Enhancing Periodontal Outcomes Through Nutritional Support

Typical non-surgical periodontal therapy involves a combination of in-office treatments targeted in removing toxins and irritants from the gingival environment, as well as home care instructions to minimize the proliferation of biofilm in the gingival sulcus.  Antibiotic therapies using both systemic and local delivery have shown promise initially, but often fail to convert the chronic periodontal patient to long term health.   All of the above mentioned therapies focus on the signs and symptoms the disease rather than the source of the disease.  Although bacteria are often cited as the causative agent for disease, many scientists believe that systemic host response and the immune system are actually the determinants of disease. 1,2,5   Manifestations of inflammation in the oral cavity very often correlate with systemic inflammatory processes.  Dr. David Tecosky, DMD, MAGD states, “More than 90% of systemic diseases reveal signs and symptoms in the mouth.  Most patients see their dentist on a regular basis more frequently than they do their physician.  We are in a unique position to help our patients.”  We all agree that the oral-systemic connection exists, so how can we enhance the services we offer our patients to not only improve treatment outcomes, but improve their overall well being also?

About Periodontal Disease

Periodontal disease (PD) is the result of an inflammatory response resulting from the interaction between pathogenic bacteria and the host’s immune response.3,4  As a result of stimulation by bacterial antigens, polymorph nuclear leukocytes (PMN) produce reactive oxygen species (ROS) during phagocytosis as part of the host response to infection culminating in oxidative damage to gingival tissue, periodontal ligaments and alveolar bone. 4,5,6  These ROS contribute to tissue destruction by damaging DNA, causing lipid peroxidation and stimulating proinflammatory cytokines release.  It has been postulated in the literature that the damage from ROS can be modulated by the presence of antioxidants, through the mechanism of electron transfer, thereby neutralizing the ROS. 5 Antioxidants are defined as a molecule capable of slowing or preventing the oxidation of other molecules. 6 Data from research collected suggests that there are mechanisms in which nutrition, particularly antioxidants, can influence periodontal disease onset, progression and wound healing. 5  Since our bodies manufacture only limited antioxidants, we have to rely on our diet and supplementation to provide the necessary supply of these nutrients.

Antioxidants

The benefits of diets rich in antioxidants are widely recognized.  As we age, vitamins and minerals are less efficiently absorbed and internal production declines, paving the way for increased risk of inflammatory burden and degenerative disease.7  Dietary antioxidants include essential vitamins and minerals as well as phytochemicals present in plant food. Antioxidants can prevent cancer-causing DNA damage, protect blood vessels against atherosclerosis, help optimize blood flow to the heart and brain, and protect brain cells against oxidative death that can lead to Alzheimer's disease, Parkinson's disease and other degenerative conditions that increase in age.^4,5,7   In fact antioxidants can protect our cells from just about all diseases associated with inflammation and the aging process.

Rationale and Implementation

So how do we integrate antioxidant therapy and nutrition into our everyday practice? We must educate our patients about the importance of a diet high in fruits and vegetables.  The National Institute of Health now recommends 9-12 servings of F & V per day. Data from the National Health and Nutrition Examination Survey (NHANES) reported that less than 11% of the nearly 24,000 Americans surveyed achieved USDA guidelines for both fruit and vegetable consumption; that means 9 out of 10 people do not consume the recommended servings of fruit and vegetables each day to prevent disease. Since RDA standards do not outline the amount of nutrients needed for optimal health and because of our consumption of low-nutrient, high-calorie foods that are highly processed, hybridized, genetically modified, shipped long distances, and grown in nutrient-depleted soils, most of us are nutritionally bankrupt and our immune systems are vulnerable to the ravages of free radical induced disease.

What all this adds up to is clear. Nutritional supplementation is not optional. Based on mounting evidence and confirmed by the Journal of the American Medical Association8 and The New England Journal of Medicine9, the medical community strongly believes that we should all be taking and recommending basic supplements including vitamins, minerals, antioxidants and high quality omega three fish oil toALL our patients.  The economic impact of investing in our nutritional health through supplementation is compelling. New research from the Lewin Group has shown that spending pennies a day on a few key nutritional supplements can dramatically reduce sickness and chronic disease — and greatly decrease healthcare expenditures as a result.10

When determining which supplements to recommend a review of the literature is instructive, but burdensome as there are hundreds of thousands of scientific articles and clinical trials relevant to nutrition, particularly antioxidants, and inflammatory disease.  Below are some current abstracts as they relate to specifically periodontal disease, but we must keep in mind that ALL diseases influenced by the inflammatory process are improved by an upgrade in nutritional status. I have highlighted the conclusion for expediency, but encourage the reader to conduct your own due diligence by searching PubMed or other evidence based search engines using key words such as “antioxidants and oral health” etc.

