Diet, nutrition and dental disease

The mouth is often considered the terrain of the dentist, with the oral cavity being treated in isolation from the rest of the body, and often separately from the ‘rest of medicine’.

The mouth, however, IS attached to the rest of the body, and it is not a case of ‘what happens in the mouth, stays in the mouth’. On the contrary, what happens in the mouth can often be a sure sign of what is happening in the rest of the body.

It is now well established that there are direct links between oral diseases and other chronic diseases e.g., cardiovascular diseases, chronic obstructive pulmonary diseases, diabetes, rheumatoid arthritis, and cancer, due to their shared preventable risk factors, linked to diet and lifestyle ^(1,2).

This week’s blog aims to highlight the nutrients which may help to minimise the risk of developing dental disease, support resolution and help improve treatment outcomes. It also explores key issues and concepts which are often overlooked, and how a more systemic approach to managing oral diseases, could have a beneficial impact on overall health outcomes.

What is dental disease?

The most common dental diseases are periodontal disease and dental caries (decay)⁽³⁾.

Periodontal disease

Periodontal disease is a non-communicable, inflammatory condition with a multifactorial aetiology. A genetic propensity and an imbalance (dysbiosis) of the oral microbiome is central to its development, but the host response, and resilience, is critical to its progression.

Periodontal disease results in loss of the alveolar bone (bone specific to the jawbone which supports the teeth). As bone support is lost, teeth become mobile or drift out of alignment. Chewing ability may become impaired as teeth are less able to withstand masticatory forces, and tooth loss is common in advanced stages of the disease. 

Gingivitis

Gingivitis, inflammation of the gingivae, is diagnosed when there is increased bleeding of the gums. Gingivitis and periodontal disease are considered as a continuum of the same disease⁽⁴⁾ although gingivitis does not always progress to periodontal disease. Gingivitis is reversible if the underlying cause is addressed and corrected, whereas the bone loss of periodontal disease destruction cannot be reversed.

Caries

Dental caries (decay) occurs when organic acids are produced by oral bacteria in the plaque, in response to dietary intake of refined carbohydrates and simple sugars. The increased acidity leads to demineralisation of teeth, and proteolytic destruction of the organic portion of the tooth (dentine), resulting in cavities⁽⁵⁾. 

Dental Erosion

Dental erosion involves the dissolution of the tooth structure from acids of non-bacterial origin. It is not specifically a disease but occurs when acidic food and drinks are consumed, including soft drinks and fruit juice⁽⁶⁾. 

The impact of specific diets on dental health

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It is unlikely that your dentist will discuss nutrition, or the role of specific nutrients on dental health. This is because nutrition is not a subject that is taught extensively at dental school.

A dietary approach to dental disease is not a new concept. Dr Western A. Price, a dentist in the 1920-30’s, from Cleveland USA, became aware of increased frequency of dental caries, malformed facial structures and crowded dental arches in his dental patients. He hypothesized that the ‘modern diet’, high in refined flour and sugar, and low in nutrients required for bone growth and remodelling, was responsible for the increase in dental disease and malformation he was seeing in his dental patients.

He embarked on a worldwide expedition, across five continents, to assess indigenous people of Switzerland, Gaelic communities in the Outer Hebrides, Eskimos and Indians of North America, Melanesian and Polynesian South Sea Islanders, African tribes, Australian Aborigines, New Zealand Mauri and the Indians of South America.

He compared those still eating a traditional diet to those from similar communities, now consuming a more ‘modern diet’.

He concluded that dental caries and malformed dental and facial architecture was the result of nutritional deficiency, more specifically the fat-soluble vitamins A and D, and ‘factor X’ which was determined much later as Vitamin K2^(7).

Many dentists will not have heard of Western A. Price, as his research appears to have been overlooked by mainstream dentistry in favour of the ‘germ theory of dental disease’ ⁽⁸⁾, and removal of bacteria to prevent disease.

Recent research, however, is drawing on Dr Price’s conclusions, and establishing robust associations between specific diets ^(9–11), and other nutrients on dental disease, bone formation and bone remodelling ⁽¹²⁾. Supportive evidence also exists for the role of vitamin C ^(13,14), antioxidants ⁽¹⁵⁾, specific minerals ^(16,17) essential fatty acids ⁽¹⁸⁾ and B vitamins⁽¹⁹⁾ in the prevention of dental disease, or enhancement of treatment outcomes⁽²⁰⁾.

Diet and caries

It is well established that sugar has a role in the aetiology of dental caries.

