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Approximately 12% of the entire global population is affected by severe periodontitis,1 and data suggest that 46% of US adults over 30 years of age have some form of destructive periodontitis.2 In the United States, less than 10% of the population is thought to have nutritional deficiencies; however, when adjusted for age, gender, race, and ethnicity, deficiencies for some nutritional indicators can be as high as one third of certain population groups.3 The three most common deficiencies in the United States are for vitamin B, iron, and vitamin D. Less common deficiencies include those for vitamin A, vitamin E, and folate.3 Given the known impact of micronutrient deficiencies on overall health and oral health, it is imperative that oral healthcare providers understand the relationship between deficiencies in specific nutrients and their effects on periodontal health.
Periodontitis is an inflammatory disease affecting the supporting tissues of the teeth (eg, gingival tissues, cementum, periodontal ligament, alveolar bone) that is initiated by dysbiotic dental plaque biofilm in a susceptible host.4 Bacteria and bacterial byproducts within such biofilms initiate a host immunoinflammatory response, which results in soft- and hard-tissue destruction. The bidirectional interaction between periodontitis and many health conditions has been well-established through epidemiologic studies.5 A similar bidirectional influence between periodontitis and nutrient deficiencies has been suspected due to findings of decreased numbers of erythrocytes and hemoglobin levels among periodontitis patients.6 Recent data have linked serum/plasma micronutrient levels to periodontal disease status. These micronutrient levels are dependent upon diet, lifestyle factors, and/or nutrigenetic characteristics and impact the function of many systems throughout the body.7 Micronutrient deficiencies, particularly those involving vitamin C, vitamin D, or vitamin B12, may be related to the onset and progression of periodontal disease. Functional foods or probiotics may be helpful in the prevention of periodontal disease and during the active treatment of periodontitis; however, there is a limited understanding of the biologic mechanisms involved.5
Facilitating optimal nutrient intake may provide an adjunctive method to prevent the development of periodontal disease and improve outcomes during periodontal therapy. Dietary supplements, such as juice powder, calcium, and vitamin D, have demonstrated a positive impact on periodontal clinical parameters when used adjunctively to ongoing periodontal therapy.8 In addition, trace mineral micronutrients, such as iron, zinc, copper, and selenium, are essential for regulating the immunoinflammatory pathways, and their levels in the human body may be reflective of the state of the ongoing destructive process in patients with chronic periodontitis.5
One commonality between periodontitis and other inflammatory conditions is the presence of reactive oxygen species (ROS) in excess. This leads to oxidative stress, which is an imbalance between free radicals and antioxidants in the body.9 Free radicals are unstable atoms split from oxygen molecules that can damage cells and are linked to various diseases. Conversely, antioxidants can prevent or reduce the damage done by ROS.9 Total antioxidant capacity is often evaluated during a disease state to determine the antioxidant response against ROS.9 The gingival crevicular fluid at sites with periodontitis demonstrates depleted total antioxidant capacity, which is likely due to the oxidative stress related to local inflammation. The performance of periodontal therapy, such as scaling and root planing, can restore a healthy total antioxidant capacity to the gingival crevicular fluid by reducing local inflammation.9 Limited evidence exists regarding the effect of specific antioxidants on periodontal health. This may be due to the combinatorial effects of antioxidants in vivo because they are able to recycle each other from their oxidized counterparts.9 Nonetheless, antioxidants such as vitamins A, C, and E and their relationship to periodontal disease are of interest to researchers, clinicians, and patients alike.
Beta-carotene, a natural pigment responsible for the red, orange, and yellow colors in many fruits and vegetables, is a precursor to vitamin A, or retinol. It functions as an antioxidant, scavenging for free radicals, and also helps to maintain the integrity of epithelial cells. Considering beta-carotene's antioxidant potential, studies suggest that a significant inverse association exists between it and periodontitis.10 Beta-carotene deficiency has been associated with periodontitis prevalence and gingival bleeding, and its antioxidant properties may significantly contribute to the maintenance of periodontal health.11 For example, in nonsmokers with generalized periodontitis, a higher dietary intake of beta-carotene and other antioxidants has been associated with greater reductions in probing depths following nonsurgical periodontal therapy.11
Vitamin C (ie, ascorbic acid) facilitates collagen synthesis and acts to protect against tissue damage by scavenging ROS.12 Historically, cases of scurvy, a disease caused by extreme vitamin C deficiency, were frequent among sailors who lacked access to vitamin C-containing foods during long voyages at sea. Due to scurvy's association with severe gingival bleeding and tooth mobility, it has been postulated that vitamin C deficiency plays a role in gingivitis. In one study, consumption of a 7-day diet that was adequate in all nutrients except for vitamin C resulted in no changes in plaque index or probing depths; however, increased bleeding on probing was noted.12 In another, an inverse relationship between the prevalence of inflammatory periodontitis and serum antioxidant vitamin C concentrations was found, and this relationship was stronger with more severe forms of periodontal disease and in those who had never been smokers.13Research has shown that dietary supplementation with grapefruit for 2 weeks increased plasma vitamin C levels and improved sulcular bleeding scores.14 Vitamin C may also weaken the cytotoxic effects of Porphyromonas gingivalis, a known periodontal pathogen, on human gingival fibroblasts.13,15 Given these findings, it is likely that adequate vitamin C intake may contribute to improved periodontal health and outcomes of periodontal therapy.
