Nutrition in periodontics

BY: - D R . R A I N A J P K H A N A M
Nutrition in Periodontics

Contents
 Introduction
 Basics of nutrition
 Role of macronutrients on periodontium
 Role of carbohydrates
 Role of proteins
 Role of fats
 Role of micronutrients on periodontium
 Role of vitamins
 Role of minerals
 Antioxidants in periodontal health
 Conclusion

Introduction
NUTRITION
Is the science that interprets the interaction of nutrients and other
substances in food in relation to maintenance, growth, reproduction, health
and disease of an organism. It includes food intake, absorption, assimilation,
biosynthesis, catabolism and excretion.
Nutrients
A substance used by an organism to survive, grow and reproduce.
Nutrients are classified into two types:-
1. Macronutrients
2. Micronutrients

Macronutrients
An energy-yielding nutrient. Macronutrients are those nutrients
that together provide the vast majority of metabolic energy to an
organism. They are required in larger quantities.
There are mainly three macronutrients:
1. Carbohydrates
2. Proteins
3. Fat

Micronutrients
Are required in small quantities in the diet, which are essential
for a range of biological process important in supporting optimal
health.
It includes:-
1. Vitamins
2. Minerals

Carbohydrates
They are the most abundant
organic molecules in nature
primarily comprising of
elements carbon, hydrogen
and oxygen being classified
into monosaccharide,
oligosaccharides and
polysaccharides.
Carbohydrates are also
known as protein sparing in
that if inadequate amounts
of dietary carbohydrate are
ingested, the body will break
down protein to provide
glucose for essential
functions.

 Based on the number of sugar units in the molecule. These compounds
can be chemically classified into:-
 Monosaccharide
 Disaccharides
 Polysaccharides

Monosaccharide are the basic building block
of all carbohydrates and glucose is the most
abundant of these sugars.
Other common monosaccharide are
1. Fructose
2. Galactose
 During the process of digestion, many
carbohydrates are broken down or converted
into glucose, which is then transported by the
blood to all the cells in the body. Within cells,
the process of cellular respiration
metabolizes glucose to produce the energy
necessary to sustain life.
 Same chemical makeup C6H12O6, differing
only in the arrangement of the atoms within
the molecules.
 In the body, most fructose and galactose
are converted into glucose and metabolized
as such.

Disaccharides are composed of two
monosaccharide chemically joined together.
The most common disaccharide is sucrose, or
table sugar, formed from a molecule of
glucose and a molecule of fructose.
 Other disaccharides are the milk sugar
lactose (a combination of glucose and
galactose) and maltose (formed by two
glucose molecules), which is largely found
in germinating grains.
 Table sugar, which primarily comes from
sugarcane and sugar beet, is at least 97%
pure sucrose with little nutritional value.
 During digestion, these disaccharides are
broken down to yield their component
monosaccharide.

Starch is broken down into glucose by
enzymes in saliva and the small intestine and
is transported by the bloodstream to body
cells.
Polysaccharides, also known as complex carbohydrates, contain hundreds to thousands
of individual sugar units.
Starch is the storage form of glucose found in
plants; it occurs abundantly in seeds, some
fruits, tubers and taproots.

Glycogen is the body’s storage form of glucose, found in the liver and skeletal muscles.
 When the levels of glucose in the
blood are higher than the demands
of the cells, the excess is used for the
synthesis of glycogen in liver and
muscle cells. Only a limited amount
of glycogen can be stored as a
reserve-no more than a day’s worth
of energy needs.
 Excess glucose beyond this amount is
generally converted to fat.

Fiber
Another important dietary component is fiber, which is derived from plant
sources. Although not digestible, it does provide bulk and other benefits.
There are many types of dietary fiber:
 Cellulose
 Lignin
 Hemicelluloses
 Pectin
 gums
 mucilage
 others

Cellulose a principal component
of plant cell walls, is another
polysaccharide composed of
glucose; however, humans do not
have the enzymatic ability to
break the bonds connecting the
glucose molecules in cellulose as
they do for starch and glycogen
and thus cellulose passes through
the digestive tract as roughage,
largely unaltered.

 Lignin
a cell wall component in plant cells that have secondary walls, is not a
polysaccharide but a complex polymer.
 Pectin and hemicelluloses
which are cell-wall polysaccharides, form the matrix in which cellulose fibrils
are embedded. Pectin also occur in the middle lamella between adjacent
cells.
 Gums and mucilage
are exudates from various plants that are used commercially as thickening
agents in prepared foods.

