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Oral Health - How to Reduce Risks of Periodonitis

by Nelson Wood(more info)

listed in dentistry, originally published in issue 127 - September 2006

Oral Health is crucial to the preservation of whole body health. Oral diseases, particularly periodontal disease, share many common risk factors with systemic diseases (e.g. inflammation, obesity, diabetes, hypertension, and elevated blood lipids and cholesterol).[1] Poor oral health may warrant the search for more serious underlying disease processes, as it has been documented that oral infections, particularly periodontitis, are associated with systemic disease pathogenesis: i.e. glucose intolerance, diabetes mellitus, insulin resistance,[1] cardiovascular conditions (e.g. atherosclerosis, heart attack, congestive heart failure and coronary artery disease),[2]-[4] respiratory conditions,[5] obesity,[6]-[7] hyperlipidemia, osteoporosis,[8] harmful pregnancy outcomes,[9] and rheumatoid arthritis.[10]

Several hundred billion bacteria can be found in a clean mouth, and if the mouth isn't satisfactorily cleaned, this quantity increases tenfold. These bacteria form firm clusters, dental plaque, that adhere to oral surfaces, and are not easily eliminated by the body's natural immune responses so must be mechanically removed. Dental plaque becomes more difficult to remove as it matures, forming a harder substance called calculus, which must be removed professionally by a dentist or dental hygienist.

The three most prevalent problems in the mouth are dental caries and the periodontal diseases, gingivitis and periodontitis. All are caused by numerous factors centring on dental plaque, nutrition and dietary factors, oral hygiene, genetics, environment and lifestyle. Dental caries, or missing teeth, can also make it difficult to bite and chew, thus compromising oral function, and consequently may worsen nutritional status and encourage systemic diseases, low self-esteem and a general decline in the quality of life.[11]-[12]

Peridontal Diseases (Gingivitis and Periodontitis)

Periodontal diseases are a group of related, but immensely diverse inflammatory diseases, involving the supporting structures that surround and anchor the teeth. Periodontitis will effect the majority of adults at some time in their lives.[13] They comprise two main categories: gingivitis and periodontitis, both of which are plaque-induced[14]-[20] inflammatory conditions that are considered infectious.[21] Gingivitis is a reversible condition that begins when the bacteria in plaque cause gum inflammation. If left untreated, it can progress to periodontitis. Gingivitis, inflammation of the gingival tissues only, can usually be reversed with daily brushing and flossing, and regular cleaning by a dentist or dental hygienist.

Periodontitis is an irreversible condition that destroys the jaw bone, and can lead to tooth loss. Susceptibility to periodontal disease varies among individuals,[22] and can be due to genetic factors,[23]-[24] poor host resistance (i.e. immune function), inadequate nutrition,[25] environmental and behavioural factors.[26] Some people are more prone to periodontal disease than others, but this doesn't mean that they will necessarily get the disease.

Clinical signs of gingivitis are redness, swelling, bleeding to touch, spontaneous bleeding, and/or visible pus; in the absence of any bone loss, periodontal pocketing, or apical tissue migration along the tooth root. These signs can typically be observed after 10-20days of plaque accumulation.[27]

Gingivitis can be divided into two varieties; those affected by local factors (plaque); and those that are affected by local factors and modified by specific host systemic factors. At the local level, frequent dietary sugar intake can be responsible for increased plaque accumulation and gingivitis.[28]-[29] Modifying factors for gingivitis include metabolic causes (e.g. hormonal disturbances present during puberty and pregnancy, and diabetes), genetic factors (e.g. Down's syndrome),[30]-[31] and environmental factors (e.g. vitamin C deficiency, calcium channel blockers – nifedipine – cyclosporine – an immuno-suppressive drug, phenytoin – used to control epilepsy), smoking, antibiotics, corticosteroids and non-steroidal anti-inflammatory drugs (NSAIDS).[32] Other factors that can modify gingival inflammatory responses are immune deficiencies, HIV/AIDS, and psychological stress.[33] Psychological stress in adults leads to heightened gingivitis expression, and may be mediated by increased plaque accumulation.[34] Acute necrotizing ulcerative gingitivis (ANUG) has also been associated with stress.[35]

