Vitamins as an Adjunct to Traditional Periodontal Therapy

Overall health plays a crucial role in oral health; the link between the two has been well documented. Periodontal disease is characterized by chronic inflammation, which compromises the supporting tissues and structures of the teeth. According to Van derVelden and coauthors, periodontal disease “is also associated with low serum/plasma micronutrient levels, which may result from dietary and/or lifestyle factors as well as nutrigenetic characteristics.”¹ This inflammatory process causes a condition known as oxidative stress, in which the equilibrium between oxidants and antioxidants becomes unbalanced in favor of oxidants. This stress reaction can lead to cell destruction, further exacerbating periodontal disease. Additionally, it can elicit increased inflammatory response from other areas within the body as well. This increases the potential for poor oral health outcomes, which in turn can contribute to medical conditions such as cardiovascular disease and diabetes.

Antioxidants are molecules with the capacity to retard or prevent the oxidation of other molecules and thereby avert oxidative stress. They are necessary to help fight infection and, additionally, have an anti-inflammatory effect. Not having antioxidants in the necessary proportion or quantity leads to decreased immunity and an increased risk of inflammatory diseases.² Our bodies produce only a limited amount of antioxidants naturally; thus, we must rely on diet and additional supplements to obtain the essential nutrients that we need. According to Scardina and Messina, “the aim of nutritional support in inflammatory diseases is to provide the right energy and nourishment to respond to the increased demand for protein synthesis in the acute phase, inflammatory mediators, antioxidant defense mechanisms, as well as for the promotion of tissue reparation.”³ Theoretically, if we can reduce the inflammatory response in the periodontium, we can achieve a better state of oral health as well as general health. Therefore, a diet rich in vitamins and nutrients can potentially help to prevent this condition and arrest its development.

Vitamins

Vitamins have come to play a key role in the treatment of periodontal disease. Evidence has shown that serious nutritional deficiencies modify the body’s response to dental biofilm, thereby contributing to gingival diseases.⁴

A vitamin is an organic substance that is necessary in minute amounts for proper growth, development, and optimal health.⁵ Some of their many functions include:

• helping the body process other nutrients.

• participating in the formation of blood cells, hormones, genetic material, and nervous system chemicals.

• acting as coenzymes to assist enzymes in carrying out their functions.⁵

Specific vitamins and compounds proven to aid in the treatment of periodontal disease are vitamins A, C, D, and E, as well as the B complex vitamins.⁶

Vitamin A

Fat-soluble vitamin A functions as an antioxidant. It is essential for building and maintaining healthy tissues like the mucous membranes and epithelial tissue.^5,6 Its function as an antioxidant aids in maintaining the integrity of mucosal tissues and the proper differentiation of cells, including those of the immune system.⁷ According to Rugg-Gunn et al, some epidemiological surveys have linked the deficiency of vitamin A to increased periodontal disease.⁶

B Complex Vitamins

B complex vitamins comprise eight water soluble vitamins: thiamine (Bl), riboflavin (B2), niacin (B3), pantothenic acid (B5), pyridoxine (B6), biotin (B7), folic acid (B9), and B12. The American Dental Hygienists’ Association lists B vitamins as important to oral health.⁸ They are essential for a variety of bodily functions such as growth and development, blood health, and the maintenance of periodontal tissue.

Vitamin C

Vitamin C, also known as ascorbic acid, is a water-soluble nutrient that acts as an antioxidant agent against tissue-destroying oxidants associated with periodontal disease.^8,10 In a longitudinal, single-blind, randomized study, Staudte and coauthors wrote, “One of the important roles of vitamin C in metabolic function is collagen synthesis, particularly in the course of wound healing; this is relevant for the maintenance of oral tissues such as the periodontal ligament, the formation of bone matrix, and the integrity of blood vessel walls.”¹¹ In the study, Staudte and coauthors tested the plasma vitamin C levels of 58 patients with chronic periodontal disease. The test group consumed two grapefruits a day for 2 weeks. At the conclusion of the study, there was a substantial reduction of sulcus bleeding index in the test group as well as a marked increase in vitamin C plasma levels. “Plasma absorbic acid levels reflect the vitamin C supply to the tissues of an individual subject,” the researchers concluded.¹¹

Vitamin D

The main role of vitamin D, also known as calciferol, is to assist the intestinal absorption of the minerals calcium and phosphorus in order to maintain proper bone health. It has also been shown to play a role in immune function and have anti-inflammatory properties.¹² These factors may help promote healthier gingival tissues, reduce inflammation, and prevent oxidative damage from occurring. A deficiency in vitamin D and calcium can cause both bone loss and increased inflammation characteristic of periodontal disease.¹² Due to the latter, vitamin D has begun to be used in the treatment of periodontal disease as well as other medical conditions.