Carbohydrates in Periodontal Health
Sugar intake has long been established as the major contributing factor in plaque
formation. It has been observed that sucrose is more cariogenic than fructose and
glucose. Sugars contribute to dental caries and periodontal disease because
bacteria ferment them and produce acid, leading to the demineralization of the
tooth structure.
Studies have revealed that Xylitol, a sugar alcohol produced by the hydrogenation of xylose
sugar, is an artificial sweetener used as an alternative to conventional sugars. It may have
an antibacterial effect against periodontal pathogens such as Porphyromonas gingivalis and
Aggregatibacter actinomycetemcomitans and provided a significant inhibitory effect on
gingivitis. Hence, a reduction of sugar intake, coupled with scaling, root planing and the use
of xylitol and maltitol containing gums have the potential to improve the periodontal
health of the general population.

Human experimental studies have investigated directly the possible role of
dietary sugar in the etiology of periodontal disease, although an association
between the amount of plaque formed and the frequency of sugar intake have
been demonstrated and shown that sucrose-rich diets favor large deposits of
plaque and dietary sugar has an important contributing role in progressive
periodontal disease and concluded that frequent sugar intakes result in increased
gingival inflammation, as measured by gingival bleeding on probing, in
experimentally induced gingivitis.
Recommended diet:-
300-500gm/day (adults)

Proteins
Protein is the most common
substance in the body after
water, making up about 50%
of body’s dry weight.
Proteins are polymers of
amino acids which form
the fundamental basis of
structure and function of
life and are components of
defensive molecules that
help to control the disease
process.
During digestion, proteins
may be broken down into
their component amino acids
by enzymes in the digestive
tract and transported in the
bloodstream to the liver and
body tissues.

Based on the nutritional requirements, amino acids are grouped into two classes

From the nutritional point of view, proteins are classified into
 Complete proteins:
Consisting of all the ten essential amino acids by the human body to promote
good growth. e.g: egg albumin, milk casein.
 Partially incomplete proteins:
These proteins partially lacking one or more essential amino acids and hence
promote moderate growth. e.g: wheat and rice proteins.
 Incomplete proteins:
These proteins completely lack one or more essential amino acids. Hence
they do not promote growth at all. e.g: gelatine, zein.

low levels of serum proteins leads to:-
Albumin
Edema
Ferritin
Anemia
Ceruloplasmin
Hair depigmentation
Retinol binding protien
Xerophthalmia
Lipoprotiens
Fatty infiltration of liver

C L I N I C A L F EAT U R ES O F M A R A S M U S :
G ROW T H R E TA R DAT I O N
W E I G H T LO S S
M U S C U L A R AT RO P H Y
LO S S O F S U B C U TA N EO U S T I S S U E
Marasmus
Marasmus is severe form of malnutrition in infants who were early weaned from breast
feeding. Marasmus is caused by severe deprivation of both calories and protein and it is
more frequent.

L ES I O N S O F B U C C A L M U CO SA .
S I G N I F I C A N T G E N E R A L I Z E D O ST EO P O RO S I S .
A LV EO L A R B O N E LO S S .
R A I S E D O R A L H YG I E N E I N D E X S C O R ES W I T H
M O R E P E R I O D O N TA L PAT H O LO G I C CO N D I T I O N S .
D EG E N E R AT I O N O F C O N N EC T I V E T I S S U E F I B R ES
I N T H E G I N G I VA L A N D P E R I O D O N TA L L I G A M E N T.
O ST EO P O RO S I S O F A LV EO L A R B O N E .
R E TA R DAT I O N I N D E P O S I T I O N O F C E M E N T U M .
Kwashiorkor
Kwashiorkor is primarily a disease of infants and young children with peak incidence
of 1-3 years. It is characterized by:

Protein in periodontal health
Protein calorie malnourished children have higher incidence of necrotizing ulcerative
gingivitis and periodontitis which may extend to the adjacent tissue causing necrosis and
destruction of orofacial tissue called noma or cancrum oris.
In a study conducted by Stefaniel Russell et al (2010) they examine the exposure of early
childhood protein-energy malnutrition (ECPEM) is related to worsened periodontal
status in the permanent dentition during adolescence by using WHO diagnostic criteria
(Community Periodontal Index, WHO 1997).
Recommended diet:-
 1gm/kg body wt. (adults)
1.5-2gm (children)

Fats
Fats are usually
considered culprits in
the diet because they
are associated with
cardiovascular disease,
but some fat is
necessary because it
serves several vital
functions and some
fats are heart-health.
Fats and related
compounds belong to a
larger category of
organic molecules
called lipids.

