• Gingivitis: inflammation of the gums, characterized by redness, contour changes, and bleeding
• Periodontitis: localized pain, loose teeth, presence of dental pockets, redness, swelling, or pus; X-ray may reveal bone destruction
Periodontal disease is an inflammatory condition of the gums (gingivitis) and/or support structures (periodontitis). Periodontal disease typically progresses from gingivitis to periodontitis. It may be a manifestation of a more systemic condition, such as diabetes, anemia, vitamin deficiency states, leukemia, or other disorders of white blood cell function.1 An association with hardening of the arteries has also been reported, as periodontal disease is associated with an elevation in C-reactive protein—an important marker for systemic inflammation and an independent risk factor for heart disease.2
Since there can be significant loss of the bone that supports the teeth (alveolar bone) without much inflammation, the definition of periodontal disease used in this chapter excludes the processes that cause only tooth loss (the majority of which is due to osteoporosis).1 These noninflammatory conditions reflect systemic disease, with local factors playing only a minor role. Therefore, the focus in such cases should be on treating the underlying condition rather than the “periodontal disease.” For a discussion of the factors involved in noninflammatory alveolar bone loss, see the chapter “Osteoporosis.”
The focus of this chapter is on the use of nutrition and lifestyle factors to aid in prevention and control of inflammatory periodontal disease. This disease is a good example of a condition that is probably best treated with the combined expertise of a dentist or periodontist and a nutritionally minded physician. Although oral hygiene is of great importance in treating and preventing periodontal disease, it is not sufficient in many cases. The patient’s immune system and other defense mechanisms must be normalized if development and progression of the disease are to be controlled.1,3 To a large extent, a person’s nutritional status determines the status of his or her defense mechanisms.
The frequency of periodontal disease increases directly with age. The rate of periodontal disease is approximately 15% at age 10, 38% at age 20, 46% at age 35, and 54% at age 50. As a group, men have a higher prevalence and severity of periodontal disease than women. The occurrence of periodontal disease is inversely related to increasing levels of education and income; rural dwellers have a higher level of severity and prevalence than city dwellers.1
Causes
Understanding the underlying process of any disease leads to a more effective treatment plan. In periodontal disease, this means understanding the normal protective factors in the gums and supporting structures (periodontium). Many experts agree that the presence of bacteria is not sufficient to cause disease; a person’s immune status and other defense mechanisms must be involved.3 These are discussed below.
The Environment of the Gingival Sulcus
The gingival sulcus is the V-shaped crevice that surrounds each tooth. The anatomy of the gingival sulcus is ideal for growth of bacteria, as it is resistant to the cleansing action of saliva. Furthermore, the gingival fluid (the fluid found in the sulcus) provides a rich nutrient source for microorganisms. The clinical determination of the depth of the gingival sulcus is an important part of the diagnosis. Individuals who have periodontal disease should see their dentist no less than once every six months for proper evaluation and cleaning.
Bacterial Factors
Bacterial plaque has long been considered the causative agent in most forms of periodontal disease.1 However, immune system factors are now known to be involved as well.1,3 Bacteria secrete numerous compounds that weaken a person’s immune system, including endotoxins and exotoxins, free radicals and collagen-destroying enzymes, and waste products.1
Neutrophil Function
White blood cells known as neutrophils constitute a first line of defense against microbial overgrowth. When neutrophils function inadequately, the periodontium can be damaged.1,3 Neutrophil function is lower in older people generally, as well as in patients with diabetes, Crohn’s disease, and Down syndrome.1,3 These patients are at extremely high risk for developing rapidly progressing periodontal disease, as are people with temporarily low levels of neutrophils.
Neutrophils can also play a role in tissue destruction. As they defend the body against microbes, neutrophils release numerous free radicals (which break down collagen), inflammatory compounds, and a compound that stimulates alveolar bone destruction.1,3
Complement Activation
The complement system is composed of at least 22 proteins that circulate in the blood. Upon activation, complement components act in a cascade fashion. The complement system plays a critical role in the resistance to infection, but it also plays a big role in the tissue injury of periodontal disease, because complement activation increases gingival permeability, allowing bacteria and bacterial by-products to penetrate gum tissue.1,3 In periodontal disease, activation of complement within the periodontal pocket is possibly the major factor in tissue destruction.