Gingivitis may resolve itself or lay quiet for an indeterminate period; however, the potential for periodontal pocket formation exists at any time. When pockets are detected clinically, they usually are associated with calculus present on the tooth's root surfaces. The progression from gingivitis to periodontitis requires varying amounts of time in different individuals, and may not happen at all in others.[36] Six months is typically required for gingivitis to advance to periodontitis,[37] pockets form between the gums and the tooth, trapping more harmful bacteria and food particles, and the gums may recede, exposing the root surfaces and increasing their sensitivity to heat and cold.[27] Teeth can loosen due to bone destruction. The body's host response prevents bacterial growth into the tissue, and removes bacterial products, by-products and enzymes that have penetrated the tissue.[38]-[39] But, it can also activate enzymes which can result in collagen loss and tissue breakdown, leading to a periodontal pocket.[40]-[41] Gingivitis precedes periodontitis, implying that the prevention of gingivitis is the key to preventing periodontitis. Prevention is the basis to good oral health.

Periodontitis frequently involve anaerobic bacteria (unable to survive in oxygen) found in dental plaque.[4]2 The three most common bacteria associated with periodontitis are Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, and Tannerella forsythia.[43]-[44] These bacteria discharge hydrogen sulfide, ammonia, amines, toxins, and enzymes that elicit inflammatory responses leading to periodontitis.[44]

Periodontitis is a cumulative condition. Once bone is lost, it is almost impossible to regain it, and most patients lose additional tooth-supporting (alveolar) bone over a period of years.[45]-[50] The bone destruction seen in periodontitis can be fairly even, and result in receding gum lines. However, more frequently, gaps are seen between an individual tooth and its socket; termed a periodontal pocket. Shallow periodontal pockets can deepen, eventually becoming deep enough to jeopardize the socket's support of adjacent teeth.[45]-[50] Of interest is that periodontitis which occurs over time only occurs at reasonably few dental sites that essentially undergo extensive periodontal destruction.[51]-[54]

Periodontitis may be overlooked until its later stages, or until abscesses, bleeding gums, loose teeth, spaces between teeth, bad breath and/or pain are present.[44] The reason why some people develop periodontitis more readily than others is highly elusive and is thought to involve many different reasons, some modifiable (behaviour, environment and nutrition) and others not modifiable (genetics).[55]

Prevention and Modifiable Risk Factors

Local risk factors include pre-existing disease, as evidenced by deep-probing depths, and plaque retentive areas associated with defective dental restorations,[47] and high fermentable dietary sugar. Therefore, defective dental restorations should also be replaced and dietary sugars should be reduced.

Vigilant bacterial plaque removal and infection control should be performed at least twice daily. If periodontal disease has progressed, the dentist, periodontist, or dental hygienist, removes plaque by cleaning the teeth (termed scaling and root planning). Medications, such as antibiotics, are sometimes used in conjunction with teeth cleaning. Surgery might be necessary if the inflammation and deep periodontal pockets remain following the above treatments. All of these treatments require the patient to maintain excellent daily home care.

Systemic and environmental factors, such as diabetes[50]-[56] and smoking[57] and other tobacco product use,[58]-[62] stress, depression,[26] and alcohol consumption,[63] have all been linked to periodontitis. Emotional stress often increases the severity of gingivitis[64] and periodontitis.[26] Modifying these behaviours, such as quitting tobacco use, drinking less alcohol, and improving dietary intake and nutritional status, improves periodontal health as well as treatment outcomes. Physical activity, in the form of walking, has been shown to be beneficial to periodontal health.[65]

Periodontitis can cause tooth loss, and may thus compromise your health by making eating difficult. Individuals who cannot chew or bite comfortably are less likely to consume high-fibre and nutrient-rich foods such as fruits and vegetables, thereby reducing their intake of essential nutrients, which can have very harmful effects on the body's general and oral health.

Nutritional and botanical therapies have demonstrated positive effects for people with gingivitis, gingival bleeding, periodontal pocketing and periodontal attachment and bone loss. Topical and systemic nutritional supplementation may be a beneficial adjunct to gingivitis and periodontitis therapy.