LIPIDS: Lipids are a heterogeneous group of
organic compounds relatively insoluble in
water and soluble in organic solvents.
FATTY ACIDS: Fatty acids are carboxylic acids
with hydrocarbon side chain. They are the
simplest form of lipids.
 They are the concentrated fuel
reserves of the body.
 They are important as cellular
metabolic regulators.
 They constitute the cell membrane,
give shape and smooth appearance to
the body.
 They protect the internal organs and
act as an insulating material.
Fatty acids can be separated into two
types:
 Saturated
 Unsaturated

 SATURATED FATTY ACIDS:
Saturated fatty acids contain all single bond between the carbon atoms and have the maximum
number of hydrogen atoms (it is said to be saturated with hydrogen).
 UNSATURATED FATTY ACIDS:
Unsaturated fatty acids have one or more double bonds between carbon atoms and consequently
fewer hydrogen atoms.
 A fatty acid with one double bond is called monounsaturated fatty acid and lacks two hydrogen
atoms.
 A fatty acid has two or more double bonds and lacks four or more hydrogen Atoms is called as
polyunsaturated fatty acid (PUFA).
 ESSENTIAL FATTY ACIDS:
The fatty acids that cannot be synthesized by the body and therefore should be supplied in the
diet are known as essential fatty acids (EFA). They include:
 Linolenic acid
 Linoleic acid
 Arachidonic acid

Heshman EI Sharkawy (2010), 81 healthy subjects with advanced chronic
periodontitis were treated with SRP followed by dietary supplementation of
fish oil (900 mf EPA+DHA) and 81 mg aspirin daily. Whereas control group was
treated with SRP and placebo. The results demonstrate a siginificant reduction
in probing depth and a significant attachment gain after 3 and 6 months in the
omega–3 group compared to baseline and the control group. which suggest
that dietary supplementation with omega-3 PUFAs and 81 mg aspirin may
provide a sustainable, low cost interventation to augment periodontal therapy.
Recommended diet:-
 10-20gm/day (adults)
25% extra (children)

Vitamins
Vitamins are organic
substances that are
present in food in small
quantities. They are
utilized in metabolic
reactions in the body.
They are classified as:
1. Fat soluble
(A,D,E,K)
2. Water soluble (B,C)

Vitamin A
(Retinoic Acid)
 Helps maintain good
vision.
 Resistance to infections.
 Supports growth and
repair of body tissues.
 Maintains integrity of
white and red blood cells.
 Assists in immune
reactions.
 Maintain the stability of
cell membranes.
 Regulation of epithelial
differentiation.

Deficiency of vitamin A
SYSTEMIC CONDITIONS
 Deficiency of vitamin A results in
ocular, dermatologic and mucosal
manifestations.
 Ocular manifestations include
nocturnal blindness (nyctalopia),
xeropthalmia, keratomalacia and total
blindness.
 Dry and rough skin with degeneration
of mucosa leading to infections
constitutes dermatological effects.
 Epithelial cells of gastrointestinal
tract, urinary tract, and respiratory
tract can undergo keratinizing
metaplasia.
ORAL CONDITIONS
 Vitamin A has an important role in
the development of teeth,
especially in the formation of
ameloblasts (in enamel) and
odontoblasts (in dentin).
 Vitamin A deficiency during pre-
eruptive stages of tooth
development leads to enamel
hypoplasia and defective dentin
formation in developing teeth.
 Vitamin A is also involved with
normal teeth spacing and promotes
osteoblast function of the alveolar
bone.

Vitamin A in periodontal health
Menezes et al presented a case report (1984) and found that a 20-year-old
woman presented with gingival erosions, ulcerations, bleeding, swelling and
a loss of keratinization. Headache, dry mouth and loss of hair, she reported
a history of taking 200,000 IU of vitamin A daily for 6 months to reduce
acne. When the vitamin supplementation was stopped, gingival
improvement was noted within 1 week. In 2 months, the appearance of the
oral tissues was found to be normal. One week later a tangible
improvement in periodontal health was observed.
Recommended diet:-
 900gm (adult men)
 700gm (adult women)

Vitamin D
(Calcitriol)
 Regulates absorption
of calcium and
phosphorus for bone
health.
 Has a role in the
immune system-
Antigen-presenting cells,
macrophages and
lymphocytes express a
nuclear receptor for
vitamin D.