Vitamin E consists of a group of lipid-soluble compounds with a characteristic phenolic-chromanol ring linked to an isoprenoid side chain.16 Vitamin E plays important antioxidant and anti-inflammatory roles, and it has been suggested that it improves periodontal treatment outcomes.16 Serum levels of alpha-tocopherol, a saturated form of vitamin E, have been inversely associated in a nonlinear trend with mean probing depths and periodontal disease severity.17 Furthermore, vitamin E supplementation has demonstrated a reduction in bleeding upon probing and periodontal inflammation.18 A higher intake of vitamins A, B, C, and E along with omega-3 fatty acids has been demonstrated to improve healing after nonsurgical periodontal therapy in nonsmokers but not in smokers.11 These preliminary findings suggest that vitamin E can play a role in improving periodontal outcomes and that its supplementation may present an advantage during initial healing after periodontal therapy.
Vitamin B Complex
Vitamin B complex refers to eight water-soluble vitamins that together perform functions essential to the body.16 The B complex vitamins include thiamine (B1), riboflavin (B2), niacin (B3) pantothenic acid (B5), pyridoxine (B6), biotin (B7), folate (B9), and cobalamin (B12). Although all of the vitamins in the vitamin B complex are required for cell growth, vitamins B1, B2, B3, and B7 are mainly involved in energy production. Vitamin B6 is necessary for amino acid metabolism, and B9 and B12 aid in cellular division.16 Vitamin deficiencies in the complex may also play a role in the progression and severity of periodontal disease. Vitamin B2, B3, B6, and B12 deficiencies have been linked to hemorrhagic gingivitis and periodontitis.19 These vitamins support healthy immune functions by strengthening epithelial barriers as well as cellular and humoral immune responses.19 Vitamin B complex supplementation has been associated with statistically significant higher mean clinical attachment gain in both shallow and deep sites.20 Although heterogeneity exists in clinical investigations, the direct effect of these micronutrients may be influenced by other factors, such as age and smoking status, which can obscure results.20 Additional research to assess the relationship between vitamin B complex and periodontal health is needed.
Vitamin D and Calcium
Vitamin D includes several forms of cholecalciferol, a hormone whose biologically active form is known as calcitriol.21 It is well-known that Vitamin D plays a role in the regulation of plasma calcium and phosphorus levels for bone metabolism, but it is also essential for cellular development, neuromuscular functions, and inflammatory system modulation.21 Vitamin D has also been found to inhibit pro-inflammatory cytokines and T-lymphocyte proliferation.21 Because it is present in very few naturally occurring food sources, exposure to sunlight is the most common source.21 Vitamin D and the vitamin D receptor complex interact with receptor activator of nuclear factor kappa-B ligand (RANKL) expression and downregulate osteoprotegerin, thereby increasing differentiation and activation of osteoclasts and consequently bone resorption. When vitamin D levels become low, parathyroid hormone indirectly stimulates bone resorption in order to increase them; therefore, increasing vitamin D intake may reduce bone resorption. Dietary studies suggest that individuals in the highest quintile of daily dairy product intake are 20% less likely to have periodontitis than those in the lowest quintile of intake.22 However, this finding may also be related to overall nutritional status and/or socioeconomic status. In addition, Vitamin D deficiency has been linked to adverse periodontal treatment outcomes and poor wound healing for up to one year postoperatively.23
Essential Trace Minerals
Balanced levels of trace minerals are essential for optimal host immune responses and have been found to play a role in preventing the progression of chronic conditions, including periodontitis.10 Iron (Fe++), the most abundant essential trace mineral, serves many functions in the human body and is found mainly in the blood.24 The recommended daily allowance of iron varies with age and gender, and the highest levels are recommended for women of reproductive age.24 Within the periodontal structures, iron plays an important role in maintaining alveolar bone homeostasis. In animal models, periodontal ligament cells have been shown to regulate iron uptake and control the cytodifferentiation of cells into osteoblasts and mineralization.24 In addition, iron has a number of functions in the innate and adaptive immune responses. Although evidence linking iron deficiencies to the development of periodontitis is sparse, inflammation from periodontitis may result in an increase of pro-inflammatory cytokines, which then suppress erythropoiesis in the bone marrow and lead to periodontal disease progression.6
Other essential trace minerals, including selenium, zinc, and copper, have antioxidant enzymes that can aid in neutralizing ROS and prevent tissue damage, and they also play important roles in regulating immune function and wound healing.25 Therefore, achieving ideal levels of these micronutrient minerals may be a critical component of periodontal care.25
To maintain optimal periodontal health and maximize the response to periodontal therapy, excellent nutrition is critical. Table 1 outlines the recommendations for the daily intake of micronutrients and the current evidence regarding their individual roles in improved periodontal health before, during, and after periodontal therapy.26 Possible mechanisms for the relationships between micronutrients and periodontitis development, progression, and wound healing have been proposed based on the underlying mechanisms of action of the individual micronutrients. Although available research regarding the supplementation of micronutrients indicates promising results, further investigation is necessary. Additional randomized, controlled, longitudinal human studies are still needed to develop a more robust understanding of the relationships between individual micronutrients and periodontal health. It should be noted, however, that because the medical literature supports nutrition's critical role in wound healing processes and the maintenance of overall health, following the recommendations for daily micronutrient intake is not only beneficial to oral health but also beneficial to systemic health. Host susceptibility remains a necessary element of the onset and progression of periodontal disease; therefore, the modulation and influence of such susceptibility by improving micronutrient levels may improve and maintain periodontal health. Because nutrient supplementation is associated with minimal or no adverse effects, demonstrating the abilities of micronutrients to enhance treatment outcomes could reveal them to be a valuable adjunctive tool in the management of periodontal diseases.
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About the Authors
Mengyi Shi, DMD
University of Alabama at Birmingham
School of Dentistry
Andrea Pizzini, DDS, MS
Clinical Assistant Professor
Department of Periodontics
West Virginia University
School of Dentistry
Morgantown, West Virginia
Maria L. Geisinger, DDS, MS
American Board of Periodontology
Professor and Director
Advanced Education Program in
University of Alabama at Birmingham
School of Dentistry
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