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| The Importance of Nutrition in Dental Health |
| by Marc Lazare, DDS New York, NY |
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Summary
In the United States we find that chronic malnutrition is very rare, except for certain eating disorders such as anorexia and bulimia. What we do find are that unbalanced diets and subclinical inadequacies are very common.(1) Even bodybuilders who look as if they are eating right, may not be getting all of the nutrition that they need. Why is it that a person who has impeccable oral hygiene may develop caries and periodontal disease, while another, who is neglectful of his/her oral hygiene, may not have any problems? The answer, I believe, lies in the difference between their nutritional intakes.
Learning Objectives
After reading this article the reader should be able to:- Discuss the role vitamins and minerals serve in maintaining optimum oral health
- List several factors that can be nutrient depleting and/or limit their absorption
- Explain why a dentist may serve as a patient’s nutritional educator
- Describe some of the oral manifestations of nutrient deficiencies and which groups of individuals are most affected
Introduction
A lack of certain nutrients can become a factor in periodontal disease by making it more difficult for the mouth to resist infection. Subclinical deficiencies of ascorbic acid, iron and zinc could compromise collagen metabolism, which would have the effect of decreasing the resistance of the gingival tissue to bacterial plaque.(1) There are a number of oral health conditions that may be associated with dietary deficiencies, such as: Periodontitis, root caries, alveolar osteoporosis, loss of taste, halitosis, Glossitis and Chelitis. So what recommendations should a dentist make to their patients regarding diet and nutrition? The number one suggestion should be to eat a well balanced diet and to take the necessary nutritional supplements, because chronic malnutrition is rare, but unbalanced diets are very common.
Diet and nutrition play important but separate roles in oral health. Diet has a direct effect on the oral cavity, while nutrition has a systemic effect. The effects of nutrition on primary development begin at 2 to 3 months of gestation. For example, collagen, the protein found in dentin, depends on vitamin C for normal synthesis. In enamel, the small amount of protein that is present resembles keratin, and depends on vitamin A for its formation.(2) Both diet and nutrition are crucial to the development, eruption and maintenance of teeth.
The food pyramid and dietary guidelines, as described by the RDA (Recommended Dietary Allowances) should be utilized as a guide. Remember…the RDA values are not for the sick; they are the minimal needs of a healthy person’s nutritional intake. They are designed to help Americans choose diets that will promote good health, support active lives, and reduce chronic disease risks.(3) In dental caries only a single class of nutrients are involved in its etiology... the fermentable carbohydrates. However, in periodontal disease we find that a broad spectrum of nutrients are involved in maintaining optimum host resistance.(1) When the proper amounts of vitamins and minerals are ingested, periodontal disease is less prevalent. Disease tends to occur less frequently in a well nourished body.
Discussion
There are many factors that affect our nutrition and the way vitamins and minerals are absorbed into our system. Some of these factors include: food processing, smoking, alcohol, drugs, stress, car exhaust fumes, radiation, chemicals, polluted air and polluted water.(4) Alcohol, aside from damaging and discoloring your fillings, can irritate and dry out the mucous lining in your mouth. As a result, damaged oral tissue and xerostomia are more likely to occur, which will in turn deplete various nutrients including zinc, iron, selenium, folic acid choline, magnesium and vitamins E, A, B2, B6, B12 and B3.5, 6,11 Deficiencies of these vitamins and minerals creates a dry mouth resulting in halitosis, a systemic disorder that causes bad breath.(7)
(See chart on the Key Nutrients in Dental Health.)
Smoking has been shown to decrease vitamin C levels in the blood tissue, thus retarding the formation of collagen, slowing the healing process, and decreasing the body’s ability to fight off infection.(5, 8) Smokers break down vitamin C about twice as fast as non-smokers.(8) It is for this reason dentists should recommend that their patients refrain from smoking after surgical procedures. Smoking also depletes vitamin B1, folic acid and calcium.(11)
Stress is one of the most overlooked causes of nutrient depletion. Any stressful situation increases the rate at which your body utilizes vitamins and minerals.(11) Since illness is one form of stress to the body, it makes perfect sense to have the proper balanced diet, especially when the first sign of disease presents itself.
