Nutritional Factors in Gum Disease
The health of our teeth and gums depends very much on good nutrition. Martin Hum PhD, DHD looks at how the right diet can prevent gum disease from developing, and at some nutritional supplements that can stop it in its tracks
In the early part of the 20th century, Dr Weston Price, an American dentist, became interested in the relationship between diet and tooth decay. He embarked on a series of expeditions, which took him, over many years, throughout North and South America, Europe, Africa, Australia, New Zealand and the Pacific islands. Wherever he found ancient, indigenous populations eating simple, traditional diets, he was struck by their sturdy dental arches, perfect teeth and low incidence of tooth decay and other dental problems. Where people from those same cultures had adopted a "Western" diet of tinned foods, white flour and sugar, they suffered from tooth decay, gum disease, malformed dental arches and crowded teeth.1 Dr Price took pains to exclude hereditary factors in his comparisons, often looking at families where some siblings had adopted a Western diet and others had kept to the traditional way of eating. All over the world, from the Alaskan Inuit to the New Zealand Maoris, the results were the same. The Western diet was disastrous for dental health.
Diet clearly has an effect on dental health as much as on any other aspect of health. But what are the specific nutritional factors in the development of gum disease, a complaint that affects 54% of adults by the age of 50? (2) And how do foods and nutritional supplements work to prevent, halt and possibly even reverse this condition? Before we answer those questions, we need to understand what gum disease is and how it starts.
WHAT IS GUM DISEASE?
Gum disease, or periodontal disease as it is more correctly known, starts as gingivitis, an inflammation of the gums around the teeth, often characterised by tenderness, redness and bleeding during brushing. If untreated, it may develop into pyorrhoea, which is a chronic, degenerative disease of the gums, characterised by further gum inflammation, bad breath, discharge of pus and loosening of the teeth. As inflammation progresses, the gums recede from the teeth allowing deeper tissues -the collagen, ligaments and bone supporting the teeth – to become affected. This is periodontitis. As it becomes more advanced, deep pockets form between the teeth and the surrounding tissue, abscesses develop under the roots of the teeth, bone loss continues and teeth may fall out. In adults over the age of thirty, more teeth are lost from periodontal disease than from tooth decay.(2) In addition to causing pain, general malaise, fatigue and bad breath, periodontal disease is associated with a higher risk of heart disease, respiratory disease and nutritional deficiencies.
WHAT CAUSES GUM DISEASE?
Bacteria in the mouth are implicated in almost all forms of gum disease, through the development of plaque. Plaque gradually becomes mineralised and hardens into tartar or calculus, through the action of sialic acid in the saliva. It cannot then be removed by brushing and provides an anchorage for further build-up of bacteria. Plaque-forming bacteria produce free radicals, toxins, and connective tissue-destroying enzymes which initiate the inflammatory process. The mouth, like the gut, naturally supports a population of bacteria, which are necessary for oral and digestive health. These bacteria are present in people who don’t develop gum disease, as well as in those who do. So other factors must also be involved in the disease process.
The immune system is well adapted to protect us, and neutrophils provide the first line of defence against bacterial overgrowth. Any condition that compromises neutrophil function leaves the person at risk from developing periodontal disease. This is why there is a high incidence of the problem in older people and those with diabetes, Crohn’s disease, leukaemia, HIV and Down’s syndrome. The release of histamine from the mast cells brings about inflammation and is thus a factor in gum disease. This can happen in response to IgE antibodies, it can be triggered by bacterial toxins and free radicals or by mechanical trauma (e.g. rough or vigorous brushing). Increased concentrations of IgE antibodies are found in the gums of people with periodontal disease, suggesting that allergic reactions may be a factor in development of the disease.(3) Anything that favours the accumulation of plaque will also be a factor in periodontal disease. Faulty fillings and crowns, that provide an overhang where plaque can build up, may be a cause. People with amalgam fillings are more likely to have gum disease. Mercury accumulation from amalgam fillings may affect the ability of the immune system to combat plaque-forming bacteria and may suppress the activity of free radical-scavenging enzymes such as glutathione peroxidase and superoxide dismutase, allowing free radicals to damage periodontal tissues. (4) Tobacco smoke also causes free radical damage to the gums and is often a major contributory cause of gum disease in smokers.(5)
WHERE DOES DIET FIT IN?
Perhaps the biggest factor in the build-up of plaque is sugar (and to a lesser extent other refined carbohydrates) in the diet. These foods create acidic conditions in the mouth that are ideal for the proliferation of plaque-forming bacteria. Just as importantly, sugar consumption depresses the immune system, particularly by inhibiting the action of neutrophils.(6) Because large amounts of B vitamins are used up in sugar metabolism, a diet high in sugar and low in whole foods can lead to deficiencies in these vitamins, which are necessary for healing.