IgE and Mast Cell Function
Mast cells are white blood cells that reside in tissues. They contain histamine and other inflammatory compounds in packets known as granules. The release of the contents of these packets (in response to allergy antibodies, complement activation, trauma, endotoxins, and free radicals) is a major factor in periodontal disease.1 The finding of increased allergy antibody (IgE) concentrations in the gingiva of patients with periodontal disease suggests that allergic reactions may be a factor in the progression of the disease in some patients.4
Amalgam Restorations
Faulty dental work is a common cause of gingival inflammation and periodontal destruction.1 Overhanging margins from a poorly done filling or crown provide an ideal location for the accumulation of plaque and the multiplication of bacteria. If the restoration is a silver amalgam filling, there may be even more involvement because over time the mercury in those fillings is released into the body, where it decreases the activity of antioxidant enzymes, including glutathione peroxidase, superoxide dismutase, and catalase.5 The support structures of the teeth are particularly sensitive to free radical damage.6
The Collagen Matrix
The collagen matrix of the periodontal membrane serves to anchor the tooth to the alveolar bone and allows the dissipation of the tremendous amount of pressure exerted during chewing. The health of this collagen matrix affects its ability to resist inflammatory mediators, bacteria and their by-products, and destructive enzymes. Because periodontal collagen is constantly being renewed, it is extremely vulnerable when the necessary cofactors for collagen synthesis (protein, zinc, copper, vitamins C, B6, and A, etc.) are absent or deficient.
Miscellaneous Factors
Numerous local factors favor the progression of periodontal disease. These include food residue, unreplaced missing teeth, malocclusion, tongue thrusting, bruxism (grinding of the teeth), toothbrush trauma, mouth breathing, and tobacco smoking.
Tobacco smoking is associated with increased susceptibility to severe periodontal disease and tooth loss.1,7,8 Many of the harmful effects of smoking are a result of free radical damage. Furthermore, smoking greatly reduces vitamin C levels, thereby intensifying its damaging effects.9
Therapeutic Considerations
From a nutritional perspective, therapeutic goals in treating periodontal disease are:
• Decrease wound healing time (the time needed for wound healing is longer in patients who are more susceptible to periodontal disease)10
• Improve membrane and collagen integrity
• Decrease inflammation and free radical damage (inflammation can promote periodontal disease)
• Enhance immune status
Diet and Nutritional Supplements
Vitamin C
Vitamin C plays a major role in preventing periodontal disease, as is evident from many experimental studies.1,11–14 The classical symptom of gingivitis seen in scurvy (severe vitamin C deficiency) illustrates the vital function vitamin C plays in maintaining the integrity of the periodontal membrane and collagen matrix.1 The effects of deficiency on the bone include osteoporosis and retardation or cessation of bone formation. Subclinical vitamin C deficiency plays a significant role in periodontal disease through these effects and through its role in delaying wound healing.
Decreased vitamin C levels are also associated with increased susceptibility of the oral tissues to endotoxins and bacterial by-products, as well as impaired function of white blood cells (particularly neutrophils).
Sugar
Sugar is known to significantly increase plaque accumulation while decreasing white blood cell function.15,16 The inhibition of neutrophil function is due to competition with vitamin C. Vitamin C and glucose are known to compete for intracellular transport sites, with this intracellular transport being largely insulin-dependent. (See the chapter “Immune System Support” for further information on nutrient factors and immune function.)
If we consider the fact that the average American consumes in excess of 150 g sucrose and other refined carbohydrates per day, it is safe to say that most Americans have a chronically depressed immune status, which puts them at increased risk for periodontal disease.
Vitamin A
Vitamin A deficiency predisposes a person to periodontal disease. Deficiency of vitamin A is associated with abnormal cell structures in the periodontium, inflammatory infiltration and degeneration, periodontal pocket formation, plaque formation, increased susceptibility to infection, and abnormal alveolar bone formation.1 Vitamin A is necessary for collagen synthesis, wound healing, and enhancing numerous immune functions.
Zinc
Zinc’s importance in treating periodontal disease cannot be overstated. Zinc functions synergistically with vitamin A in many body processes.17 The severity of periodontal disease is directly associated with decreased zinc levels.18In the United States, marginal zinc deficiency is widespread, particularly among the elderly. This is clearly a factor in the increasing prevalence of periodontal disease with age, although the geriatric population as a whole is at higher risk for developing numerous nutrient deficiencies.
