NUTRITION & its role in

PERIODONTOLOGY

Presented By: Guided By:

Dr Komal Saini Dr Priyanka Chopra (professor & HOD)
Pg 2nd year & Faculty
CONTENTS

 Introduction
 Classification of nutrients
 Macronutrients
 Micronutrients
 Nutrients, periodontal health and specific conditions
 Dietary recommendations for periodontal disease management
 Conclusion
 Refrences
 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.
 Around 400 BC, Hippocrates, who recognized and was concerned
with obesity, which may have been common in southern Europe at the
time, said, "Let food be your medicine.“
 Balance Diet Contains a variety of food in such quantities &
proportions that the need for energy is adequately met for maintaining
health, vitality & general well being
 Periodontal health is influenced by a number of factors such as oral
hygiene, genetic, systemic health and NUTRITION
 Balanced diet has an essential role in maintaining periodontal health.
 Studies have attempted to find a correlation between tooth loss,
periodontal health, and nutrition.
NUTRIENTS

Macronutrients

Micronutrients
Macronutrients
Micronutrients
 MACRONUTRIENTS

 Macronutrients are nutrients required in large quantities, for example

proteins, carbohydrates, and fats in addition to oxygen and water.
 High carbohydrate intake has been implicated in periodontal disease and
dental caries.
 A strong link between obesity and periodontal diseases has been reported
by hujoel in a study in 2009.

Hujoel, P. Dietary carbohydrates and dental-systemic diseases. J. Dent. Res. 2009, 88, 490–
502.
 CARBOHYDRATES
 The primary role of carbohydrates is to supply energy to all cells in the body.

 If the body already has enough energy to support its functions, the excess
glucose is stored as glycogen.

 Some glucose is converted to ribose and deoxyribose, which are essential

building blocks of important macromolecules, such as RNA, DNA, and ATP.

 As blood-glucose levels rise, the use of lipids as an energy source is inhibited.

Thus, glucose additionally has a “fat-sparing” effect.

 The formation of structural components of the body such as cartilage,

nervous tissue, and bone are dependent on carbohydrate.
Function Of Fats
Chemical messengers

Storage and provision of energy

Maintenance of temperature

Membrane lipid layer formation

The source of "fat-soluble" vitamins

 PROTEINS

 Most abundant organic molecules of the living system.

 Proteins form the fundamental basis of structure and function of life.
 A protein contains a number of amino acids. As many as 300 amino
acids are present in nature. Of these only 20 known as standard
amino acids are repeatedly found in the structure of proteins.

Adult male Adult woman

1.0g/kg/day 1.0g/kg/day
RDA or 60g/day or 55g/day

Pregnant Infants
woman (1-2years)
78g/day 15.2g/day
Function Of Proteins
 Building blocks The most important function of protein is to supply amino acids
to cells for their continuous replacement throughout life. From conception to
growth at various levels protein is very essential
 Regulatory function Haemoglobin- carries O2 to tissues. Plasma proteins like
albumin and globulin- play imp role in regulating osmotic pressure and water
balance within the body. Proteins also function as buffers, thus helping various
sites of chemical reaction to maintain its pH.
 Formation of enzymes, hormones and other secretions
 Source of energy when the diet contains insufficient carbohydrate and fat for
fuel proteins are used as a fuel by the body.
 WATER
 Water is excreted from the body in multiple forms; including urine and
feces, sweating, and by water vapor in the exhaled breath. Therefore it is
necessary to adequately rehydrate to replace lost fluids.
 European Food Safety Authority recommend total water intakes of 2.0 L/day
for adult females and 2.5 L/day for adult males.
 Dietary fibres
• The complex carbohydrates that are not digested by the human enzymes are
collectively referred to as dietary fibre.(Trowell 1972)

• They include polysaccharides, oligosaccharides, lignin and associated plant

substances.
 MINERALS
 Minerals are inorganic elements.

 Only 4% of human body weight is composed of minerals.

 Some dieticians recommend that these can be supplied from foods in which they
occur naturally, or sometimes even from natural inorganic sources (such as
calcium carbonate from ground oyster shells).