Recent studies at the University of Buffalo Periodontal Disease Centre, New York State, USA, have shown that alcohol is a factor in gum disease. Increasing alcohol consumption from 5 units to 20 units a week increases the risk of periodontal disease from 10% to 40%. It is thought that alcohol may inhibit blood clotting, suppress new bone formation and reduce levels of B vitamins. (7) Alcohol dehydrates the mouth, so that bacteria are not washed away so readily by saliva, and plaque formation occurs faster.
Several nutritional deficiencies are associated with periodontal disease. The best documented is vitamin C, whose deficiency ultimately causes scurvy, a disease characterised by bleeding, suppurating gums and the loss of teeth. Vitamin C is vital in forming the amino acids needed for the production of collagen, an important component of the tissues that support the teeth. Vitamin C is needed too, for bone formation and calcification, and for wound healing. (8) Low levels of vitamin C have been shown to be associated with an increased risk of periodontal disease (9), increased permeability of the oral mucosa to bacterial toxins (10), as well as with impaired immune response. Deficiencies of vitamins A and E may also predispose to periodontal disease. (2)
Deficiencies of protein, vitamin D or calcium may lead to the resorption of bone around the teeth and destruction of the periodontal ligaments that anchor the teeth to the jawbones. Women with severe osteoporosis are three times more likely to experience tooth loss. (11) Reduced gastric acidity is associated with resorption of calcium from the bone supporting the teeth. This is probably because calcium absorption from the gut is decreased when gastric hydrochloric acid levels are low, leading to calcium deficiency. Vitamin D is essential for calcium absorption from the gut and helps maintain the proper balance of calcium and phosphorus in the bones.
The care of a periodontal specialist, combined with good oral hygiene and plaque control measures, is essential in treating gum disease. A periodontist will use techniques such as scaling to remove plaque deposits above and below the gumline, root planing to smooth rough root surfaces so that the gum can heal, and oral irrigation to flush out bacteria and toxins. If very deep pockets have formed around teeth and bone has been lost, periodontal surgery may be recommended to remove gum flaps, so that the roots of the teeth are accessible for cleaning. Recently, techniques for regenerating lost periodontal attachment have been developed. A gel containing the protein amelogenin has been used with some success as an adjunct to surgery, to reawaken the growth of periodontal tissue.
NUTRITIONAL THERAPY FOR GUM DISEASE
In general terms, the diet that provides for good gum health is no different from that which provides for optimal health of the whole body. It should be nutrient-rich and based on fresh natural foods, whole grains, vegetables, fruit, fish, beans and seeds. It should be low in sugar, refined carbohydrates, salt and alcohol and should avoid damaged fats, artificial additives and allergenic foods. Foods that are high in bioflavonoids, such as blue-black fruits, onions, citrus pith and hawthorn berries should be included as these compounds are important in maintaining healthy collagen structure. (12) A diet that is high in fibre may protect against gum disease by promoting the secretion of saliva. (13)
Specific nutritional supplements have been used with success in the treatment of periodontal disease. The following daily supplement programme is likely to be helpful.
Coenzyme Q10 (50 to 150 mg).
Coenzyme Q10 (Co Q10) is chemically similar to vitamin E and is involved in electron transfer in the mitochondria. Early work suggested that people with periodontal disease may be deficient in Co Q10.(14) In double blind trials, 50mg a day of Co Q10, given for three weeks, led to a significant reduction in the symptoms of gingivitis.(15) More recent studies have shown that the topical application of Co Q10 may also improve periodontitis (16), although the conclusions of this research have been questioned.(17)
Vitamin C (2 to 4g).
Vitamin C supplementation can improve the symptoms of periodontitis in people who have a low intake of the vitamin (below 35 mg daily) (18), although there is less evidence that it benefits people who already consume adequate amounts in their diet. (19) However, vitamin C is necessary to maintain a healthy immune system, to combat free radical damage and to promote healing. A daily supplement would seem sensible.
Bioflavonoids (500mg to 1g).
The bioflavonoids that often accompany vitamin C in foods, which are important for collagen structure, can reduce gum inflammation when taken as a supplement. (20)
Vitamin A is necessary for collagen synthesis and wound healing, maintaining the integrity of periodontal tissues and enhancing immune function. Beta-carotene may be the best form of vitamin A to take, due to its affinity with gum tissue, potent antioxidant activity and safety at high dosages. (21)
Zinc functions synergistically with vitamin A, inhibits plaque growth and helps to stabilise membranes in the periodontal tissues. (22) Citrate or picolinate are the best forms to take.
Vitamin E (200 to 400 i.u).
Vitamin E has been shown to be of benefit in severe periodontal disease, due to its antioxidant and wound healing properties.
Selenium and vitamin E act synergistically as antioxidants.
Folic acid (2mg).
Double blind studies have shown that folic acid can significantly reduce gum inflammation. (23) This is a particularly important supplement for women who are on the contraceptive pill or are pregnant.