Oral tissues have a higher turnover rate than other tissues of the body. This rapid turnover time, together with the ongoing repair of damaged tissues, demands a higher nutrient requirement than other body tissues. Consuming a healthy diet, high in essential nutrients, can help the health of your teeth, gums and supporting oral bone. If you are unable to obtain these nutrients that are in demand during periodontal stress from your diet, you should consider supplementing your diet with key nutrients that are known to be helpful in maintaining the health of teeth, gums and their supporting bone (alveolar bone). These suggestions must not be seen as an alternative to dental treatment or dental advice.

Malnutrition has the potential to influence the prognosis of periodontal infections adversely,[66] and elicits adverse alterations in the oral microbial ecology, and in the volume, antibacterial and physicochemical properties of saliva.[67]

Individuals with periodontitis have diets that are deficient in many essential nutrients including; calcium, thiamin, vitamin A, riboflavin, niacin, folic acid, zinc and magnesium, when compared to the RDAs (Recommended Daily Allowance) for these nutrients.[68] Gum disease may benefit from the following supplements: vitamin C, bioflavonoids, coenzyme Q10, vitamin E, vitamin A, selenium, zinc, vitamin B complex, calcium, magnesium, and other nutrients.

Key Nutrients and Supplements

Topical Considerations

Clinically, topical application of coenzyme Q10 (CoQ10) to periodontal pockets significantly reduced gingivitis, bleeding and gingival enzyme activity.[69] Clinical studies showed that topical application of CoQ10 was extraordinarily effective in reducing periodontal pocket depths,[70] and clinical symptoms of gingivitis and periodontitis.[71] Lactoferrin was shown to reduce the adhesion of several oral bacteria,[72],[32] stop the growth of certain periodontitis causing bacteria, and kill certain periodontitis and cavity causing bacteria.[73]

Extensive clinical trials, using oral rinses and toothpaste products containing Mexican Sanguinaria extract (derived from bloodroot),[74] have shown its effectiveness in reducing plaque build-up and gingivitis.[75]-[80] Other studies using a combination of Sanguinaria extract and zinc chloride were also beneficial,[81]-[82] and suggested that zinc may provide a mild enhancement of Sanguinaria extract effectiveness against gingivitis.[82]

Green tea, which contains the polyphenol (-) Epigallocatechin gallate, and green tea extract applied topically, can also help prevent periodonitis.[83]-[85] Using non-human primates, vitamin B3-supplemented toothpaste showed a similar improvement in gingival health as the 0.5% chlorhexidine (antimicrobial) toothpaste group, but significant improvement over the control toothpaste group.[86] Two independent clinical trials using a herbal mouth rinse versus distilled water,[87] and herbal tooth paste versus Colgate® Total,[88] showed significant improvements in gingivitis and gingival bleeding; the herbal toothpaste also significantly reduced plaque and stain relative to Colgate® Total.[88] Mouth care products which contain essential oils, such as tea tree oil, eucalyptus oil and menthol, significantly reduced both gingival inflammation and bleeding when compared to fluoride-containing products.[89] Hydrogen peroxide has been shown to inhibit plaque formation and reduce gingivitis, promoting healthy gums and teeth.[90]

Folic acid-containing mouthwash has been used in the treatment of gingivitis and its accompanying inflammation; it significantly reduced gingival redness and bleeding in subjects whose dietary intakes of folic acid were mostly below 200 milligrams daily.[91] In a double-blind study, of the effects of folic acid supplemented at 2mg twice daily for 30 days, revealed that folic acid supplementation may increase gingival resistance to local irritants,[92] however, in mouthwash form, it can improve gingival health, and showed significantly greater local effects rather than systemic influences.[93]-[96]

Systemic Considerations:

Nutritional supplements are best taken in combination and should contain adequate levels of zinc, copper, calcium, phosphorus, magnesium, selenium, vitamins A, C, D and E, vitamin B complex, bioflavonoids, additional antioxidants, botanicals and other nutrients.