The functions of zinc in the gingiva and periodontium include stabilization of membranes, antioxidant activity, collagen synthesis, inhibition of plaque growth, inhibition of mast-cell degranulation, and numerous immune-enhancing activities.17–20 Zinc is also known to significantly reduce wound healing time.
Plaque growth can be inhibited by the use twice per day of a mouthwash that contains 5% zinc.19 However, lower concentrations of zinc or less frequent mouthwash use is not particularly successful.
Vitamin E and Selenium
These two nutrients function synergistically in antioxidant mechanisms and seem to potentiate each other’s effect. Vitamin E alone has been demonstrated to be of considerable value in treating patients with severe periodontal disease.1,21 This can largely be attributed to the decreased wound healing time associated with vitamin E.
The antioxidant effects of vitamin E are particularly needed if amalgam fillings are present. Mercury depletes the tissues of the antioxidant enzymes superoxide dismutase, glutathione peroxidase, and catalase. In animal studies, this effect is prevented by supplementation with vitamin E.5 Another reason supplemental selenium is beneficial is that it is displaced by mercury from several enzyme systems. Higher levels allow it to better compete with mercury for inclusion in the enzymes.
The antioxidant activities of selenium and vitamin E also deter periodontal disease because the effects of free radicals are extremely damaging to gums.
Coenzyme Q10
Coenzyme Q10 is involved in energy production, and it is also an effective antioxidant. Coenzyme Q10 is widely used in Japan to treat many conditions, including periodontal disease. A review of seven studies found that 70% of the 332 patients involved responded favorably to CoQ10 supplementation.22 A double-blind study comprising 56 subjects found that the supplemented group responded significantly, while the placebo group displayed very little change in periodontal pocket depth and tooth mobility.23
Flavonoids
As a group, these compounds are an essential nutritional component of any periodontal disease treatment program. Flavonoids are extremely effective in reducing inflammation and stabilizing collagen structures. Flavonoids affect collagen structure by decreasing membrane permeability, thereby decreasing the load of inflammatory mediators and bacterial products; preventing free radical damage; inhibiting destruction of collagen; inhibiting mast cell degranulation; and cross-linking with collagen fibers directly to increase their stability and strength.24–26
Perhaps the most useful source of flavonoids is either grape seed or pine bark extract, as the proanthocyanidins in both have been shown to possess a wide range of actions useful against periodontal disease.27,28
The flavonoid components of green tea (Camellia sinensis) are also useful, as they have demonstrated activity against gingival bacteria and direct anti-inflammatory effects as well. Population-based studies have shown that green tea intake protects against periodontal disease and tooth loss.29 Clinical studies have focused on direct, local effects with either chewable candy alone or dissolvable strips impregnated with green tea catechins. In the study with the strips, pocket depth and proportion of disease-causing bacteria were markedly decreased.30 The study using the chewable candy was double-blind and indicated that the green tea chews significantly reduced plaque and the inflammatory degree of the gingiva.31 A double-blind study showed that chewing gum containing procyanidolic oligomers also minimizes gingival bleeding and plaque accumulation.32
QUICK REVIEW
• Periodontal disease is best treated with the combined expertise of a dentist or periodontist and a nutritionally minded physician.
• Although oral hygiene is of great importance in treating and preventing periodontal disease, it is not sufficient in many cases.
• The immune system and other defense mechanisms are essential in preventing and controlling periodontal disease.
• Faulty dental work is a common cause of gingival inflammation and periodontal destruction.
• Tobacco smoking is associated with increased susceptibility to severe periodontal disease and tooth loss.
• Vitamin C plays a major role in preventing periodontal disease.
• Sugar is known to significantly increase plaque accumulation while decreasing white blood cell function.
• Vitamin E has been demonstrated to be of considerable value in treating patients with severe periodontal disease.
• Coenzyme Q10 is useful in periodontal disease.
• Flavonoids, particularly those found in grape seed, pine bark, and green tea extract, are extremely effective in reducing inflammation and stabilizing collagen structures of the gums.
• Folic acid has produced significant reductions of gingival inflammation in double-blind studies.
• Sanguinarine, an alkaloid derived from bloodroot, is useful in preventing dental plaque.