A diet that is high in fibre may protect against gum disease by promoting the secretion of saliva
TOPICAL TREATMENTS AND HERBAL MOUTHWASHES
Co Q10, folic acid and zinc have shown to be beneficial when used topically for gum disease. A mouthwash containing copper citrate is claimed to be effective in preventing plaque bacteria from sticking to the teeth below the gumline. A herbal mouthwash containing chamomile, echinacea, myrrh, peppermint, clove, caraway and sage has been used successfully to treat gingivitis. (24) White oak bark, tea tree, goldenseal, grapefruit seed extract and aloe vera may also be helpful, due to their immune boosting, bactericidal or anti-inflammatory properties.
Price, W. Nutrition and Physical Degeneration. The Price-Pottenger Foundation 1972.
Carranza, F. Glickman’s Clinical Periodontology. W. B. Saunders 1984.
Hyyppa, T. Gingival IgE and histamine concentrations in patients with periodontitis. J. Clin. Periodontol 1984;11:132-7.
Bartold, P., Wiebkin, O. and Thonard, J. The effect of oxygen-derived free radicals on gingival proteoglycans and hyaluronic acid. J Periodontal Res 1984;19:390-400.
Christen, A. The clinical effects of tobacco on oral tissue. J. Am. Dental Asso 1970;81: 1378-82.
Ringsdorf, W., Cheraskin, E. and Ramsay, R. Sucrose, neutrophil phagocytosis and resistance to disease. Dent Surv 1976;52:46-48.
Grossi, S. University of Buffalo News. Quoted on www.floss.com
Woolfe, S., Hume, W. and Kenney, E. Ascorbic acid and periodontal disease: a review of the literature. J. Western Soc. Periodontol 1980;28:44-60.
Vaananen, M., Markkanen, H., Tuovinen, V. et al. Periodontal health related to plasma ascorbic acid. Proc. Finn. Dent. Soc 1993;89:51-59.
Alvares, O. and Siegel, I. Permeability of gingival sulcular epithelium in the development of scorbutic gingivitis. J. Oral Path 1981;10:40-48.
Jeffcoat et al. Systemic osteoporosis and oral bone loss: evidence shows increased risk factors. J. Am. Dental Assoc, Nov 1993, 49-56.
Rao, C., Rao, V. and Steinman, B. Influence of bioflavonoids on the metabolism and cross linking of collagen. Ital. J. Biochem 1981;30:259-70.
Alvares, O. Nutrition, diet and oral health. Chapter 14 in Worthington-Roberts, B. (Ed.), Contemporary developments in nutrition. Mosby 1981.
Nakamura, R., Littarru, G. and Folkers, K. Deficiency of coenzyme Q in gingiva of patients with periodontal disease. Int. J. Vitam. Nutr. Res 1973;43:84-92.
Wilkinson, E. et al. Adjunctive treatment of periodontal disease with coenzyme Q10. Res. Commun. Chem. Pathol. Pharmacol 1976;14:715-9.
Hanioka, T., Tanaka, M., Shiskuisi, S. and Folkers, K. Effect of topical application of coenzyme Q10 on adult periodontitis. Mol. Aspects Med 1994;15:Suppl:241-8.
Watts, T. Coenzyme Q10 and periodontal treatment: is there any beneficial effect? Br. Dent. Journal 1995;178: 209-13.
Aurer-Koselj, J., Kralj-Klobucar, N., Buzina, R. and Bacic, M. The effect of ascorbic acid supplementation on periodontal tissue ultrastructure in subjects with progressive periodontitis. Int. J. Vitam. Nutr. Res 1982;52:333-41.
Vogel, R., Lamster, I., Wechsler, S. et al. The effects of megadoses of ascorbic acid on PMN chemotaxis and experimental gingivitis. J. Periodontol 1986;57:472-9.
Carvel, I. and Halperin, V. Therapeutic effect of water soluble bioflavonoids in gingival inflammatory conditions. Oral Surg. Oral Med. Oral Pathol 1961;14:847-55.
Burton, G. and Ingold, K. Beta-carotene: an unusual type of liquid antioxidant. Science 1984;224:569-73.
Hsieh, S., Hayali, A. and Navia, J. Zinc. Chapter 9 in Curzon, M. and Cutress, T. (Eds), Trace Elements in Dental Disease. John Wright, Boston 1983.
Pack, A. and Thomson, M. Effects of extended systemic and topical folate supplementation on gingivitis of pregnancy. J Clin. Periodontol 1982;9:275-80.
Serfaty, R. and Itic, J. Comparative trial with natural herbal mouthwash versus chlorhexidine in gingivitis. J. Clin. Dentistry 1988;1:A34.
Hazan, S. and Cowan, E. Diet, Nutrition and Periodontal Disease. American Society of Preventive Dentistry, 1975.
Krause, M. and Mahan, L. Food, Nutrition and Diet Therapy. W.B. Saunders, 1984.
Murray, M. and Pizzorno, J. Encyclopaedia of Natural Medicine: Periodontal Disease. Little, Brown & Co, 1995.
Todd, G. Nutrition, Health and Disease. Whitford Press, 1985.
Martin Hum is a registered nutritional therapist who regularly writes for nutritional magazines and is a member of the Optimum Nutrition Advisory Board.
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