Nutrition's role in perio

The Set-Up

“Nutrition plays a key role in periodontal health and healing. Many issues in this field remain unsolved. In this article, Dr. Ryder explores some aspects of nutrition and periodontics.,”Dr. Peter O. Cabrera, Team Lead

Periodontal diseases are among the most common inflammatory diseases with a primary bacterial etiology. As such a common inflammatory disorder, it is understandable that dental clinicians often face questions from patients, as well as colleagues, about how nutritional approaches can help prevent and treat periodontal diseases.

It seems like every month we see new studies on the potential benefits food supplements, vitamins, minerals, and certain foods have on periodontal health. From a broader nutritional perspective, there have been interesting and important new insights into the association between obesity and inflammatory disease in general and periodontal diseases in particular. Nutrition and periodontal diseases is an extensive, complex field, making it easy for clinicians to lose their bearings as to what may or may not work. Several unsubstantiated claims have been made based on anecdotal evidence, rather than well-designed studies. This is understandable as nutritional studies are, by their nature, difficult to perform because nutritional deficiencies can have serious effects on a person’s level of inflammation, resistance to infection and overall health. Studies on less severe dietary deficiencies or dietary supplements and their effect on periodontal disease, which involve not only the study of gingival inflammation but also the loss of periodontal support, require long observation periods and a large numbers of patients

The case for supplements

Patients and fellow dentists often want to know how effective vitamin supplements are in preventing and treating periodontal diseases. Almost every vitamin has been suggested as a possible supplement for treating periodontitis. We know severe deficiencies in certain vitamins, such as B complex vitamins like Riboflavin (B2) and Folic Acid, can increase clinical signs of periodontal inflammation and breakdown. Vitamin E’s anti-inflammatory effects may make it an effective topical application for reducing gingival inflammation. Researchers are exploring this through animal testing. 

A variety of vitamin supplements may have some yet-to-be-demonstrated beneficial effects. Perhaps the most attention, as well as the best evidence, for vitamin and mineral supplementation comes from our classic understanding of Vitamin C’s role, and the new evidence for the role Vitamin D and calcium plays in periodontal health.

We know the dietary Vitamin C (or ascorbic acid) deficiency, known as scurvy, can lead to severe periodontal inflammation, loss of periodontal support and tooth loss. Dietary Vitamin C supplementation can help reduce this severe condition. While overt scurvy is relatively rare, reported cases condition still appear in the literature as case reports. We most often see it in special patient groups such as the malnourished and autistic children.

Less severe deficiencies in Vitamin C can lead to increased gingival inflammation and periodontal breakdown. This, too, often can be corrected with Vitamin C supplementation.

Vitamin D’s expanding role

During the past decade, Vitamin D and calcium’s role in periodontal inflammation and host defenses has emerged. Both adequate Vitamin D levels and calcium intake are important for healthy bones, including bone support around the teeth. Severe calcium loss in bones, such as in post-menopausal women who develop osteoporosis, can make patients more susceptible to periodontal bone loss.

However, Vitamin D’s role in maintaining healthy bones is just part of the story. Recent evidence shows Vitamin D has several other important beneficial effects, both for overall health and possibly for periodontal health. These studies show Vitamin D can boost the body’s resistance to infection and reduce destructive clinical inflammation. Studies on large populations have shown that gingival inflammation is associated with lower levels of serum Vitamin D. These exciting new observations have led to several studies designed to examine the possible benefits Vitamin D supplementation has on improving periodontal health, particularly in populations without sufficient levels of this vitamin, either through lack of sun exposure or diet.

New directions: Probiotics and fish oil

The major initial cause of periodontal diseases is the complex organization of bacterial plaque that accumulates on the tooth surface as a maturing biofilm with an increase in the proportion of potentially more toxic bacteria. Fellow dentists often ask about the possibility of using probiotics as a nutritional supplement. The idea behind such an approach would be to disrupt the harmful biofilm’s development by substituting a less harmful species of bacteria into the plaque biofilm. In the last several years, some published studies have shown using a probiotic drink with a benign form of lactobacillus can help reduce some of gingival inflammation’s clinical and laboratory signs. While these initial observations show promise, we need to await further studies to know whether this probiotic approach has the potential for major, long-term therapeutic effect on periodontal treatment.

As periodontal diseases have both a microbial cause and a major inflammatory component, it is understandable that other nutritional approaches with anti-inflammatory effects may show promise in periodontal treatment.

Omega-3 fatty acids, which are found in oily fish and other foods, and their anti-inflammatory effects have generated considerable interest in the last several years. In particular, these Omega 3 fatty acids resolve pathways of inflammation toward an anti-inflammatory and reparative profile. Animal studies have shown the benefits Omega-3 fatty acids have on periodontal inflammation. Whether these benefits carry over to human periodontal disease awaits future human studies.

What do we tell our patients?

It is clear nutrition’s role in periodontal disease is a promising area of investigation, with some potentially novel new approaches emerging in the near future. For now, it is important for all our patients to maintain a balanced diet with adequate intake of essential vitamins and minerals at the minimum recommended daily requirements.

As to whether specific dietary supplements can be used in excess of these daily requirements as a way to prevent or treat periodontal diseases is still open to speculation and still requires large-scale, well-designed studies to confirm. We certainly should educate our patients about the potential for harm if any of these supplements are taken in severe excess, such as sharing case reports on the harmful effects excess Vitamin A supplementation can have. In addition, several studies suggest that excessive intake of ginger, ginseng, garlic or gingko biloba may increase bleeding tendencies. This may lead to an increased tendency for the gingival to bleed on probing, and may prolong bleeding times during surgical procedures. However, if our patients wish to explore taking nutritional supplements specifically to prevent or treat periodontal diseases, we certainly shouldn’t discourage this approach. We do need to make sure our patients understand that while this approach may have benefits, “the jury is still out” on most of these dietary approaches, ”but they should “stay tuned” for future developments.

 
About the author

Dr. Mark Ryder is a Professor and Chair of Periodontology and Director of the Postgraduate program in Periodontology at the University of California, San Francisco, where he has taught for 31 years. He received his dental and specialty training from the Harvard School of Dental Medicine. He has written more than 150 articles, abstracts and book chapters and lectures extensively on diagnosing and treating periodontal diseases.