Folic Acid
The use of folic acid in double-blind studies, either as a mouthwash or as a pill, has produced significant reductions of gingival inflammation, as determined by reduction in redness, bleeding tendency, and plaque scores.33–37 Folic acid mouthwash (0.1% folic acid) is significantly more effective than oral supplementation consisting of either 2 or 5 mg folic acid per day, suggesting a local mechanism of action.35–37 Folic acid has also been demonstrated to bind plaque-derived toxins.
The use of folic acid mouthwash is particularly indicated for pregnant women and women using birth control pills, in whom hormonal changes appear to reduce the amount of folic acid in the cells of the oral cavity.38–40 People taking drugs that interfere with folic acid (e.g., chemotherapy agents, epilepsy drugs, and drugs used in Crohn’s disease and ulcerative colitis) also benefit from folic acid mouthwash.
Botanical Medicines
A number of botanical compounds have shown an ability to inhibit plaque formation, including green tea polyphenols and glycyrrhetinic acid from licorice, but the most extensively studied compound is an alcoholic extract of bloodroot.
Bloodroot
Bloodroot (Sanguinaria canadensis) contains a mixture of alkaloids, but chiefly sanguinarine, which is available in commercial toothpastes and mouth rinses. Sanguinarine demonstrates properties that are useful in preventing dental plaque formation. It has broad antimicrobial activity and anti-inflammatory properties. In vitro studies indicate that the antiplaque action of sanguinarine is due to its ability to prevent bacteria from adhering to tissue. Electron microscope studies demonstrate that bacteria exposed to sanguinarine aggregate and become morphologically irregular.41
Sanguinarine appears to be less effective than chlorhexidine mouthwash, but it is effective in many cases and does have the advantage of being a natural compound as opposed to a synthetic one.41,42
Gotu Kola
An extract containing the triterpenoids of gotu kola (Centella asiatica) has demonstrated impressive wound-healing properties. These properties can be put to good use in treating severe periodontal disease or if surgery is required. One study demonstrated that gotu kola extract was quite helpful in speeding recovery after laser surgery for severe periodontal disease.43
TREATMENT SUMMARY
Since many factors are involved in the initiation and promotion of periodontal disease, effective therapy requires that all relevant factors be controlled. Since there are as yet no clear guidelines for determining which factors are most important for any given person, a general approach is recommended here. If you are a smoker, we strongly encourage you to stop, as continued smoking greatly decreases the success of any therapy for periodontal disease.
Oral Hygiene
Visit a dentist periodically to have plaque and tartar removed. Brushing after meals and daily flossing are necessary.
Diet
A diet high in fiber may have a protective effect by increasing salivary secretion. Avoiding sugar and refined carbohydrates is extremely important. Follow the general guidelines detailed in the chapter “A Health-Promoting Diet.”
Nutritional Supplements
• A high-potency multiple vitamin and mineral formula as described in the chapter “Supplementary Measures”
• Key individual nutrients:
Vitamin B6: 25 to 50 mg per day
Folic acid: 800 mcg to 2 mg per day, or wash mouth with 1/2 fl oz of a 0.1% solution of folic acid twice a day
Vitamin B12: 800 mcg per day
Vitamin C: 500 to 1,000 mg three times per day
Vitamin E (mixed tocopherols): 100 to 200 IU per day
Selenium: 100 to 200 mcg per day
Zinc: 30 mg zinc picolinate per day (45 mg per day if another form), or wash mouth with 1/2 fl oz of a 5% zinc solution twice per day
Vitamin D3: 2,000 to 4,000 IU per day (ideally, measure blood levels and adjust dosage accordingly)
• Fish oils: 1,000 mg EPA + DHA per day
• One of the following:
Grape seed extract (>95% procyanidolic oligomers): 100 to 300 mg per day
Pine bark extract (>95% procyanidolic oligomers): 100 to 300 mg per day
Green tea extract (>80% polyphenol content): 150 to 300 mg per day
• Coenzyme Q10: 50 to 100 mg three times per day
Botanical Medicines
• Bloodroot: use toothpaste containing the extract sanguinarine
• Gotu kola: Dosage is based upon the triterpenic acid content. Recommended dosage is 30 mg of triterpenoids twice daily. For example, for an extract containing 6% triterpenoids, the dosage would be 500 mg twice daily.