a case of Hand schuller christian
disease. F.Kokelj ,C.Plozzer.Acta dermatovenerologica,2001
vol no 3.

- Osteolytic lesions in the calvarium- an important manifestation
of Hand schuller christian disease. V K Sharma .
Ind J Radiol Imaging 2002 ,12:3:391 -392.
- Effect of aspargine on demineralized bone matrix implants.
Hickory .J.D.R 58,139,1979;187.
- Tissue tolerance to orthodontic banding.
Dusterwinkle , J.Periodontology 37;132;1966
- Orthodontic tooth movement during an ascorbic acid
deficiency.
Litton ,A J O 65.290;1974.

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