Studies dating back as far as 1920s reported significantly lower caries rates in children who were given a low carbohydrate diet to manage their diabetes ⁽²¹⁾.

Recent research supports the consumption of a diet high in refined carbohydrates, and low in fruits and vegetables, with the onset, and progression of dental caries ^(22,23). Decreasing dietary sugar is still recommended to prevent dental decay but brushing teeth to remove bacteria has often been the focus, and the easier option. In response to the studies linking dental caries to sugar (late 1920’s), the sugar industry promoted oral hygiene practices, and fluoride to prevent dental caries. Coca Cola advertisements claimed, ‘dental hygiene is key!’ ⁽²⁴⁾.

Newer concepts are considering plaque biofilms to be protective of teeth, and it is the consumption of sugar, and refined carbohydrates, which is changing the ecology of the biofilm to favour demineralisation ⁽²⁵⁾. 

Diet and periodontal disease

The impact of a variety of diets on periodontal disease outcomes has also been addressed. Anti-inflammatory diets (high in omega 3 fats, fibre and antioxidant nutrients, and low in carbohydrates) have been shown to significantly decrease gingival bleeding, without alterations in plaque levels ^(26–28). Similar results have been seen with the administration of the stone age diet ⁽¹⁰⁾ and the Mediterranean diet ⁽²⁹⁾.

Calorie restriction and intermittent fasting may also have positive associations due to the systemic benefits of these practices, but further research is required to establish their role in dental diseases ⁽³⁰⁾.

According to these studies, the transition towards a more whole foods, low carbohydrate, high fibre, anti-inflammatory diet, which is high in antioxidants, could have a major role in oral disease prevention, even in the absence of biofilm removal.  

Nutrients to support oral structures

Micronutrients can have a significant impact on both the hard and soft tissues of the oral cavity, and it is becoming more apparent that dental diseases, such as periodontal disease and dental caries, may be managed more successfully with additional nutritional support. 

Teeth and Bones

Vitamin A, D, and K2, magnesium, calcium, and phosphorous are important in bone formation, and mineralisation of teeth. They work together, to create and maintain bone, and the mineral content of teeth ^(5,31). This enables broken bones to mend, tooth sockets to heal, and teeth to actively be moved into a straighter alignment (orthodontics).

Vitamin D is essential for the absorption of calcium from the gut, and magnesium is required for vitamin D to function. Vitamin K2 and magnesium ensure calcium is shunted into our bones and teeth, and not into soft tissues, which could otherwise lead to atherosclerosis, kidney stones or gall stones. These nutrients are essential for dental treatments, which require osseointegration (implants), or tooth movement (orthodontics) ^(20,32).

Vitamin D deficiency has been associated with childhood caries since 1928 ⁽³³⁾,  and more recent studies confirm these findings. ^(23,34,35) Yet, this is still relatively overlooked in dental practice. 

Collagen

Collagen consists of the amino acids glycine and proline, and is abundant in connective tissue system, skin, joints, and periodontium and alveolar bone. Collagen fibrils connect the roots of teeth to bone, and its production relies on vitamin C, zinc and copper.

Deficiency of vitamin C leads to scurvy, clinically seen as profusely bleeding gums, and periodontal disease (⁽¹⁴⁾. Significant improvements in periodontal disease outcomes have been demonstrated with oral collagen supplements combined with professional plaque control practices ^(36).

Mucous membranes

Vitamin A, zinc, glutamine and arginine are important nutrients for maintaining mucous membranes ⁽³⁷⁾. When the barriers are robust, they protect the inner body from toxins, bacteria, chemicals or any substance, including food proteins, which should not be within the system. The term ‘leaky gut’ is often used to describe increased permeability of the mucosal gut barrier. ‘Leaky gums’ is a newer term related to the increased permeability of the gingival mucosa as a result of bleeding gums, or periodontal lesions.

This may result in translocation of pathogenic oral bacteria to other sites and may be the link to other systemic diseases including Alzheimer’s disease, and rheumatoid arthritis ^(38,39). 

Nutrients to support the immune system.

Inflammation

An inflammatory response should ideally be short lived, with the immune system returning to a state of surveillance following resolution of the healing process, or eradication of the offending pathogen. Problems arise when the inflammatory response is overzealous, or fails to resolve the underlying infection, or clear debris from damaged cells.

Periodontal disease is a chronic inflammatory disease which occurs in response to a dysbiotic oral microbiome. If eradication does not occur, or dysbiosis is not resolved, the inflammatory process may become chronic.