There are many drugs that play a major role in preventing one from receiving the benefits of a well-balanced meal. Some of these drugs include: aspirin, cold remedies, allergy pills, corticosteroids, laxatives, antacids, barbiturates, diuretics, caffeine, and even birth control pills.(4, 11)
Aspirin can triple the excretion rate of vitamin C; caffeine robs the body of B vitamins, vitamin C and potassium; oral contraceptives decrease folic acid, vitamins C, B2, B6, B12 and E; and Penicillin decreases vitamin B6, niacin, and vitamin K. Other examples of how medications deplete nutrients include: antacids, which decrease vitamin A and the B complex vitamins; antihistamines, which deplete vitamin C; and laxatives, which interfere with phosphorous metabolism while depleting levels of calcium, potassium, and the fat soluble vitamins A, D, E and K.(11)
Perhaps the most startling example of how nutrients are lost can be depicted in the journey your food takes from the farm to your plate. Nutrients may be lost due to premature harvesting, or during the transportation and storage of produce. Food processing itself depletes the majority of key nutrients, not to mention the canning, cooking, freezing, and thawing processes.(4) For example, frozen green peas lose 83% of their vitamins in processing; canned peas lose up to 94%. Apples can lose over 50% of their vitamin C content in storage.(19) In other words, it is hard enough even for those who choose to eat healthy to receive the necessary supply of vitamins and minerals. What about those people who choose to eat poorly? The majority of Americans do not eat fresh vegetables, but rather eat frozen, processed, and canned vegetables. We are living in a society where children grow up on Big Macs rather than a fresh, home-cooked meal; where candybars, instead of fresh fruit, are the after-school snack of choice. And the results of these poorly balanced diets are evident in the mouths of dental patients.
The 1987 October analysis of the USDA Food Consumption Survey showed that not one person, of the 21,000 people that were surveyed, consumed 100% of the RDA for ten key nutrients. These ten key nutrients included: vitamins B6, B12, A, C, thiamin, riboflavin, calcium, magnesium, iron and protein.(19) According to an article written in the NY Times, only 1 in 10 people have adequate diets (9/25/91).(12) In a 10 state study conducted by the US Public Health Service, it was found that 50%, of the 12,000 people surveyed, were below the US RDA levels for one or more vitamin or mineral.(4)
What Role do Vitamins and Minerals Play in Dental Care?
They play a crucial part in helping the body combat bleeding gums, swollen gums, loosening of teeth, decay, and halitosis (bad breath). More specifically, vitamins and minerals help to form antibodies, help fight bacteria and infection, aid the immune response, destroy foreign substances and eradicate toxins.(10) Vitamins cannot be utilized or absorbed without the presence of minerals. And minerals cannot be made by living systems... Their origin is in the soil.
Since healthy people tend to see their dentist more routinely than their physician, their dentist may become their primary nutritional educator. One of the most common signs of vitamin deficiencies is oral lesions.(13) One may see a change in texture of the gingiva and lips, and burning sensations of the tongue. Some of the oral manifestations of deficiency and metabolic disorders readily identified by dentists are: osteoporosis, diabetes, anemia, anorexia, and bulimia.
Aside from having the ability to recognize oral pathology, dentists are able to contribute in the prevention of defects caused by nutrient deficiencies. For example, a recent study concluded that folic acid plays a vital role in the prevention of birth defects such as cleft lip and cleft lip/palate during pregnancy.(13) Women who may need more folic acid include frequent dieters, drug or alcohol users, smokers, women on a birth-control pill, and women who consistently do not eat well-balanced meals.(14)
One of the most neglected categories of people in terms of adequate nutrition is the elderly population. Because elderly patients consume fewer specific nutrients, their mechanism for tissue maintenance becomes impaired.(15) Physical and mental disabilities, and social isolation tend to reduce the ability and desire to eat well. In addition, an elderly individual may suffer from loose or ill-fitting dentures, which can cause the simple action of eating to become unbearable. Patients suffering from Alzheimer's Disease may forget that they did not yet eat. Two of the deficiencies common to elderly individuals include: a vitamin B-complex deficiency (which can cause Angular Chelitis, deep red lips and a severe bald tongue), and a vitamin C deficiency (known as Scurvy… a rare condition in younger populations but known to cause gingival bleeding, ulcerations and the loosening of teeth among the elderly).(15) In the early 1900’s Pellagra (a Niacin deficiency) was a widespread problem. Although it is much less prevalent, there are still cases of Pellagra reported, with early signs of the disease including mucous membrane lesions affecting the tongue and oral cavity. Swelling of the tongue, pain and ulceration of the gingiva are among the symptoms.(15)