G ROW T H R E TA R DAT I O N
P RO M I N EN C E O F CO STO C H O N D R A L
J U N C T I O N S ( R AC H I T I C R O SA RY )
B OW I N G O F LO N G B O N ES
D E V E LO P M EN TA L A N O M A L I ES O F
D E N T I N A N D E N A M E L
D E L AY E D E R U P T I O N
H I G H C A R I ES R AT E
A B N O R M A L LY W I D E P RE D EN T IN
ZO N E
I N T E RG LO B U L A R D E N T I N .
Rickets
Deficiency causes rickets in children

O ST EO M A L AC I A F R EQ U E N T LY R ES U LT S I N D I F F U S E S K E L E TA L PA IN A N D
F R AC T U R E W I T H R E L AT I V E LY M I L D I N J U RY.
Osteomalacia
Deficiency causes osteomalacia in adults.
Hypercalcemia is responsible for producing most of the symptoms of vitamin D toxicity.
Symptoms include gastrointestinal disorders, demineralization of bone, bone pain,
drowsiness, continuous headaches, irregular heartbeat, loss of appetite, muscle and
joint pain, frequent urination, excessive thirst, weakness, nervousness, itching and
kidney stones.
Hypercalcemia

Vitamin D in periodontal health
Vitamin D and calcium deficiency have been found to result in generalized jaw bone
resorption and loss of PDL.
Krall et al (2001) found that low
vitamin D levels have been
associated with increased gingival
inflammation, tooth loss, clinical
attachment loss, and maternal
periodontal disease during
pregnancy.
Nithya Anand et al (2016) showed
significant associations between
periodontal health and intake of vitamin
D and calcium and that dietary
supplementation with calcium and
vitamin D may improve periodontal
health, increase bone mineral density in
the mandible and inhibit alveolar bone
resorption
Recommended diet:-
 400IU/day (infants)
 600IU/day (children)
800IU/day (adults)

Vitamin E
(Alpha tocopherol)
 Found primarily in
plant oils, green leafy
vegetables, wheat germ,
whole grains, egg yolk,
nuts, seeds and liver.
 Fat-soluble
antioxidant. Helps in
maintaining cell
membranes, red blood
cell integrity.
 Prevents per oxidation
of polyunsaturated fatty
acids.

Vitamin E in periodontal health
Muscle and neurological problems are the consequence of vitamin E deficiency. Early
diagnostic signs of deficiency include leakage of muscle enzymes such as creatine kinase
and pyruvate kinase into plasma, increased levels of lipid peroxidation products in
plasma, and increased haemolysis.
Goodson (1973) treated 14 patients with periodontal disease with vitamin E under the
assumption that vitamin E inhibits prostaglandins. Sulcus fluid volume was compared
before and after administration of vitamin E and found that there is a reduction in
inflammation after 3 weeks. He reported the favourable effects of vitamin E in
maintaining periodontal health and controlling inflammation.
Recommended diet:-
15-20mg/day

Vitamin K
 Major sources are Green,
leafy vegetables, cabbage
type vegetables.
 Helps to make factors
that promote blood
clotting.
 Necessary for
postransitional
carboxylation of glutamic
acid.

Vitamin K in periodontal health
Deficiency leads to coagulopathy because of inadequate synthesis of prothrombin and
other clotting factors. The most common oral manifestation is gingival bleeding, with
chances of spontaneous bleeding at levels below 20%.
Vitamin K is an important pharmacological agent used to reverse the anticoagulant
effects of warfarin and routinely administered for patients undergoing hemodialysis.
Hence, if periodontal therapy is to be administered to patients with kidney failure,
vitamin K can be used to treat any bleeding incidents.
Recommended diet:-
 120gm (adult men)
 90gm (adult women)

Vitamin B1
(Thiamin)
 Helps metabolize
carbohydrates.
 Maintain appetite
and normal digestion.
 Part of a coenzyme
used in energy
metabolism, have a role
in peripheral nerve
conduction.

Deficiency of Vitamin B1
Beriberi is the classical disease of thiamin deficiency, affecting the muscular, nervous,
cardiovascular and gastrointestinal systems. Beriberi can develop in 7–10 days.
Alcoholic patients with chronic thiamine deficiency manifest neurologic symptoms known
as Wernicke’s Encephalopathy characterized by mental confusion, nystagmus, ataxia.It
is also known as “antineurotic factor” due to its antagonistic pharmacologic action
against acetylcholine.
Oral manifestations include:
Hypersensitivity of the teeth and
oral mucosa.
Gingiva may become “dusty-rose”
in colour.
Loss of gingival stippling.
 Flabby, red, edematous tongue.
 Aphthous ulcerations.

