Nutrition in a Nutshell – Top Five Nutrition Tips for Clinical Practice.

©Juliette Reeves 2019

Over the last ten years or so we have seen an increasing body of evidence emerging to suggest a possible relationship between nutrition, chronic inflammation and periodontal disease. Whilst periodontal disease is still considered to be a biofilm induced disease, a variety of risk factors have been identified that modify the host response and tip the balance from health to disease. These risk factors include lifestyle factors such as stress, smoking, obesity and nutrition[i].

The 2015 European Federation of Periodontology (EFP) Manifesto recommends that "Modifiable lifestyle associated risk factors for periodontitis should be addressed in the dental surgery within the context of comprehensive periodontal therapy, i.e. smoking cessation programs and advice on lifestyle modifications (diet and exercise)”[ii]. Below is a five point check list that will help us to quickly, safely and effectively asses our patients diets and provide evidenced based information and guidance in everyday practice.

[i] Genco RJ,Borgnakke WS:Risk Factors for Periodontal Disease Periodontology 2000,2013;62(1):59-94.

[ii]  European Federation of Periodontology Manifesto 2015 online information available at: http://www.efp.org/efp-manifesto/manifesto.htm  accessed 10/1/19

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1.Refined Carbohydrates: There is significant evidence to show that an of excess refined carbohydrates in the diet drives chronic inflammation and oxidative stress which is also manifested in the oral tissues[3] [4]. Glucose and triglyceride spikes following a meal containing high levels of simple sugars and saturated fats generate inflammation and have been termed “meal induced inflammation”[5].  Reducing refined carbohydrates and including more complex low Glycaemic Index (GI) foods helps avoid glucose spikes and meal induced oxidative stress and reduce gingival inflammation 4 [6].

Refined carbohydrates include sugar, refined grains and flour products such as white bread, white pasta and noodles, white rice, rice cakes and rice noodles, boxed cereals, instant oatmeal cereals.

Replace with wholemeal bread, buckwheat noodles (Soba noodles) brown rice, wholemeal pasta, rye crackers, oat cakes.

2.Antioxidants: Inflammation is driven by oxidative stress, which underpins all chronic diseases[7]. Oxidative stress is a significant confounding factor between periodontal inflammation and systemic diseases[8].  Oxidative stress is a normal part of the inflammatory process which releases reactive oxygen species (ROS) that are needed to destroy invading micro-organisms, however, over a prolonged period this reaction can exert oxidative stress on otherwise healthy tissues.  Antioxidants are important for not only limiting oxidative damage and tissue damage, but also in preventing a prolonged activation of the immune response which occurs with chronic inflammation.  Oxidative stress occurs when there are not enough antioxidant micronutrients to “mop up” damaging reactive oxygen species.  

Research has suggested that lowered local and systemic antioxidant capacity is a feature of periodontal disease[9]. Low levels of antioxidants may be implicated in the susceptibility and progression of chronic periodontal disease and high concentrations of antioxidants in health may represent an important anti-inflammatory defence system in the progression of inflammatory periodontal disease[10].

Dietary antioxidants include vitamins A,C and E and the minerals selenium and zinc. These are found in all fresh fruit, berries, vegetables, nuts, seeds, oily fish and wholegrains.  It is recommended that at least five portions of fruit and vegetables are consumed daily[11].

3.Essential Fats The anti-inflammatory effects of Omega-3 polyunsaturated fatty acids (PUFAs) have long been recognised and have shown therapeutic effects in diseases such as Rheumatoid Arthritis, cardio-vascular diseases and other chronic inflammatory diseases[12] [13] [14]. It is now recognised that resolution of chronic inflammation is not simply a passive termination of inflammation but an active biochemical process. Resolution is now considered to be a different process from the anti-inflammatory processes which requires the pro-resolving metabolites of Omega 3 PUFAs[15].

Increased intake of Omega-3 PUFAs decreases expression of pro-inflammatory cytokines such as IL-1, IL-6 and Tumour Necrosis Factor (TNF) and may also improve clinical outcome measures in periodontal disease[16] [17] [18] .