Vitamin C is important for collagen synthesis, and also promotes healthy cell development, proper calcium absorption, normal tissue growth and repair, strengthens blood capillaries, protects against infection, and can also enhance immune function. Those with a history of ANUG are known to ingest less vitamin C compared to healthy people.[97] Clinical studies, using vitamin C deficient diets, revealed that measures of gingival inflammation were directly related to their plasma vitamin C deficiency status,[98] and vitamin C supplementation did improve gingival health in these people.[99] However, megadoses of vitamin C in normal human subjects did not positively affect the gingival response to periodontal cleaning and scaling.[100] Vitamin C deficiency is known to lead to severe periodontal disease in certain individuals such as the elderly and cigarette smokers.[101] Therefore, these individuals should consider taking a vitamin C supplement. Vitamin C is more effective taken with bioflavonoids, calcium and magnesium, and other antioxidants. Citrus bioflavonoid supplementation has been shown to encourage jaw bone formation[102]-[103] and can enhance the effectiveness of vitamin C. Bioflavonoids should be taken with vitamin C and calcium.

Vitamins E and A are potent antioxidants, as they protect cells by neutralizing free radicals that cause oxidative cellular damage. Vitamin E also exhibits anti-inflammatory properties which may limit inflammation-induced tissue destruction.[104] Vitamin E should be taken with a range of antioxidants, including vitamin C, beta-carotene and selenium. Vitamin A is essential for normal growth and maintenance of oral tissues and bones, is important in protein synthesis, and assists immune function. Vitamin A deficiency has been associated with periodontal pocket formation.[105] Vitamin A should be taken with B group vitamins, vitamins C, D, and E, choline, essential fatty acids, calcium, phosphorus and zinc for the best results.

Oral tissues are composed of rapidly growing cells with a high turnover rate, as a consequence increasing the need for B complex vitamins, vitamin B1, B2, B3, B5, B6, B9, B12, and biotin. Vitamin B complex helps maintain the body's normal immune function. Lower levels of B complex vitamins are associated with tooth loss.[106] The B vitamins are usually taken in the form of vitamin B complex with vitamin C.

Calcium intake of 800mg or more daily is essential to the normal development and maintenance of teeth, and their supporting structures. Calcium deficiency has been associated with gingival inflammation, pocket formation and alveolar bone resorption.[107] Vitamin D is also essential for the development and maintenance of teeth and oral bone. Vitamin D, in its proper form, also promotes intestinal absorption of calcium. Magnesium is essential for the mobilization of calcium from bone and assists in bone maintenance, formation and regeneration. Magnesium deficiency can lower the rate of jaw bone formation and lead to widening of the periodontal ligament (which connects the tooth to alveolar bone).[108]

Selenium helps fight infections,[109] and works best with vitamins E, and A. Zinc is important in bone metabolism, including alveolar bone, and is vital for wound healing, immune function, cell division and general growth of all tissues. Zinc is also the natural enemy of bacteria.[110] Other micronutrients important to good gum and oral health are copper, molybdenum and vanadium. Copper helps to stabilize newly formed collagen tissues in the mouth. Molybdenum is important in the growth and development of alveolar bone, dentin, and enamel.[111] Vanadium is required for cellular metabolism and the formation of healthy bones and teeth.

Depending on the condition of your gums and teeth, I recommend you see your dentist at least twice, possibly four times a year, to limit the progression of plaque and periodontal problems, and to be examined for oral cancer. Proper oral care, lifestyle and dietary adjustments, as well as nutritional supplementation, can help many individuals reduce the risk of gum disease and tooth loss.


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About Nelson Wood

Nelson Wood DMD DSc MS has been practising dentistry since 1982. He holds a DMD. from the University of Pennsylvania School of Dental Medicine and a Doctorate of Science degree in Nutritional Sciences from Boston University School of Dental Medicine. He is currently in private practice and was an Associate Professor in the Department of Periodontics and Preventive Sciences at the University of Mississippi Medical Center School of Dentistry. Dr. Wood, internationally published in scientific journals in the fields of nutrition, oral health and systemic diseases, has published over 50 articles and abstracts on oral health and nutrition and has also authored several book chapters. Dr. Wood is on the editorial board of several peer-reviewed journal publications. Dr Wood may be contacted via

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