Vitamin E

Vitamin E is an anti-inflammatory agent that aids in the control of periodontal disease. It decreases inflammation in the body, which in turn helps decrease gingival inflammation. Vitamin E also plays an important role as an antioxidant. It prevents cell damage by impeding free radical activity that damages gingival tissue.¹³ Its numerous salutary effects throughout the body have led the popular health press to describe its benefits as endless

Role of the Dental Hygienist

Dental hygienists play a pivotal role in the treatment of periodontal disease and serve as a vehicle to bring education and knowledge to our patients. Providing patients with nutritional counseling and proper dietary information can help them establish and maintain not only good oral health but good overall health as well. It is important to ask patients what, if any, vitamins or supplements they are taking as part of their daily regimen, as many do not list vitamin consumption or intake on their medical histories. This is an opportune time to have a discussion with your patients and inform them of all the potential benefits vitamin supplements can offer as an aid in the fight against periodontal disease. As oral healthcare providers, we have the responsibility to be educated not only on traditional ways of achieving optimum oral health and disease prevention but on innovative nontraditional methods as well. As each individual patient is unique, being able to offer different treatment modalities for treating their disease and improving their oral health is of great importance.

Conclusion

Research on the subject of vitamins and the potential benefit that they may have when used as an adjunct to periodontal therapy is gaining momentum. While currently there are no specific dietary guidelines in place as they relate specifically to the promotion of improving oral health and one’s periodontal condition, some current studies are showing great potential in demonstrating a positive relationship between vitamin therapy and the ability to treat and also arrest the onset and progression of periodontal disease.

What we do know is that the vitamins and nutrients that we consume, whether dietary or supplemental, are the fuel that dictates how our bodies will function and respond to outer and inner stressors. If we feed our body the right fuel—a diet rich in vitamins, nutrients, and antioxidants—the health benefits to our oral health and overall health will be invaluable.

As with any medication, dietary supplements can cause a range of side effects, allergic reactions, and have unfavorable interactions with other medications that an individual may be taking. In addition, we are all unique in that each of us makes, stores, and processes vitamins and minerals at a different rate than the next person. For this reason, it is imperative that patients consult with their healthcare provider prior to adding any additional supplements to their daily regimen in order to discuss the best course of action and plan that will fit their specific individual needs (Table I).

The Recommended Dietary Allowance (RDA), food sources, and some supplement benefits listed in the above table were taken from the Office of Dietary Supplements/National Institutes of Health website. Please note that the RDA for all nutrients varies depending on the age of the individual. The table above was constructed based on adult dosages and recommendations. “Intake recommendations for nutrients are provided in the Dietary Reference Intakes (DRIs) developed by the Food and Nutrition Board (FNB) at the Institute of Medicine (IOM) of the National Academies (formerly National Academy of Sciences). Recommended Dietary Allowance (RDA) is the average daily level of intake sufficient to meet the nutrient requirements of nearly all (97 percent to 98 percent) healthy individuals.”^14-19

References

1. Van der Velden UU, Kuzmanova DD, Chapple IC. Micronutritional approaches to periodontal therapy. J Clin Periodontol. 2011;38:142-158.

2. Fatima Z, Bey A, Zia A. Protective role of nutrition in periodontal oxidative damage. Guident. 2012;5(11):64-68.

3. Scardina GA, Messina PP. Good oral health and diet. J Biomed Biotechnol. 2012;20:121-128.

4. Perry DA, Beemsterboer P, Taggart EJ. Periodontology for the Dental Hygienist. 2nd ed. Philadelphia: W.B. Saunders, 2001.

5. Ehrlich AB. Nutrition and Dental Health. 2nd ed. Albany, NY: Delmar, 1994.

6. Rugg-Gunn AJ, Nunn JH. Nutrition, Diet, and Oral Health. New York: Oxford, 1999.

7. Kaye EK. Nutrition, dietary guidelines and optimal periodontal health. Periodontology 2000. 2012;58(1):93-111.

8. American Dental Hygienists’ Association. Oral health nutrition. Available at: www.adha.org/resources-docs/7256_Oral_Health_Nutrition.pdf.