Omega 3 fatty acids are found in nuts and seeds such as almonds, brazil nuts, sunflower, sesame and pumpkin seeds. Oily fish such as; salmon, mackerel, herring, tuna, sardines. Other sources include avocados, flaxseed oil, hempseed oil, seaweed[19].  

4.Vitamins  Defined as a group of organic compounds that are essential for normal growth and nutrition, these are essential nutrients required in small quantities in the diet because they cannot be synthesized by the body. Vitamin deficiencies can lead to a number of diseases such as rickets, scurvy, osteoporosis, pellagra and beriberi.

Vitamins A C and E are important antioxidants. Low serum Vitamin C and total antioxidant status is associated with periodontitis[20] in addition Vitamin D has also been implicated as having an important role in reducing the risk of periodontal disease[21].

The most active form of Vitamin D is synthesised primarily by the skin via exposure to sunlight to produce Vitamin D3. It is also available from dietary sources as Vitamin D2. Risk factors for Vitamin D deficiency include limited exposure to sunlight, ageing, obesity, fat malabsorption and some medications[22].   Vitamin D has also been shown to have implications for oral health with some studies showing an association between serum Vitamin D concentration and gingival inflammation, periodontitis and tooth loss[23] [24] [25] A more recent study demonstrated a reduction in pro-inflammatory mediators in periodontal ligament cells[26].

The Scientific Advisory Committee on Nutrition (SACN) recommends a daily intake of 400 IUs or 10-12 micrograms22.

Food sources include, oily fish, mushrooms, fortified foods such as margarine and milk, eggs, beef and calves liver.

Daily sunlight exposure is recommended at noon for 9 minutes (light skin) and 25 minutes for darker skin.

5.Minerals The minerals in our diet are essential for a variety of bodily functions. They are important for building strong bones and teeth, blood, skin, hair, nerve function, muscle and for metabolic processes.  A number of minerals including calcium, magnesium and zinc have been studied with reference to periodontal disease risk and treatment outcome.

Intake of calcium below recommendations is associated with fewer teeth in both males and females and intakes of calcium and dairy foods were significantly and inversely associated with periodontitis [27] [28] [29]. Concentrations of serum magnesium and calcium have been related to periodontal parameters. It was shown that a higher Mg/Ca ratio was associated with a significantly lower level of periodontitis[30]. Zinc has also been implicated in the progression of periodontal disease with serum zinc deficiency being associated with increased alveolar bone resorption and risk of periodontal disease[31] [32] .

Food sources of include dairy products, dark green leafy vegetables, sea food, nuts and seeds, beef and oily fish.

Government recommendations for a well balanced diet include the decrease of sugars and refined carbohydrates. The avoidance of excess saturated fats and the inclusion of oily fish and omega 3 fatty acids in the diet. Adequate lean protein sources are important along with at least 5 portions of fresh fruit and vegetables daily[33].

Recently Woelber was able to demonstrate significant effects on periodontal parameters using an holistic approach to nutrition by implementing a diet based on the reduction of refined carbohydrates ,sugars, saturated and trans fats , increased fruit and vegetables, daily omega 3 fatty acid intake, daily intake of vitamin C from fruit and vegetables, vitamin D, antioxidants and fibre. The results of this pilot study showed that despite constant plaque levels in both groups, all inflammatory parameters decreased in the experimental group to approximately half that of the baseline values. Illustrating that an oral health optimized diet can significantly reduce gingival and periodontal inflammation in a clinically important range without any changes in oral hygiene performance[34].

Nutrition plays and integral part in overall health and wellbeing and also has implications for oral health. Recommending adequate dietary intake remains an important role the dental profession can play in helping to determine those at risk of nutrient deficiency and offsetting any oral health sequelae. As a profession we are in a prime position to encourage healthy lifestyle practices in our patients, not only in an effort to improve their periodontal health but also to enhance their overall health, wellbeing and quality of life.