 Many minerals have been proven important to human nutrition and there are
other with unknown essentiality.
1) Calcium • development of bone and 0.8 to 1.0 g/day Milk, cheese, egg, green
teeth leafy vegetable, legumes,
nuts, whole grain
• muscle contraction &
relaxation

• blood coagulation

• nerve impulse transmission

2) Phosphorus • development of bone and 0.8 to 1.0 g/day Cheese, pea nut, beef, fish,
teeth eggs, milk and milk
products, all vegetables,
• maintains metabolism of
wheat, oats, rice
fats and carbohydrate

• in the formation of high

energy phosphates,
nucleotide coenzymes,
nucleic acids
3) Potassium • chief cation in 3-4g/day Milk and milk products, meat, fruits
intracellular fluids mainly orange, bananas, whole
grains, coffee
• maintain acid base
balance, osmotic
pressure

• regulates muscle activity

4) Sodium • Chief cation of 5-10g/day Table salt, milk and milk products, fish,
extracellular fluid meat, spinach, beets, carrots

• Maintain acid base

balance, water balance,
osmotic pressure

• Regulate nerve impulses

• muscle activity
MICRO MINERALS
Iron • Plays imp role in 10-15 mg/day Meat, whole grain, cereals,
formation of Hb legumes, almonds,

• Involved in O2 transport
and biological oxidation

Iodine • Basic component of 150-200 μg/day Iodized salt, seafood, salt

thyroxin and tri- water fish
iodothyronine

• Contribute to normal
growth and
development of body
Zinc • Co factor for enzymes 10-15 mg/day Meat, legumes, nuts, milk,
fish
• Aids in protein synthesis

• Aids in normal growth

and development

• Promotes wound healing

Molybdenum • Constituent of enzymes 75-250 μg/day vegetables
in metabolism

Selenium • Involved in anti-oxidant 50-200 μg/day Meat, egg, seafoods,

function along with vit. vegetables grown in selenium
E rich soil

Chromium • Promotes insulin 10-100 μg/day Meat, whole grain

function (as glucose
tolerance factor)
Role of Key Nutrients in
Periodontal Health
 Study conducted by Ekuni et al in 2008 on Japanese young adults
found an association between high body mass index (BMI) and high risk
of periodontal disease.
 higher body fat content has been associated with increased gingival
bleeding in older patients
 Polyunsaturated fats (such as omega-3s) have been observed to have a
positive effect on periodontal health .

Hujoel, P.P.; Drangsholt, M.; Spiekerman, C.; DeRouen, T.A. Periodontal disease and coronary heart
disease risk. JAMA 2000, 284, 1406–1410
  A variety of nutrients have a major impact on periodontal health.
 The influences of nutritional supplements and dietary components have
been known to affect healing after periodontal surgery.
 The human diet contains a number of antioxidants in the form of
micronutrients.Antioxidants may overcome the ROS-mediated
inflammation of periodontal tissues.
 Oxidative stress was recently defined as “an imbalance between
oxidants & antioxidants in favour of the oxidants, leading to a
disruption of redox signalling & control and/or molecular damage.

Iwasaki, M.; Manz, M.C.; Taylor, G.W.; Yoshihara, A.; Miyazaki, H. Relations of serum ascorbic acid and -tocopherol to periodontal disease. J.
Dent. Res. 2012, 91, 167–172.
This shows how bacteria present in the plaque biofilm stimulate a pro-inflammatory cellular response.
Bacteria are recognised by cell surface receptors (Pattern recognition receptors) which results in activation
of pro-inflammatory transcription factors (e.g. Nuclear factor kB) in the cytoplasm of the cell. The activated
transcription factor migrates into the nucleus binds to DNA and causes changes in gene expression resulting
in pro-inflammatory cytokine production in mitochondria. These cytokines are transported out of the cell and
cause an inflammatory response and increases in local levels of oxidative stress.
Carbohydrates and Periodontal
Health
 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.
 Xylitol, a sugar alcohol produced by the hydrogenation of xylose sugar, is an
artificial sweetener used as an alternative to conventional sugars .
 Study by Kim et al in 2016 concluded that Xylitol may have an antibacterial
effect against periodontal pathogens such as Porphyromonas gingivalis and
Aggregatibacter actinomycetemcomitans.