Microbiome

The germ theory of disease in the 19^th century and the advent of antibiotics, antifungals, antivirals and antiseptics had led us to believe that all bacteria are detrimental to health, and eradication is essential for health.

We now understand that the human body is inhabited by trillions of bacteria, and other microbes which are protective, and without which, we could not survive.

As well as regulating the immune system, the commensal bacteria crowd out the pathogenic bacteria, minimise invasion from pathogens, and protect the mucosal barriers. They also produce vitamin K2, B vitamins, and short chain fatty acids (SCFAs) which are beneficial to the host.

There is still much to learn about the microbiome, and its role, but balance is important.

When the microbiome is in balance health outcomes are positive, the opposite is true of an imbalanced microbiome. Dental diseases have an imbalanced microbiome at their core, and strategies to rebalance rather than remove, the oral microbiome may be key to the management of oral disease ⁽³¹⁾.

Building and maintaining a healthy microbiome

Diets high in fibre, vegetables, fruits antioxidants and prebiotics help to create healthy microbial balance, whereas diets low in fibre, fruits and vegetables and high in sugar, refined carbohydrates, and processed foods create dysbiosis.

Fermented foods such as kimchi, sauerkraut and fermented vegetables are rich in probiotics (friendly bacteria), which can positively influence the metabolic activity of the microbiome ^(40). 

Antioxidants

Inflammation creates free radicals, which damage surrounding tissues, leading to oxidative stress. Antioxidants ‘soak up’ free radicals and prevent the damage to localised tissues which would otherwise occur ^(26,41).

Vitamin C, vitamin E, and glutathione are the major antioxidants which help to decrease oxidative stress; they are recycled within the body to maintain their antioxidant capacity. Coenzyme Q10 (CoQ10) ⁽⁴²⁾ green tea extract, lycopene and quercetin have also shown to have a beneficial effect on periodontal disease ^(43–47).

Immune modulation – essential fatty acids, vitamin D and zinc.

There are many nutrients which have a role in immune modulation.

Omega 3 fatty acids are anti-inflammatory in their action, but the balance of omega 6 to omega 3 polyunsaturated fatty acids is important. A ratio of 3:1 (omega 6 to omega 3) is ideal, and a higher omega 6 to 3 is considered inflammatory. Those consuming a western style diet have a higher intake of vegetable oils, and higher omega 6 to omega 3 ratios, which has been correlated to periodontal disease ⁽²⁷⁾, and increased risk of periodontal disease progression⁽⁴⁸⁾.

Increasing omega 3 fats can improve periodontal disease markers⁽⁴⁹⁾, but reduction of the inflammatory omega 6 component is also necessary, for optimal inflammatory balance. Oily fish is a rich source of omega 3 fats, flaxseeds and walnuts however have a decreased impact due to the inefficiency of the conversion to DHA and EPA.

Vitamin D is known to be immunomodulatory. It is anti-inflammatory and has antiproliferative effects. Vitamin D’s role in periodontal disease prevention goes beyond just preventing bone loss ^(50,51).

Lower serum levels of zinc have been identified in those with periodontal disease.

Zinc has immunomodulatory effects, having an essential role in maintaining the integrity of mucous membranes, and in wound healing ⁽⁵²⁾. 

The impact of nutrition on oral health is seemingly apparent, yet nutrition education is still not reaching those at the forefront, delivering care.

Incorporating nutritional therapy into dental practices could be a practical way of offering a more systemic approach to oral health, with the added benefit of enhancing overall health. 

References 

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Guest blog by Keeley Nicholas BDS. MFGDP(UK). MSc (Nutritional Therapy). IFMCP. mBANT. rCNHC. mIFM. mGDC.

Keeley is a registered Nutritional Therapist, and a Certified Functional Medicine Practitioner.

She worked as a General Dental Surgeon for twenty-five years, but now focuses on nutrition. She is co-founder of The Emporium of Health (www.emporiumofhealth.com), where she uses Functional Medicine to support her 1-2-1 clients, and is in the process of establishing a corporate offering, to make Functional Medicine more accessible. She has special interest in biotoxin illness, autoimmunity, and brain health.

keeley@emporiumofhealth.com

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Thank you to Keeley for this excellent article. If you have questions regarding the topics that have been raised, or any other health matters, please do contact our team of Nutritional Therapists.

nutrition@cytoplan.co.uk
01684 310099

Last updated on 3rd January 2024 by cytoffice