Practical Tips for Introducing Nutrition into Practice.

Have some written material available to give patients with healthy diet advice and health food lists.

Advise the patient that at the next appointment you will be looking at diet and giving nutrition advice – this prepares the patient so they know what to expect next visit.

Ask the patient to keep a 2 day food diary – any longer than this can become onerous to the patient.

Don’t give the patient more than 3 dietary changes in one visit. I.e.; avoid added sugars, increase fruit and vegetable intake, eat more oily fish.

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Resources:

www.nutrition.org.uk/healthyliving/resources.html

www.nutrition.org.uk/healthyliving/healthydiet/eatwell.html

www.gov.uk/government/publications/the-eatwell-guide

www.healthystart.nhs.uk/for-health-professionals/healthy-start-resources/

www.healthyeating.org/Healthy-Eating/Healthy-Living/Weight-Management/Article-Viewer/Article/230/Food-Diary

[1] Genco RJ,Borgnakke WS:Risk Factors for Periodontal Disease Periodontology 2000,2013;62(1):59-94.

[2]  European Federation of Periodontology Manifesto 2015 online information available at: http://www.efp.org/efp-manifesto/manifesto.htm  accessed 10/1/19

[3] Sidi A, Ashley F. Influence of frequent sugar intakes on experimental gingivitis. J Periodontol 1984; 55: 419-423.

[4] Baumgartner, S., Imfeld, T., Schicht, O. et al. The impact of the Stone Age diet on gingival conditions in the absence of oral hygiene. J Periodontol 2009; 80: 759–768.

[5] Monnier L, Mas E, Ginet E, et al. Activation of oxidative stress by acute glucose fluctuations compared with sustained chronic hyperglycemia in patients with type 2 diabetes. J Am Med Assoc 2006; 295:1681-1687.

[6] O’Keefe et al :Dietary strategies for improving post-prandial glucose, lipids, inflammation,  and cardiovascular health. J Am Coll Cardiol 2008;51(3):249-255

[7] Hensley K, Robinson KA, Gabbita SP, et al. Reactive oxygen species, cell signalling, and cell injury. Free Radic Biol Med 2000; 28(10):1456-62.

[8] Chapple ILC, Genco R:  on behalf of working group 2 of the joint EFP/AAP

workshop. Diabetes and periodontal diseases: consensus report of the Joint EFP/ AAP Workshop on Periodontitis and Systemic Diseases. J Clin Periodontol 2013; 40 (Suppl. 14): S106–S112.

[9] Chapple I.L.C : Role of free radicals and antioxidants in the pathogenesis of the inflammatory periodontal diseases. J. Clin Pathol: Mol Pathol 1996; 49:247-255.

[10]Chapple I.L.C., Brock G., Eftimiadi C., Matthews J. B. : Glutathione in gingival crevicular fluid and its relation to local antioxidant capacity in periodontal health and disease. J. Clin Pathol: Mol Pathol 2002; 55.

[11] Public Health England : New Eatwell Guide illustrates a health balanced diet. 2016 online information available at:  https://www.gov.uk/government/news/new-eatwell-guide-illustrates-a-healthy-balanced-diet - accessed 10/2/19

[12] Zhang MJ; Spite M. Resolvins: anti-inflammatory and proresolving mediators derived from omega-3 polyunsaturated fatty acids. Annual Rev Nutr.  2012; 32:203-27 

[13] Gioxari A, Kaliora AC, Marantidou F, Panagiotakos DP. Intake of ω-3 polyunsaturated fatty acids in patients with rheumatoid arthritis: A systematic review and meta-analysis. Nutrition. 2018 Jan;45:114-124.

[14] De Caterina R. n-3 fatty acids in cardiovascular disease. N Engl J Med. 2011; 364:2439–2450.