Vitamin B2
(Riboflavin)
 Major sources are
Milk, yogurt, meat, leafy
greens, whole grains.
 Part of coenzymes
used in energy
metabolism.
 Supports normal
vision and skin health.

Riboflavin deficiency includes angular cheilosis,
dermatitis and anemia.
Oral manifestations include
 Fungiform papillae become swollen and slightly
flattened and mushroom shaped during early
stages of riboflavin deficiency.
 tongue has pebbly or granular appearance.
 Severe chronic deficiencies lead to progressive
papillary atrophy and patchy, irregular
denudation of the tongue.
 The tongue may become purplish red or magenta
colored because of vascular proliferation and
decreased circulation.
 Marginal gingiva and oral mucosa have a purplish
color and are edematous.

Vitamin B3
(Niacin)
 Part of coenzyme used
in metabolism.
 Supports skin,
nervous and digestive
system.
 Important in pentose,
steroid, fatty acid
biosynthesis, glycolysis,
protein metabolism and
oxidation of lactate and
pyruvate.

Oral manifestations include
 Gingivitis
 painful, wedge shaped, punched out ulcers
involving the interdental papillae and
marginal gingiva.
 The lesions in humans are necrotic,
exudative, and foul smelling.
 Epithelial changes particularly in the areas
exposed to sunlight (neck region) result in a
characteristic skin rash called Castle’s
necklace.
Deficiency disease of niacin is pellagra, the symptoms of which include dermatitis,
dementia, and diarrhea.

Vitamin B5
(Pantothenic Acid)
Vitamin B6
(Pyridoxine)
 Part of coenzyme A, which is used in
energy metabolism.
 Part of a coenzyme that helps the
body to synthesize nonessential
amino acids.
 Role in protein metabolism especially
tryptophan.

However, no deficiency
manifestations have been reported in
humans.
Hypovitaminosis of B6 may often occur with
riboflavin deficiency, because riboflavin is
needed for the formation of the coenzyme
PLP (pyridoxal phosphate).

Vitamin B7
(Biotin)
 Part of a coenzyme used in energy
metabolism, fat synthesis, amino acid
metabolism and glycogen synthesis.
 Part of coenzymes used in new cell
synthesis, blood cell formation,
protein metabolism and prevention
of neural tube defects, synthesis of
DNA is impossible in the absence of
folic acid.
Vitamin B9
(Folic Acid)

 Biotin deficiency in humans has been clearly documented with prolonged
consumption of raw egg whites, which contain biotin-binding avidin.
 Biotin deficiency has also been observed in cases of parenteral nutrition with solutions
lacking biotin given to patients with short-gut syndrome and other causes of mal-
absorption.
Oral signs of biotin deficiency
 pallor of the tongue
 patchy atrophy of the lingual papillae.
 Although the pattern resembles geographic
tongue

 Folate deficiency, the most common vitamin deficiency among the B complex
vitamins, may occur secondary to excessive alcohol consumption, pregnancy /
lactation, kidney dialysis, liver disease, inadequate dietary intake, gastrointestinal
disease or medications that interfere with folate absorption or metabolism.
Oral signs of folic acid deficiency
 Glossitis
 The tongue becomes fiery red and papillae are absent.
 Marked chronic periodontitis with loosening of teeth may occur.
 Folic acid deficiency impairs immune responses and resistance
in Candida.

Vitamin B12
(Cobalomin/Cynocobalomin)
 Part of coenzymes used in
new cell synthesis.
 Helps to maintain nerve
cells.

Pernicious anaemia is associated with vitamin B12 deficiency, which is also called as
Addisonian anaemia, Biermer anaemia, Hunter Addison anaemia, Lederer anaemia,
caused by a genetic defect resulting in deficient absorption of vitamin B12 from the small
intestine.
Early signs of B12 deficiency are numbness of the extremities and difficulty walking.
Gastrointestinal manifestations of vitamin B12 deficiency includes:
 Diarrhea
 Anorexia
 Weight loss
 Hepatomegaly
 Spleenomegaly
 Congestive heart failure

Oral manifestations
 glossopyrosis (unexplained pain of the tongue)
 followed by swelling and pallor with eventual
disappearance of the filiform and fungiform
papillae.
 The tongue may be completely smooth, shiny, and
deeply reddened with a loss or distortion of taste.
 Bright red, diffuse, excruciating painful lesions may
occur in the buccal and pharyngeal mucosa.
 Xerostomia
 Cheilosis
 hemorrhagic gingival and bone loss .