Frostell, G.; Birkhed, D.; Edwardsson, S.; Goldberg, P.; Petersson, L.; Priwe, C.; Winholt, A. Effect of Partial substitution of invert sugar for sucrose in
combination with Duraphat® treatment on caries development in preschool children: The Malmö study. Caries Res. 1991, 25, 304–310
Kim, S.; Park, M.H.; Song, Y.R.; Na, H.S.; Chung, J. Aggregatibacter actinomycetemcomitans-induced AIM2 inflammasome activation is suppressed by xylitol in
differentiated THP-1 macrophages. J. Periodontol. 2016, 87, e116–e126
  Oral hygiene measures and regular non-surgical debridement both contribute to
the improvement of periodontal health.

 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 .

Keukenmeester, R.; Slot, D.; Rosema, N.; Van Loveren, C.; Van der Weijden, G. Effects of sugar-free
chewing gum sweetened with xylitol or maltitol on the development of gingivitis and plaque: A
randomized clinical trial. Int. J. Dent. Hyg. 2014, 12, 238–244.
Diagrammatic representation of effects of a diet high in refined sugar, carbohydrate and saturated fat on
neutrophil function which results in production of a ‘respiratory burst’ ultimately leading to release of
oxidant species and pro-inflammatory mediators into tissues thereby increasing oxidative stress and
causing local tissue damage.
Proteins

 Protein depravation studies conducted on rats by Stahl et al in 1950s resulted in

the breakdown of periodontal ligaments, degeneration of gingival tissues, and
resorption of the alveolar bone.

Stahl, S.S.; Sandler, H.C.; Cahn, L. The effects of protein deprivation upon the oral tissues of the rat
and particularly upon periodontal structures under irritation. Oral Surg. Oral Med. Oral Pathol. 1955,
8, 760–768.
 Vitamins and Periodontal Health

 various vitamins are required for maintaining health oral and periodontal tissues.
 Nutritional deficiency of vitamins results in oral manifestations such as scurvy and
rickets etc.
 A higher intake of vitamins A, B, C, and E along with omega-3 fatty acids results in
improved healing after non-surgical periodontal therapy .

Dodington, D.W.; Fritz, P.C.; Sullivan, P.J.; Ward, W.E. Higher intakes of fruits and vegetables, beta-carotene, Vitamin C,
-tocopherol, EPA, and DHA are positively associated with periodontal healing after nonsurgical periodontal therapy in
nonsmokers but not in smokers. J. Nutr. 2015, 145, 2512–2519
Nutrient Dietry sources Importance In Reported Refrences
Periodontal Health Improvement
in PD and CAL
(Mean mm, SD
Vitamin A Cod liver oil, carrots, Not clear. Research PD: 0.52 0.03 Dodington et al 2015
capsicum, liver, indicates CAL: n.d.
sweet potato, broccoli, insignificant
leafy vegetables improvement in
periodontal
health upon
supplementation
B-vitamins B1—Liver, oats, pork, Supplementation PD: 1.57 0.34 Neiva et al 2005
potatoes, eggs may CAL: 0.41 0.12
accelerate post-
surgical healing.
B2—Bananas, dairy,
green beans
B3—Eggs, fish, meat,
mushrooms, nuts

B5—Avocados, meat,
broccoli
 Dietry sources Importance In Periodontal Reported Refrences
Health Improvement
in PD and CAL
(Mean mm, SD

Vitamin B6 Meat, vegetables,

nuts, banana

Vitamin B12 Animal products

Vitamin C Citrus fruits, Gingival bleeding and PD: 0.58 0.14 Abou Sulaiman et
vegetables, liver inflammation CAL: n.d. al 2010
are hallmarks of scurvy.
Supplementation may
improve
outcomes of periodontal
therapy.