[15] Serhan CN, Chiang N, Van Dyke T: Resolving inflammation: dual anti-inflammatory and pro-resolution lipid mediators. Nat Rev Immunol 2008;8(5):349-361

[16] Calder P C. n-3 Polyunsaturated fatty acids, inflammation, and inflammatory Diseases. Am J Clin Nutr 2006;83:S1505-1519S

[17] Elwakeel NM, Hazaa HH. Effect of omega 3 fatty acids plus low-dose aspirin on both clinical and biochemical profiles of patients with chronic periodontitis and type 2 diabetes: a randomized double blind placebo-controlled study. J Periodont Res 2015 50(6);721-729

[18] Elkhouli, A. M. The efficacy of host response modulation therapy (omega-3 plus low-dose aspirin) as an adjunctive treatment of chronic periodontitis (Clinical and biochemical study). Journal of Periodontal Research 2011, 46: 261–268.

[19]The British Dietetic Association Omega 3 Food Factsheet online information available at:  https://www.bda.uk.com/foodfacts/omega3 - accessed 10/2/19

[20] Chapple IL, Milward MR, Dietrich T. The prevalence of inflammatory periodontitis is negatively associated with serum antioxidant concentrations. J Nutri .2007; 137(3): 657-64.

[21] Van der Velden U, Kuzmanova D, Chapple ILC. Micronutritional approaches to periodontal therapy. J Clin Periodontol 2011: 38 (suppl 11): 142-158.

[22] Public Health England. Scientific Advisory Committee on Nutrition (SACN) Vitamin D and Health 2016 online information available at : https://www.gov.uk/government/publications/sacn-vitamin-d-and-health-report  accessed 10/2/19

[23] Dietrich T, Nunn Met al:(2005) Association between serum concentrations of 25-hydroxyvitamin D and gingival inflammation. Am J Clin Nutr 82, 575-580

[24] Dietrich T, Joshipura Kjet al:(2004) Association between serum concentrations of 25hydroxyvitamin D3 and periodontal disease in the US population. Am J Clin Nutr 80, 108 113.

[25] Jimenez M, Giovannucci E, et al: (2014) Predicted vitamin D status and incidence of tooth loss and periodontitis. Public Health Nutr 17, 844-852.

[26] Nebel D, et al. 1α,25-dihydroxyvitamin D3 promotes osteogenic activity and downregulates proinflammatory cytokine expression in human periodontal ligament cells. J Periodontal Res Dec 2014

[27] Adegboye ARA, Twetman S, Christensen LB, HeitmannBL. Intake of dairy calcium and tooth loss among adult Danish men and women. Nutrition. 2012; 28: 779-784.

[28] Adegboye ARA, Chirstensen LB, Holm-Pedersen P,et al. Intake of dairy products in relation to periodontitis in older Danish adults. Nutrients. 2012; 4: 1219-1229.

[29] Nishida M., Grossi S.G., Dunford R.G., Ho A.W., Trevisan M., Genco R.J. Calcium and the Risk for Periodontal Disease. J. Periodontol. 2000;71:1057–1066

[30] Meisel, P., Schwahn, C., Luedemann, J. et al  Magnesium deficiency is associated with periodontal disease. Journal of Dental Research 2005; 84, 937–941.

[31]Frithiof, L,  Lavstedt, S, Eklund, G et al : The Relationship between Marginal Bone Loss and Serum Zinc Levels. Acta medica Scandinavica. 1980;207. 67-70.  Acta medica Scandinavica 207(1-2):67-70

[32] Thomas B, Prasad BR, Kumari NS et al A comparative evaluation of the micronutrient profile in the serum of diabetes mellitus Type II patients and healthy individuals with periodontitis J Indian Soc Periodontol. 2019 Jan-Feb;23(1):12-20.

[33] Public Health England The Eatwell Guide September 2018 online information available at; https://www.gov.uk/government/publications/the-eatwell-guide - accessed 10/2/19

[34] Woelber JP, Bremer K, Vach K et al: An oral health optimised diet can reduce gingval and periodontal inflammation in humans – a randomised controlled pilot study.

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