9. Otten JJ, Hellwig JP, Meyers LD. Dietary reference intakes: the essential guide to nutrient requirements. Washington: National Academies, 2006.

10. University of Maryland Medical Center. Periodontal disease: risk factors 2011. Available at: www.umm.edu/patiented/articles/who_gets_periodontal_disease_000024_4.htm.

11. Staudte HH, Sigusch BW, Glockmann EE. Grapefruit consumption improves vitamin C status in periodontitis patients. Br Dent J. 2005;199(4):213-217.

12. Yao SG, Fine JB. A review of Vitamin D as it relates to periodontal disease. Compend Contin Educ Dent. 2012;33(3):166-171.

13. Salmeri J. Vitamin E and periodontal disease. Dynamic Dental. Apr. 11, 2012. Available at: www.dynamicdentalinc.com/blog/bid/74190/Vitamin-E-Periodontal-Disease.

14. National Institutes of Health Office of Dietary Supplements: Vitamin B6 —health professional fact sheet. Sep. 15, 2011. Available at: http://ods.od.nih.gov/factsheets/VitaminB6-HealthProfessional/. Accessed May 5, 2013.

15. National Institutes of Health Office of Dietary Supplements: Folate — health professional fact sheet. Dec. 14, 2012. Available at: http://ods.od.nih.gov/factsheets/Folate-HealthProfessional/. Accessed May 5, 2013.

16. National Institutes of Health Office of Dietary Supplements. Vitamin A — QuickFacts. Sep 5, 2012. Available at: http://ods.od.nih.gov/factsheets/VitaminA-QuickFacts/. Accessed Apr. 29, 2013.

17. National Institutes of Health Office of Dietary Supplements. Vitamin B12 — QuickFacts. Jun. 24, 2011. Available at: http://ods.od.nih.gov/factsheets/VitaminB12-QuickFacts/. Accessed May 5, 1012.

18. National Institutes of Health Office of Dietary Supplements. Vitamin D — QuickFacts. Jun. 24, 2011. Available at: http://ods.od.nih.gov/factsheets/http://ods.od.nih.gov/factsheets/VitaminD-QuickFacts/VitaminD-QuickFacts/. Accessed Apr. 28, 2013.

19 National Institutes of Health Office of Dietary Supplements. Vitamin E — QuickFacts. Oct. 11, 2011. Available at: http://ods.od.nih.gov/factsheets/VitaminE-QuickFacts/. Accessed Apr. 20, 2013.

Additional Resources

Combs GF. The vitamins: fundamental aspects in nutrition and health. San Diego: Academic, 1992.

Heidtman L. Vitamins that help periodontal disease. Available at: www.livestrong.com/article/289911-vitamins-that-help-periodontal-disease/.

Hoyle MG. Recommended dietary allowance for coenzyme q10. Available at: www.livestrong.com/article/285186-recommended-dietary-allowance-for-coenzyme-q10/#ixzz1xv1zNHHm.

Jenzsch A, Eick S, Rassoul F, et al. Nutritional intervention in patients with periodontal disease: clinical, immunological and microbiological variables during 12 months. Br J Nutrition. 2009;101(6):879-885.

Quantum Health: Natural products that make a difference: gum disease — health, nutrition, medicine, vitamins, herbs, natural healing: articles. Available at: www.quantumhealth.com/news/articlegums.html.

Neiva RF, Steigenga J, Al-Shammari KF, Wang H. Effects of specific nutrients on periodontal disease onset, progression and treatment. J Clin Periodontol. 2003;30(7):579-589.

About the Authors

Martha Macaluso, MLT, RDH, BS, is a practicing dental hygienist and an adjunct clinical instructor at both New York City College of Technology and New York University. She is currently enrolled at Hofstra University where she will be receiving her master’s degree in Health Education. She is actively involved in the profession, acting as a delegate for ADHA and Dental Hygiene Association of the State of New York, as well as a volunteer editor for the Long Island Dental Hygienists’ Association.

Loretta Mariano, RDH, BSDH, is a practicing dental hygienist for over 17 years and an adjunct clinical instructor in the Department of Dental Hygiene at Farmingdale State College. She is currently enrolled at the University of Bridgeport, completing her master’s degree in Dental Hygiene Education and is on track to graduate in May 2014. She is a member of the ADHA and an active member of the Long Island Dental Hygienists’ Association serving as an alternate delegate.