Micronutritional approaches to periodontal therapy.

J. Clin Periodontol. 2011 Mar;38 Suppl 11:142-58. Van der Velden U, Kuzmanova D, Chappel IL.

Periodontitis is associated with low serum/plasma micronutrient levels, which may result from dietary and/or life-style factors as well as nutrigenetic characteristics. Early evidence suggests beneficial outcomes from nutritional interventions; supporting the contention that daily intake of certain nutrients should be at the higher end of recommended daily allowances. For prevention and treatment of periodontitis daily nutrition should include sufficient antioxidants, vitamin D, and calcium. Inadequate antioxidant levels may be managed by higher intake of vegetables, berries, and fruits (e.g. kiwi fruit), or by phytonutrient supplementation

Bioactive antioxidant mixtures promote proliferation and migration on human oral fibroblasts.

Arch Oral Biol. 2011 Mar 31. San Miguel SM, Opperman LA, Allen EP, Zielinski J, Svoboda KK.

High and low concentrations (10(-3)-10(-5)M) of these antioxidants (RFT, PFR) may have beneficial effects on functional mechanisms regulating fibroblast migration and proliferation during gingival healing or periodontal repair.

Role of coenzyme Q(10) as an antioxidant and bioenergizer in periodontal diseases.

Indian J Pharmacol. 2010 Dec;42(6):334-7. Prakash S, Sunitha J, Hans M.

Periodontal disease is an inflammatory disease process resulting from the interaction of a bacterial attack and host inflammatory response. Arrays of molecules are considered to mediate the inflammatory response at one time or another, among these are free radicals and reactive oxygen species (ROS). Periodontal pathogens can induce ROS overproduction and thus may cause collagen and periodontal cell breakdown. When ROS are scavenged by antioxidants, there can be a reduction of collagen degradation. Ubiquinol (reduced form coenzyme Q(10)) serves as an endogenous antioxidant which increases the concentration of CoQ(10) in the diseased gingiva and effectively suppresses advanced periodontal inflammation.

Oxidative stress, systemic inflammation, and severe periodontitis.

J Dent Res. 2010 Nov;89(11):1241-6. D'Aiuto F, Nibali L, Parkar M, Patel K, Suvan J, Donos N.

Periodontal infections have been associated with a state of chronic inflammation. Analysis of these data suggests a positive association between severe periodontitis and oxidative stress.

Relationship Between Intake of Green Tea and Periodontal Disease

Journal of Perio; March 2009, Vol. 80, No. 3 Pages 372-377.

Green tea is a very popular beverage, and in vitro studies have shown that green tea polyphenols inhibit the growth and cellular adherence of periodontal pathogens and their production of virulence factors. We investigated the epidemiologic relationship between the intake of green tea and periodontal disease.Conclusion: There was a modest inverse association between the intake of green tea and periodontal disease.

Relationship between intake of vegetables, fruit, and grains and the prevalence of tooth loss in Japanese women.

J Nutr Sci Vitaminol (Tokyo). 2007 Dec;53(6):522-8. Tanaka K, Miyake Y, Sasaki S, Ohya Y, Matsunaga L, Yoshida T, Hirota Y, Oda H.

Epidemiological evidence regarding dental status and its relationship to diet and nutritional status has been limited. The present cross-sectional study examined the relationship between intake of vegetables, fruit, grains, antioxidants, and fiber and the prevalence of tooth loss. Of the 1,002 subjects, 256 women had lost 1 or more teeth. Compared with intake of vegetables other than green and yellow vegetables in the lowest quartile, consumption of the other vegetables in the highest quartile was independently associated with a decreased prevalence of tooth loss, showing a clear inverse dose-response relationship.  These findings suggested that consumption of vegetables other than green and yellow vegetables and insoluble fiber may be related to a decreased prevalence of tooth loss among young Japanese women.

Omega-3 fatty acid regulates inflammatory cytokine/mediator messenger RNA expression in Porphyromonas gingivalis-induced experimental periodontal disease.

Oral Microbiol Immunol. 2007 Aug;22(4):232-9.Kesavalu L, Bakthavatchalu V, Rahman MM, Su J, Raghu B.

Porphyromonas gingivalis is strongly implicated in the etiology of adult periodontitis by inducing inflammatory cytokines, resulting in gingival and periodontal tissue inflammation and alveolar bone resorption. This study tested the hypothesis that supplementing the diet with omega-3 fatty acid (omega-3 FA; i.e. fish oil) would exert anti-inflammatory effects in the gingival tissues of P. gingivalis-infected rats. ... These findings suggest that diets enriched for omega-3 FA modulate the local gingival inflammatory milieu of the host following oral P. gingivalis infection, which impacts on alveolar bone resorption in rats.