Vitamin D Fish eggs, Deficiency may lead to PD: 1.35 (SD Lieberman et al
mushrooms, delayed n.d.) 2007
liver, milk post-surgical healing. Local CAL: 1.4 (SD
application may accelerate n.d.)
post-surgical
Nutrient Dietry sources Importance In Reported Refrences
Periodontal Health Improvement
in PD and CAL
(Mean mm, SD

Vitamin E poultry, meat, fish, Impaired gingival PD: 0.39 0.18 García-Closas et al
nuts, seeds and wound healing CAL: n.d. 2004
cereals

Vitamin k Green vegetables, Deficiency may n.d. Aral, K et al 2015

egg yolk lead to
gingival bleeding.
No known effects
on periodontal
therapy if
supplementation
used as an adjunct
 Vitamin A
 Vitamin A is a fat-soluble vitamin that plays a role in maintaining the
integrity of epithelial cells.

 Dietary sources of vitamin A include eggs, cod liver oil, carrots, capsicum,
liver, sweet potato, broccoli, and leafy vegetables.

 A healthy individual needs approximately 900 μg/day.

 Deficiency results in retinal disorders (such as night blindness and

hyperkerotosis).
Oral manifestations of vitamin A
 Hyperplasia and hyperkeratosis of gingival epithelium

 Retardation of gingival wound healing.

 Deficiency may accentuate the deleterious effects of plaque induced

inflammation.

 Deficiency of vitamin A also interferes with the production of lysozyme, an

antibacterial agent in the saliva, which is important to control oral flora.

 Change in Alveolar Bone - replacement of bone trabeculae with fibrous

Connective tissue, reduced bone formation
 Considering the antioxidant potential,
vitamin A has been used to supplement
periodontal treatment.

Neiva, R.F.; Al-Shammari, K.; Nociti, F.H., Jr.; Soehren, S.; Wang, H. Effects of vitamin-A supplementation on
periodontal wound healing. J. Periodontol. 2005, 76, 1084–1091
Vitamin B Complex
 The vitamin B complex family consists of
B1 (thiamine),
B2 (riboflavin),
B3 (niacin),
B5 (pantothenic acid)
B6 (pyridoxine, pyridoxal, pyridoxamine)
B7 (biotin)
B9 (folic acid)
B12(cobalamins).
 B-Complex vitamins play a vital role in cell metabolism, repair, and
proliferation.
 Deficiency of vitamin B12 may lead to gingival bleeding. A recent study by
Zong et al found an inverse association between serum vitamin B12 levels
and the severity of periodontitis.
 In a study by Erdemir et al in 2007 Reduced serum vitamin B9 levels
have been observed in smokers, which may lead to periodontitis.
 Neiva et al observed that B-vitamin complex supplementation
accelerates the healing of wounds after periodontal flap
surgery.

Erdemir, E.O.; Bergstrom, J. Effect of smoking on folic acid and vitamin B12 after nonsurgical periodontal intervention. J. Clin. Periodontol. 2007, 34, 1074–
1081.
Neiva, R.F.; Al-Shammari, K.; Nociti, F.H., Jr.; Soehren, S.; Wang, H. Effects of vitamin-B complex supplementation on periodontal wound healing. J. Periodontol.
2005, 76, 1084–1091.
 Vitamin C
Anti scorbutic vitamin

History :
 James Lind 1753
 Silva 1917-27
 Szent Gyogi 1928
 Waugh & King 1932
Functions
 Cellular oxidation – reduction

 Collagen synthesis – hydroxyproline &

hydroxylysine

 Functional activity of fibroblasts & osteoblasts – by

formation of connective tissue, osteoid, dentine

 Tryptophan metabolism

 Tyrosine metabolism – oxidation of hydroxy phenyl pyruvate

to homogentisic acid
 Formation of active tetrahydrofolate

 Formation of ferritin & absorption of iron

 Electron transport chain

 Cholesterol metabolism – bile acids

 Immunologic functions – phagocytic action

 Sparing action of other vitamins

Vitamin C
 Vitamin C (ascorbic acid) is primarily required for the synthesis
of collagen and it also prevents oxidative damage by acting
as a ROS scavenger.
 Scurvy, first identified by Sir Thomas Barlow in 1883, is the name
given to the disease caused by the deficiency of vitamin C.
 Periodontal hallmarks of scurvy are bleeding, inflamed, and
painful gums. Vitamin C supplementation cures and prevents
scurvy.