Vitamin C
(Ascorbic Acid)
 Essential element in
collagen formation
(strengthens blood
vessels, forms scar
tissue, is a matrix for
bone growth).
 An antioxidant.
 Strengthens resistance
to infections.
 Improves absorption
of iron.
 Involved in formation
of folinic acid.

Deficiency of Vitamin C
The classical vitamin C deficiency disease is scurvy, a hemorrhagic disease, which
presents with
 muscle weakness
 lethargy
 diffuse tissue bleeding
 painful and swollen joints
 ecchymoses
 increased susceptibility to bone fractures
 poor wound healing
 gingivitis
 loss of integrity of the periodontal ligament.

Scurvy in periodontal health
Cardinal oral signs of scurvy include fetid odor and loosened teeth with
bright red, hemorrhagic, swollen, smooth, shiny interdental and marginal
gingival.
Possible etiologic relationships between ascorbic acid and
periodontal disease
Low levels of ascorbic acid influence the metabolism of
collagen within the periodontium, thereby affecting the
ability of the tissue to regenerate and repair itself.
Ascorbic acid deficiency interferes with bone formation,
leading to loss of periodontal bone.
Ascorbic acid deficiency increases the permeability of the
oral mucosa to titrated endotoxin and titrated inulin.

Increasing levels of ascorbic acid enhance both the chemotactic and migratory
action of leukocytes without influencing their phagocytic activity.
Depletion of vitamin C may interfere with the ecologic equilibrium of bacteria in
plaque and thus increase its pathogenicity.
Siegel C (1982) presented a case report in which, a 49-year-old man presented
with sore gums, his gingiva showed the presence of petechial hemorrhages,
crevicular bleeding and mucosal ulcerations. He reported a daily intake of 1 g of
vitamin C for 1 year, which had been stopped about 10 days previously. Taking
1 g of vitamin C for 2 weeks resulted in regression of the lesions. He stopped
taking vitamin C for 1 week and the lesions returned. The vitamin C dose was
gradually reduced to 100 mg per day over a 7 week period after which the
patient remained free of oral symptoms. This is known as rebound or
conditional scurvy.

Minerals
Minerals make up about 4%
of body weight and are
found mainly in the
skeleton, enzymes,
hormones and vitamins.
Minerals help to provide
structure for bones and
teeth, and maintain normal
heart rhythm, muscle
contraction, nerve
conduction and the acid–
base balance. Minerals are
integral parts of enzymes
and hormones.
Minerals can be classified as
either
1. Major minerals
2. Trace minerals

Calcium Phosphorus
 The principal mineral of bones and
teeth.
 Also involved in normal muscle
contraction.
 Coagulation of blood.
 Secondary messenger in hormone
action.
 Part of every cell.
 Maintains acid-base balance.
 Helps in muscle contraction.
Major Minerals

Shimazaki Y et al (2008) investigated the relationship between the intake of dairy
products, such as milk, cheese, other foods containing lactic acid (yogurt and lactic
acid drinks) and periodontal status in 942 subjects, 40-79 years of age, in Fukuoka,
Japan. The daily intake of lactic acid-containing foods in subjects with generalized
deep pocket depths or severe clinical attachment loss was significantly lower than
that in subjects with localized deep pocket depth or slight clinical attachment loss.
Thus, routine use of lactic acid-containing foods, such as yogurt, appear to have a
beneficial effect on inhibiting the development of periodontal disease, possibly
because probiotic bacteria (lactobacillus and bifid bacterium) from
fermented/lactic acid rich foods may provide protective effects for periodontitis by
suppressing the growth of periodontal pathogens in the oral cavity and stimulating
the immune system.
Calcium in periodontal health
Calcium deficiency may lead to osteoporosis

Phosphorous in periodontal health
Phosphorous deficiency lead to hypophospatasia
Liu et al (2009) performed a study in patients with aggressive and chronic
periodontitis in a hospital from China and found that serum phosphorus level
were lower in both the patient groups when compared to healthy subjects
(1.06-0.18 and 1.10-0.15 mmol /L respectively vs 1.26- 0.17, Ƥ < 0.05).

Sodium Chloride
 Major source is table salt
 Maintenance of acid-base
equilibrium and osmotic pressure
maintains neuromuscular excitability.
 Maintains viscosity of blood and fluid
balance.
 Major source is salt, soy sauce,
moderate quantities in whole,
unprocessed foods and large
amounts in processed foods.
 An electrolyte that maintains normal
fluid balance and proper acid base
balance.
 Part of hydrochloric acid found in the
stomach.