“Local and systemic total antioxidant capacity in periodontitis and health”

J Clinic Periodontol 2004; 31: p 515-521 Brock, GR, Butterworth CJ, Matthews JB, Chapple ILC,

The authors aim in this cross sectional study was to determine both local (saliva and gingival crevicular fluid) and peripheral (plasma and serum) antioxidant capacity in periodontal health and disease.  The data showed that in health, antioxidant concentrations in GCF are significantly greater than those of serum and plasma indicating a local synthesis or storage within the periodontium.  Interestingly, both serum and plasma total antioxidant capacity (TAOC) were reduced in periodontal subjects relative to controls.  The commented, “Given the established role for reactive oxygen species in cardiovascular pathology and the established links between periodontal disease and cardiovascular disease, the reduced plasma TAOC in periodontitis subjects warrants further investigation.  One may speculate that reduced plasma antioxidant defenses are a common risk factor for both diseases.”

Effects of specific nutrients on periodontal disease onset, progression and treatment

J Clinical periodontology, 2003; 30: 579-688. Neiva, RF, Steigenga, Jennifer, Al-Shammari, Khalaf, Wang, Hom-Lay,

The authors studied nutritional elements, (e.g. vitamin B-complex, vitamin C and dietary calcium) that have been strongly associated with the wound healing, periodontal disease status and response to treatment.  Vitamin C, an important aqueous antioxidant, is essential for collagen formation and healing of wounds, and is shown to improve resistance to infection.   Vitamin C deficiency also makes capillaries fragile and susceptible to rupture.  Calcium, the most abundant mineral in the body, plays a structural role and is present 99% in bones and teeth.  Many clinical trials were referenced and reviewed by the authors, and they concluded, “Several studies reported various degrees of association between nutritional elements/supplement and periodontal status, and others have reported possible positive influences of nutritional supplementation on periodontal therapeutic outcomes”  They further recommended, “Considering that nutrient supplementation shows minimal or no side effects, controlled clinical trials are able to demonstrate that it could be used to enhance response to therapy and may prove valuable in producing more predictable treatment outcomes.”

FINAL COMMENT: After reviewing the literature, it appears prudent to consider the inclusion of antioxidant rich comprehensive nutritional supplement MINIMALLY to the home care regimen for patients with periodontal symptoms.  As oral physicians we have a responsibility to our patients to elevate the standard of care in our offices and educate our patients about the irrefutable benefits of diet, nutrition and supplementation as it influences oral health.  Combining natural alternatives with traditional therapies appears to show promise in modifying systemic risk factors and providing safe methods to potentiate the clinical response during periodontal therapy.  The side benefits of improved nutritional status for our patients are longevity and extended health span.  Stay tuned for further information in your AAOSH newsletter for more research on the topic of non-invasive nutritional risk assessment and treatment recommendations in upcoming issues.  We also hope you will join us at our first annual scientific session in Chicago, June 25, 25, 2011 where national leaders like Dr Tom Nabors and Dr Brad Bale will share their expertise on the oral systemic connection and its implications in dentistry.  We are sure you will never look at our profession the same again.

To Your Health! - Jacqueline Russo, RN, DDS

Bibliography

1. Gottehrer, NR, Berglund SE.  Antimicrobial host response therapy in periodontics: a modern way to manage disease.  Dentistry Today, September 2006; 25 p 84-87
2. Waddington, RJ, Moseley R, “Embery G, “Reactive oxygen species: a potential role in the pathogenesis of periodontal disease” Journal of Oral Disease; 2000; p 138-151
3. Lee M-I, Shoji H, Yoshino F.  The role of free radicals on oral inflammatory disease.  Presented at IADR/AADR/CADR 82^nd General Session:  March 10-13, 2004 Honolulu, Hawaii.  Abstract 2444
4. Ritchie, Christine et al, Nutrition, inflammation and periodontal disease, Nutrition and Oral Health, 2003 19: p. 475-476
5. Chapple ILC. “Role of Free radicals and antioxidants in the pathogenesis of inflammatory periodontal diseases”.  Clinical Molecular Pathology 1996; 49; p 247-255
6. en.wikipedia.org/wiki/Antioxidant
7. Borek, C. Dietary antioxidants and human cancer, Integrated Cancer Therapy, 2001;3:333-341
8. Fairfield K.M., and R.H. Fletcher. (2002). Vitamins for chronic disease prevention in adults: Scientific review. Journal of the American Medical Association. 287:3116-3126.
9. Willett W.C., and M.J. Stampfer. (2002). What vitamins should I be taking doctor? New England Journal of Medicine. 345 (24):1914-1916.
10. The Lewin Group. (2006). An evidence-based study of the role of dietary supplements in helping seniors maintain their independence. Prepared for: The Dietary Supplement Education Alliance.