Camarena, V.;Wang, G. The epigenetic role of vitamin C in health and disease. Cell. Mol. Life Sci. 2016, 73, 1645–1658
An in vitro study by tsutsumi et al in 2012 suggests that local
application of vitamin c-containing magnesium salt not only
improves collagen synthesis but may also decrease ros-
induced inflammation of gingival fibroblasts.

Dentifrice containing vitamin c-containing magnesium salt has

successfully been used to reduce gingival inflammation in a
clinical trial by shimabukuro et al in 2015.

The vitamin c-containing dentifrice exhibited a significantly

higher anti-ros activity compared to conventional dentifrice.
Tsutsumi, k.; Fujikawa, H.; Kajikawa, T.; Takedachi, M.; Yamamoto, T.; Murakami, S. Effects of l-ascorbic Acid 2-phosphate magnesium salt on the properties of
human gingival fibroblasts. J. Periodont. Res. 2012, 47,
263–271.
Due to its positive effects on periodontal health, vitamin C
may also be used in coatings and/or gel forms to enhance
the osseointegration of dental implants and improve post-
surgical periodontal healing.

Ascorbate compounds are potent for scavenging free

radicals and help smokers to diminish the breakdown of
periodontal tissues by its antioxidant action.
Nishida, M.; Grossi, S.G.; Dunford, R.G.; Ho, A.W.; Trevisan, M.; Genco, R.J. Dietary vitamin C and the risk for periodontal disease. J. Periodontol. 2000, 71,
1215–1223
Vitamin D
 It enhances the absorption of minerals including calcium, magnesium,
iron, phosphate, and zinc in the intestine.
 In humans, there are two important groups of vitamin D, vitamins D2
(cholecalciferol) and D3 (ergocalciferol).
 Clinical studies have suggested that a deficiency of dietary vitamin D
leads to periodontal inflammation and a delay in post-surgical
periodontal healing.
The local effects of vitamin D supplementation on periodontal
tissues are more apparent than systemic administration.

For example, vitamin D3 coated on dental implants may

enhance osseointegration with alveolar bone. Furthermore,
intraperitoneal injections of vitamin D3 accelerates orthodontic
tooth movement, making it possible to induce orthodontic tooth
movement in patients undergoing bisphosphonate therapy
Javed, F.; Malmstrom, H.; Kellesarian, S.V.; Al-Kheraif, A.A.; Vohra, F.; Romanos, G.E. Efficacy of
Vitamin D3 Supplementation on Osseointegration of Implants. Implant. Dent. 2016, 25, 281–287.
In a clinical trial by Schulze-Späte et al in 2016 systemic
supplementation of vitamin D has not resulted in any added
3

benefits in periodontal bone formation among patients who had

undergone maxillary sinus augmentation .

Schulze-Späte, U.; Dietrich, T.; Wu, C.; Wang, K.; Hasturk, H.; Dibart, S. Systemic vitamin D
supplementation and local bone formation after maxillary sinus augmentation—A
randomized, double-blind, placebo-controlled clinical investigation. Clin. Oral Implants Res.
2016, 27, 701–706.
Vitamin E
• Vitamin E (tocopherol) is a fat-soluble vitamin that is
considered one of the key extracellular antioxidants.

• Diets rich in vitamin E include poultry, meat, fish, nuts,

seeds, and cereals.