Deficiency of sodium and chloride
Sodium deficiency in man probably never occurs in an uncomplicated form but
may present as sodium and chloride deficiency. When diets low in salt are used
for long period of time
 gradual weakness
 excessive fatigue
 lassitude
 apathy
 anorexia
 sense of exhaustion
 nausea
 muscle cramps
 peripheral vascular collapse

Potassium Magnesium
 Influences muscular activity.
 Influences nerve conduction activity.
 Influences acid base balance.
 Also has a role in cardiac function.
 Involved in the building of protein.
 Normal muscular contraction and
transmission of nerve impulses.
 Acts as a co-factor and activator of
many enzymes.

Deficiency of Potassium and Magnesium
 A potassium deficiency is more likely to occur than a sodium deficiency because, we
do not usually add potassium to our foods.
 A low potassium plasma level can be life-threatening, resulting in muscle cramps,
confusion and an irregular heartbeat.
 Hyperkalemia may be associated with mental confusion, numbness, tingling of
extremities, pallor, cold skin, weakness, disturbances in cardiac rhythm and peripheral
collapse.
 The effects of potassium deficiency or excess on the oral structures have not been
reported.
 Low levels of magnesium have been associated with a number of chronic diseases
including migraine headaches, Alzheimer’s disease, cerebrovascular accident,
hypertension, cardiovascular disease, type 2 diabetes mellitus, sickle cell disease,
preeclampsia, atherosclerosis, postmenopausal osteoporosis and chronic alcoholism.

Micro Minerals
 Fluoride - Involved in the formation of bones and teeth.
 Iodine - Essential component of thyroid hormones that regulate tissue growth and cell
activity.
 Iron - Part of the protein haemoglobin which carries O2 in the body.
Part of the protein myoglobin in muscle which makes O2 available for muscle
contraction. Necessary for the utilization of energy as part of the cells metabolic
machinery.
 Manganese - Acts as a cofactor and activator of many enzymes involved in amino acid,
cholesterol, and carbohydrate metabolism.
 Molybdenum - Important in a variety of enzyme systems.
 Selenium - Involved in antioxidant function along with vitamin E.
 Zinc - Act as cofactor of enzymes.

Deficiency of Iron and Zinc
Chakraborty et al (2014) conducted a study to see the impact of iron deficiency anemia
on chronic periodontitis and superoxide dismutase activity. The results indicates that
iron-deficiency anemia leads to a reduction in antioxidant enzymes, leading to an
increased oxidative stress and worsening of periodontal diseases.
Pushparani et al (2015) demonstrate that dietary zinc may also play an important role in
maintaining periodontal health. It has been suggested that a lack of dietary zinc leads to
worsening of periodontal disease in patients with type 2 diabetes mellitus. It further
supported the importance of zinc in preventing diabetes-related periodontitis by exerting
an antioxidant effect. Therefore, zinc supplementation may have the potential to
augment the therapeutic effects of periodontal therapy.

Deficiency of Iodine
 Iodine is present in thyroxine, triiodothyronine and helps to maintain an appropriate
metabolism.
 Inability of the thyroid gland to produce thyroxine hormone during infancy leads to
cretinism characterized by mental defects, retarded somatic growth, generalized
edema, dentofacial changes like underdevelopment of the mandible and
overdevelopment of the maxilla.
 If this insufficiency occurs in childhood then juvenile myxedema results wherein the
tongue is enlarged due to edema, delayed eruption of permanent teeth and retained
deciduous teeth.
 In adults it causes myxedema due to extravascular and extracelluar accumulation of
water and proteins leading to edematous and swollen tongue, lips, nose, eyelids,
suborbital tissues, puffiness of face and slowness in mental and physical activities.
 Iodine deficiency in diet results in simple endemic goiter and is normally seen in hilly
areas.

Deficiency of Flouride
 Fluorine prevents caries by strengthening enamel and cementum due to the formation
of fluoroapatite and exerting an antibacterial effect via inhibition of bacterial growth
and adhesion.
 Hence, topical fluoride, in the form of dentifrices, gels, foams and varnishes has been
used as a preventative measure against dental caries.
 Considering its beneficial roles, fluoride has been incorporated into various restorative
materials such as glass ionomers.
 These materials act as reservoirs that are capable of releasing fluoride into the oral
cavity.
 Fluoride is available from toothpaste, mouthwashes or fluoride rich food.
 Systemic administration of fluoride may be via water, milk and capsules.
 Additionally, fluoride supplementation may also reduce root resorption caused by
orthodontic movement of teeth.

