Periodontal disease, a bacterial infection leading to the inflammatory destruction of connective tissue and bone supporting the teeth, is a major cause of tooth loss. While often attributed to plaque buildup, the body's response and systemic health also play critical roles. Nutrition significantly affects periodontal disease, extending beyond just cavities.
Understanding Periodontal Disease
Periodontal disease is a bacterial infection that results in inflammatory destruction of the connective tissue and bone that support the teeth. As such, it is therefore one of the leading causes of our teeth falling out. Like most infections, though, the way in which our body responds may play a critical role. The standard explanation of periodontal disease is the plaque theory, which posits that the buildup of plaque leads to gingivitis or gum inflammation, which then leads to periodontitis or inflammation lower down beneath the gums. But, in some forms of periodontal disease, plaque doesn’t appear to play a critical role. There has been more interest in the last few years in the importance of systemic health, our body’s response.
The Role of Diet in Periodontal Health
Traditionally, when we think of the effects of nutrition on dental diseases, we’re only thinking about cavities. But what about the role of diet in periodontal disease? There has been less research, but if it’s about inflammation, one would expect diets rich in saturated fat to make things worse, increasing oxidative stress as well as inflammation.
Impact of Saturated Fats and Cholesterol: There does appear to be a link between cholesterol levels and periodontitis. Studies suggest that people who eat more saturated fat get more periodontitis. In one study in Japan, participants with the highest levels of saturated fat intake had double the risk.
Benefits of High-Fiber, Low-Fat Diets: "A High-Fiber, Low-Fat Diet Improves Periodontal Disease Markers" in terms of probing depth, clinical attachment loss, and bleeding on probing-all of the standard measures. Eating a healthier diet also improves body weight, blood sugar control, and systemic inflammation, but that complicates matters. Researchers have shown that you can improve periodontal disease with bariatric surgery, such as stomach stapling. After eight weeks on a diet, the study participants went back on their regular diet and gained back most of that weight. But, the periodontal disease improvements persisted, suggesting that it was more than just the weight loss that lead to the improvements.
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The Influence of Gut and Oral Flora: Might the high-fiber diet have altered their good gut flora or perhaps their oral flora?
Dietary Changes and Periodontal Inflammation
German researchers took 20 women with mild to moderate chronic periodontitis and, for a year, tried to transition their diets towards more wholesome nutrition. This meant more plant foods, more whole foods, more fresh foods-trying to center their diets around vegetables, fruits, whole grains, potatoes, and legumes (beans, split peas, chickpeas, and lentils). After 12 months, the patients showed a significant reduction of probing pocket depth and gingival inflammation. And, for the first time, the researchers measured decreased concentrations of inflammatory chemicals inside the crevice between the tooth and gums. These chemicals, which are thought to be responsible for the tissue destruction in periodontal disease, decreased by as much as 75 percent. And all the while, their oral hygiene status didn’t change, suggesting it was the diet that did it.
Recent Studies and Findings
Nitrate-Rich Diets: New data from a randomised-controlled study carried out at the University of Würzburg in Germany showed significant differences in gingival inflammation in the nitrate group compared to the control group. All patients were on a strict nitrate-poor diet. In the test group with the nitrate-rich beverage, the nitrate intake was increased by approx. 200 mg nitrate/day. There was a significant difference in the mean GI values (GI-gingival inflammation) in the nitrate group compared to the control group.
Low-Carbohydrate, High Omega-3 Diets: At the University of Freiburg in Germany, ten subjects changed their diet for four weeks. The new diet was low in simple carbohydrates (i.e. foods containing easily digested natural sugars that provide quick energy, unlike healthy complex carbohydrates such as whole grains, beans, legumes, and oats), rich in omega-3 fatty acids, vitamin D and vitamin C. It was also designed to include antioxidants and fibre. The control group did not change their dietary behaviour. Again, although plaque levels remained constant in both groups, gingival inflammation (GI), bleeding on probing (BoP), and periodontal inflamed surface area (PISA) decreased by roughly 50% in the test diet group. This reduction was significantly different compared to the control (unchanged) diet group.
Nutrition is recognized as an essential component in the prevention of a number of chronic diseases, including periodontal disease. Based on these considerations, a better understanding is required regarding how the diet, and more particularly the intake of macronutrients and micronutrients, could impact the potential relationship between nutrition and periodontal diseases, periodontal diseases and chronic diseases, nutrition and chronic diseases. To overcome this complexity, an up-to-date literature review on the nutriments related to periodontal and chronic diseases was performed. High-sugar, high-saturated fat, low-polyols, low-fiber and low-polyunsaturated-fat intake causes an increased risk of periodontal diseases. This pattern of nutrients is classically found in the Western diet, which is considered as an ‘unhealthy’ diet that causes cardiovascular diseases, diabetes and cancers. Conversely, low-sugar, high-fiber and high-omega-6-to-omega-3 fatty acid ratio intake reduces the risk of periodontal diseases. The Mediterranean, DASH, vegetarian and Okinawa diets that correspond to these nutritional intakes are considered as ‘healthy’ diets, reducing this risk of cardiovascular diseases, diabetes and cancers. The role of micronutrients, such as vitamin D, E, K and magnesium, remains unclear, while others, such as vitamin A, B, C, calcium, zinc and polyphenols have been shown to prevent PDs. Some evidence suggests that probiotics and prebiotics could promote periodontal health.