Another condition that affects the elderly is Osteomalacia (termed Rickets when found in children). Osteomalacia means the softening of the bones due to a loss of calcium from the bone skeleton. The bones then become flexible, and deformities can occur. Although the most common causes of Osteomalacia include the malabsorption of fat (steatorrhea) and increased amounts of acid in the body causing kidney failure, other causes involve vitamin deficiencies. A long-term deficiency of calcium in your diet is known to result in Osteomalacia. A shortage of vitamin D inhibits the proper absorption of calcium.(8)
Government Studies show that iron and calcium are the two minerals most deficient in American women. Two out of three women over 17 years of age do not get enough calcium in their diets. Put this in perspective - your bones and teeth contain 99% of the calcium in your body, while the other 1% is used for your heart to function, for your muscles to contract and relax, for your blood to clot, and for your nerves to transmit messages.(16) In fact, in August 1997 a panel of nutrition experts set new standards that increase the recommended daily allowance of calcium from 800mg to 1,000 mg for most adults. The recommendation increases to 1,200 mg for those people over 50 years of age, and to 1,300 mg for adolescents. The reason being that substantial evidence exists showing that most Americans do not consume enough calcium to prevent bone loss.(17)
Recent studies depict more evidence that there is a link between the mouth and the rest of the body. A study at the University of Georgia showed that individuals with unhealthy gingiva may be candidates for heart disease.(18) The study found that the bacteria involved with periodontal infections can enter into the circulation at low levels, and is capable of activating blood clots in arteries. In fact, the incidence of heart disease is about twice as high in people with periodontal disease.(20, 21) Additional studies, that were presented at the 150th annual meeting of the American Association for the Advancement of Science, showed that the bacteria in plaque are also linked to: Infective Endocarditis, lung infections, weakened immune systems, higher risk of giving birth to premature, low birth weight infants, and Diabetes.(20)
Conclusion
After all of the advances in dental office care and home care, 90% of the population are still developing Periodontal Disease.(11) Nutrient deficiency can become a major contributing factor in Periodontal Disease by inhibiting the mouth’s ability to resist infection. In other words, your diet does affect your dental health. All experts can agree that vitamins and minerals are necessary constituents for maintaining your body’s health. A significant share of dentistry lies in the prevention of disease through the consumption of a well balanced diet and the necessary nutritional supplements. Remember… Disease will occur less frequently in a well-nourished body.
References
1. Journal of the American Dental Association. "Diet, Nutrition, and Oral Health: A rational approach for the dental practice." Vol. 109. July 1984. Pp.20-32
2. "Nutrition for Health and Fitness." Riva Tougher-Decker Ph.D., RD. p.p. 581-593.
3. U.S. Department of Agriculture and U.S. Department of Health and Human Services. "Dietary Guidelines for Americans." 1995. P.3.
4. Passwater, Richard A. "A beginner’s introduction to vitamins." Keats Publishing. CT. 1983. P.6.
5. Garrison Jr., Robert H. and Somer, Elizabeth. "The Nutrition Desk Reference." Keats Publishing. New Canaan, CT. 1985.
6. Whitney, Elenor Noss; Hamilton, Eva May Nunnelley; Rolfes, Sharon Rady. "Understanding Nutrition." West Publishing Company. Fifth Edition 1990. Pp. 190-342.
7. Gary P Guillory, D.D.S. "Ridding yourself of bad breath." 1995. P.15.
8. Balch, James and Balch, Phyllis. "Prescription for Nutritional Healing." Avery Publishing Group. New York. 1997. Pp. 486-487.
9. Flora Parsa Stay, D.D.S. "The Complete Book of Dental Remedies." Avery Publishing Group. Garden City, N.Y. 1996. Pp. 14-28.
10. Lust, John. "The Herb Book." Bantam Books. 1974. Pp. 496-506.
11. Mindell, Earl. "Vitamin Bible." Warner Books. New York. 1985. Pp. 251-266.
12. Brody, Jane. The New York Times. Sept. 25, 1991
13. Dentistry Today. Volume 15 #7. July 1996. Pp. 28-33
14. Department of Health. "Folic Acid- The vitamin that helps prevent birth defects." July 1996.
15. New York State Dental Journal. "Vitamin Deficiency in the Elderly." Allen B. Konis, D.D.S. Oct. 1991. Pp. 40-42.
16. Dairy Council Digest. "The role of Calcium in Health." Volume 55, #1. Jan-Feb 1984.
17. The New York Times. "Brand-New Recipe For Healthy Bones Adds More Calcium," by Sheryl Gay Stolberg. August 14th, 1997. Pp. B1 and B6.
18. New York Newsday. "Gum Disease Study Cites Clotting," by Evelyn Lau. July 15, 1997.
19. Miller, Bruce B. "Do I need food supplements?" Bruce Miller Enterprises Inc. Dallas, Tx. 1998. P.8.
20. USA Today. Friend, Tim. Feb. 17th 1998.
21. USA Today. Sternberg, Steve. April 14th 1998. P. 1D.
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