Deficiency of Selenium
 Selenium deficiency is associated with several disease conditions such as anaemia,
asthma, adult respiratory distress syndrome (ARDS), AIDS and increased cardiovascular
disease mortality.
 Selenium deficiency results in the development of two diseases, Keshan
(cardiomyopathy) & Kaschinbeck Disease (Osteoarthropathy).
 High selinium levels in blood can result in a toxic condition called “selenosis”.
 Symptoms of Se toxicity include gastrointestinal upsets, hair loss, white blotchy nails,
garlic breath odor, irritability, fatigue and mild nerve damage.
Saxen L et al (1983) in a study of gingivitis in patients receiving selenium for the
treatment of Spielmeyer Sjogren’s disease, there were no differences noted in
the level of gingivitis or dental caries between patients taking selenium
supplementation and control patients.

Antioxidants are defined
as “those substances
which when present at
low concentrations,
compared to an
oxidizable substrate, will
significantly delay or
inhibit oxidation of that
substrate.
ANTIOXIDANTS

Role of Green Tea in Periodontal Disease
Mitoshi et al (2009) conducted a study to investigate the
relationship between intake of green tea and periodontal
disease and found that there is a modest inverse
association between the daily intake of green tea and
periodontal disease. Drinking green tea at meals and
breaks is a relatively easy habit to maintain and drinking
green tea as frequently as possible may help to maintain a
healthy periodontium. However, because the observed
relationship between the daily intake of green tea and
periodontal disease was weak, the application of
concentrated green tea components, such as catechin,
may be expected to have a more beneficial effect on the
periodontal condition.

Role of craneberry in periodontal health
 Cranberry ranks high among fruit in both antioxidant quality and quantity because of its
substantial flavonoid content and a wealth of phenolic acids.
 The antioxidant properties of the phenolic compounds in cranberry fruit may contribute
to the observed antitumor activities of cranberry extracts.
 P. gingivalis is the key pathogen in chronic periodontitis. The cranberry Non dialyzable
material (NDM) fraction (which is obtained by dialysis of concentrated craneberry juice) is a
potent inhibitor of biofilm formation by P. gingivalis, but does not affect the growth or
viability of the bacteria.
It inhibits the attachment of P. gingivalis to various proteins such as type I collagen and
fibrinogen and the coaggregation of bacteria.
These findings suggest that cranberry may reduce the capacity of periodontopathogens
to colonize subgingival sites.

Role of Pomegranate in periodontal health
Pereira JV et al (2003) evaluated the effects of
pomegranate on gingivitis, results showed a significant
reduction in gingival bleeding after using a dentifrice
containing the pomegranate extract.
Investigators noted that pomegranate’s
active components, including polyphenolic
flavonoids (e.g, punicalagins and ellagic
acid), are believed to prevent gingivitis
through a number of mechanisms including
reduction of oxidative stress in the oral
cavity, direct antioxidant activity, anti-
inflammatory effects, antibacterial activity
and direct removal of plaque from the teeth.

Role of Garlic in periodontal health
 Garlic has been used not only to flavour food but
also because it contains a sulfur-rich derivative of
cysteine felt to have medicinal benefits.
 Its anticarcinogenic actions may be explained by
particular organo-sulfur compounds.
 Diallyl sulfide, for example, which is responsible in
part for its strong taste and odor, has been shown to
selectively inhibit as well as induce certain P-450
enzymes.
In a study, Groppo FC (2007) was found that the garlic has antimicrobial properties
against streptococci and anticariogenic properties against oral microorganism.

Awatif Hassan Mohamed et al (2017) conducted a
study to evaluate the effect of water gar-lic extract
on Porphyromonas gingivalis compared to
chlorhexidine digluconate 0.2%. The results
showed that garlic water extract has inhibitory
effect on P.gingivalis isolated from the examined
group of aggressive periodontitis patients
compared to chlohexidine. Due to the widespread
use of antibiotic and the spread of antibiotic
resistance, the antimicrobial activity of garlic
extract against P.gingivalis raises the possibility
that garlic may has therapeutic use for prevention
and treatment of the onset of aggressive
periodontitis.

A WELL BALANCED DIET IS REQUIRED FOR THE
NORMAL GROWTH AND DEVELOPMENT OF AN
INDIVIDUAL. ANY INCREASE OR DECREASE OF THE
NUTRIENT IN THE LONG RUN MAY LEAD TO
DEVASTATING SITUATION. NUTRITION MAY ALTER
DEVELOPMENT, RESISTANCE AND REPAIR OF THE
PERIDONTIUM .
Conclusion

Nutrition in periodontics

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