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The Interdependent Relationship of Nutrition, Periodontal Disease, and Chronic Diseases
Nutrition, PDs and the major CDs thus form an interdependent relationship throughout life. The so-called ‘common risk factors approach’, which is well accepted in public health, combines the prevention of CDs with the control of PDs, primarily by addressing a diversity of modifiable factors such as dietary risk factors e.g., micro- and macronutrients, sugar consumption, and alcohol abuse [14]. This approach suggests that a combination of interventions on the lowest common denominator, i.e., nutrition, could improve health outcomes. The aim of this review was to collect available scientific data on the potential relationship between nutrition/PD, nutrition/CDs, and PDs/CDs. The objective is to assess if a combined nutrition strategy could contribute to reducing CD risk through a reduction in the severity and incidence of PDs.
Macronutrients and Periodontal Diseases
Macronutrients consist of carbohydrates, proteins and fats. Carbohydrates are composed of sugars, starches and fibers that have different effects on PDs. While sugar and starches are sources of glucose, fibers are a nondigestible form of carbohydrates [21]. The main sources of carbohydrates are fruits, vegetables, whole grains, milk, and milk products. While grains and certain vegetables (potatoes and corn) are rich in starch, sweet potatoes are rich in sucrose. Dark-green vegetables and fruits are sources of sugars and dietary fiber [21]. Based on the American Dental Association guideline goal, the 2010 dietary guidelines for Americans, and carbohydrate consumption, Feinman et al. (2015) have defined a high-carbohydrate diet as a diet in which carbohydrates make up more than 45% of total energy intake and a low-carbohydrate diet as a diet in which carbohydrates make up less than 26% of total energy intake [22]. In the cohort of the National Health And Nutrition Examination Survey (NHANES) data, a high consumption of added sugar was associated with a higher PD prevalence ratio of 1.42 (95% CI, 1.08-1.85) [23]. The risk of gingival infection decreased to approximately half when the consumption of carbohydrates was restricted in a four-week diet [24]. Depending on the nature of the carbohydrates consumed, the effect on PD will be different. An excessive consumption of sugar or refined carbohydrates promoted microbiota dysbiosis that induced an inflammatory reaction and caused the apparition of PDs [25,26] (Table 1). Moreover, glucose acts on periodontal ligament cells by promoting their apoptosis and inhibiting their proliferation [27]. Conversely, polyols and fibers demonstrated a protective effect on the prevention of PDs (Table 1). Xylitol produced by the hydrogenation of xylose sugar had an antibacterial effect against Porphyromonas gingivalis (P. gingivalis) and Aggregatibacter actinomycetemcomitans (A. actinomycetemcomitans), two periodontal bacteria [28,29,30]. The results from a double-blind, randomized controlled trial comparing the effect of sugar-free chewing gum sweetened with xylitol or maltitol with a chewing gum base or no gum on gingivitis and plaque scores coupled with brushing or not showed that a reduction in sugar consumption, associated with scaling and root planing, and the use of gums containing xylitol or maltitol, can improve periodontal health [29]. The difference observed could be due to the fact that contrary to glucose, polyols are not metabolized by most oral bacteria [31]. Dietary fiber intake is inversely correlated to PD, as demonstrated in the analysis of the results of the cohort NHANES (2009-2012) [22] (Table 1). Salazar et al. (2018) also concluded that there was an inverse association between PD and higher consumption of whole-grains and fruits [32].
Fats: Fatty acids consist of a straight alkyl chain, terminating with a carboxyl group. The number of carbons in the chain varies, and the compound may be saturated (containing no double bonds) or unsaturated (containing at least one double bond). Milk fat, coconut oil and palm oil are sources of short- and medium-chain saturated fatty acids (SFA) (4-12 carbons). Long-chain SFAs (>14 carbons) are found in other vegetable and animal fats. Many food sources are composed of different fatty acids. Olive oil contains monounsaturated fatty acids, saturated and polyunsaturated fatty acids [34]. We identified only one study evaluating the impact of total fat intake on PDs [35]. In this study, Hamasaki et al. (2017) analyzed the results of the 2005 National Health and Nutrition Survey and demonstrated a positive association between low fat intake (23.2% of the total energy) and PDs [35]. More than the total fat intake, it is the nature of the fat that must be considered [34]. The SFA intake could enhance oxidative stress, which has been shown to be associated with PDs, exerting its effects by damaging cells [36]. One other study demonstrated that omega-3 fatty acid (polyunsaturated fatty acids) has a positive impact on PDs whereas SFAs have a negative impact [37] (Table 1). Other authors focused on the omega-6 (polyunsaturated fatty acids) to omega-3 fatty acid ratio [24]. In a review, Bosma-den Boer et al. concluded that a modern, Western lifestyle, composed of refined carbohydrates and a high Omega-6 to Omega-3 fatty acid ratio promotes inflammatory processes [25]. In a randomized controlled pilot study, Woelber et al. (2017) obtained similar results concerning the correlation between a high Omega-6 to Omega-3 fatty acid ratio and PD [24]. The positive effect observed of a decrease in the Omega-6 to Omega-3 fatty acid ratio on PD [24] supports the theory of resoleomics described by Serhan et al. [38] and the related periodontal studies [39,40,41].
Micronutrients and Periodontal Diseases
Micronutrients consist of vitamins, minerals and trace elements. The presence of vitamins in the diet is important for maintaining periodontal health and preventing PDs [8,42] (Table 1). In a minireview, Gondivkar et al. (2018) described the association of PDs with deficiencies of vitamins A, C, E, folic acid and calcium [43].
Vitamin A: Vitamin A is a group of fat-soluble compounds that are metabolically linked to all-trans retinol [44]. Animal-derived food such as milk, cheese, liver and eggs are sources of preformed vitamin A, whereas carrots, green leaves, broccoli, ripe mangos, sweet potato, orange-yellow vegetables, fruits and red palm oil are sources of provitamin A carotenoids [8,44]. According to the UK National Health Service, men aged from 19-64 years need 0.7 mg/day of vitamin A compared with 0.6 mg/day for women of the same age [44]. Several studies have concluded that vitamin A deficiency was linked to the PDs [44]. Conversely, the increase in the amount of beta-carotene (≥7.07 mg/day) consumed is linked to a decrease in the number of sites with a probing depth > 3 mm after scaling and root planing [45].
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Vitamin B: The vitamin B complex family consists of thiamine (B1), riboflavin (B2), niacin (B3), pantothenic acid (B5), pyridoxine, pyridoxal, pyridoxamine (B6), biotin (B7), folic acid (B9), and cobalamin (B12). For adults 200 µg/day of vitamin B9, present in leafy greens and fortified cereals, and 1.5 µg/day of vitamin B12, present in fortified cereals, meat and fish, are recommended according to the UK National Health [44]. Few studies have analyzed the association between vitamin B and PDs. However, deficiency in vitamin B complex results in lower resistance to bacterial infections, which could explain the role of vitamin B, particularly vitamin B9, in PDs [43]. In a prospective cohort, Zong et al. analyzed the potential association between serum vitamin B12 with changes in periodontitis [46].
Vitamin C: Vitamin C (ascorbic acid) can be found in many fruits and vegetables. According to the UK National Health, a dose of 40 mg/day is recommended for adults [44]. Several studies have demonstrated that a low level of vitamin C was associated with PD [8,44]. In a multicenter, randomized, parallel-group, controlled clinical trial comprising 300 individuals with gingivitis, Shimabukuro et al. concluded that toothpaste with vitamin C and magnesium salt can reduce gingival inflammation [47].
Vitamin D: Vitamin D, which comes mainly from fortified cereals, mushrooms and fish, enhances the absorption of minerals such as calcium, iron, magnesium, phosphate and zinc [48]. It is composed of two groups, vitamin D2 (cholecalciferol) and vitamin D3 (ergocalciferol). The UK National Health recommends intake of 10 µg/day for adults [44]. Several clinical studies have demonstrated an association between a dietary vitamin D deficiency and PDs [49,50,51]. However, other studies have concluded that there is no link between the levels of serum vitamin D and periodontal health [49,52].
Vitamin E: The vitamin E complex family consists of eight naturally occurring, lipid-soluble antioxidant micronutrients, four of which are tocopherols and four are tocotrienols. They are the most important lipid-soluble antioxidant and they prevent lipid peroxidation [44]. The major food sources are vegetable oils, fortif…
Sugar Consumption and Periodontal Health
Sugar intake has long been established as the major contributing factor in plaque formation. It has been observed that sucrose is more cariogenic than fructose and glucose [60]. Sugars contribute to dental caries and periodontal disease because bacteria ferment them and produce acid, leading to the demineralization of the tooth structure. Studies have revealed that lactose (milk sugar) is less cariogenic than other sugars [48]. There is an established direct relationship between dental caries and the amount and frequency of sugar intake observed in earlier studies [61]. Xylitol, a sugar alcohol produced by the hydrogenation of xylose sugar, is an artificial sweetener used as an alternative to conventional sugars [62,63]. It may have an antibacterial effect against periodontal pathogens such as Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans [63,64]. Indeed, oral hygiene measures and regular non-surgical debridement both contribute to the improvement of periodontal health. Hence, a reduction of sugar intake, coupled with scaling, root planing, and the use of xylitol- and maltitol-containing gums have the potential to improve the periodontal health of the general population [62].
The Impact of Diet on Gum Health
The influence of diet on gum disease progression and periodontal treatment outcomes is increasingly evident, and it is time for oral health professionals to embrace a more holistic approach to patient care. Collaboration between oral health providers and family physicians is the key to better health.
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