• Vitamin E stabilizes the membrane structure by terminating

the free radical reaction.
 A study by Åsman etal in 1994 reported favorable effects of
vitamin E in maintaining periodontal health and controlling
inflammation. In addition, a reduction of vitamin E was observed
in patients with periodontal diseases compared to healthy
individuals.
Åsman, B.;Wijkander, P.; Hjerpe, A. Reduction of collagen degradation in experimental granulation tissue by vitamin E and
selenium. J. Clin. Periodontol. 1994, 21, 45–47.

 The level of vitamin E in the alveolar fluid of smokers is reduced,

corresponding to increased production of oxidants during
smoking. The mechanism of action of vitamin E for periodontal
health is not very well understood and needs further research.
Pacht, E.R.; Kaseki, H.; Mohammed, J.R.; Cornwell, D.G.; Davis, W.B. Deficiency of
vitamin E in the alveolar fluid of cigarette smokers. Influence on alveolar macrophage
cytotoxicity. J. Clin. Investig. 1986, 77, 789–796.
Vitamin K
 Vitamin K is a group of vitamins required for the synthesis of
proteins that are precursors or prerequisites of the formation
of blood coagulation factors such as prothrombin and
factors VII, IX, and X.
 vitamin K also plays a role in the formation of proteins
required for bone metabolism such as osteocalcin etc.
 A number of foods such as kale, spinach, collards, and
mustard are a source of vitamin

Shearer, M.J.; Newman, P. Metabolism and cell biology of vitamin K. Thromb. Haemost.
2008, 100, 530–547.
Vitamin K is an important pharmacological agent used to
reverse the anticoagulant effects of warfarin and routinely
administered for patients undergoing hemodialysis.

Although vitamin K deficiency may lead to gingival bleeding,

a recent study by Aral et al. has found that vitamin K
supplementation was not able to reduce pro-inflammatory
factors in the periodontium.
Antioxidants and Periodontal Health
 ROS are highly reactive free radicals (molecules containing unpaired
electrons) are capable of inflicting cellular and tissue damage by altering
the chemical structure of molecules.

 They particularly damage lipids by initiating a chain of lipid peroxidation.

Normally, aerobic respiration leads to the production of ROS. However,
the antioxidant defense enzymes reduce the ROS to minimize cellular
damage.

 When this balance of ROS production and antioxidant enzymes (e.g.,

glutathione) is disrupted, a state of oxidative stress occurs .
Xiang,Q.; Liu, Z.;Wang, Y.; Xiao,H.;Wu,W.; Xiao,C.; Liu, X.Carnosic acid attenuates lipopolysaccharide-induced liver
injury in rats via fortifying cellular antioxidant defense system. Food Chem. Toxicol. 2013, 53, 1–9.
 Periodontal disease is a complex process
of infective and inflammatory processes
leading to production of reactive oxidative
species (ROS), which in turn worsen
periodontitis. Antioxidants may improve
periodontal health and outcomes of
periodontal therapy by reducing the
oxidative stress

Antioxidants may help in reducing the severity of disease by scavenging ROS. A

number of dietary components that can function as antioxidants have shown
potential for improving periodontal health and healing.
Vitamins as Antioxidants
 Vitamins A, C, and E have all been observed to modulate the
anti‐oxidant defense system.
 Supplementation with vitamin C in patients undergoing
non‐surgical periodontal therapy increased the total antioxidant
capacity (TAOC)
 increased intake of foods high in vitamins A, C, and E has been
observed to decrease the severity of periodontitis in non‐smokers;
however, the same effects could not be replicated in smokers .
 supplementation with vitamin E has been observed to
simultaneously reduce levels of serum superoxide dismutase and
improve the outcomes of scaling and root‐planing .
Singh, N.; Chander Narula, S.; Kumar Sharma, R.; Tewari, S.; Kumar Sehgal, P. Vitamin E supplementation, superoxide
dismutase status, and outcome of scaling and root planing in patients with chronic periodontitis: A randomized clinical
trial. J. Periodontol. 2014, 85, 242–249.
Lycopene

 Lycopene is a red pigment present in vegetables such as

tomatoes, carrots, and watermelons.
 study by Chandra et al. suggested that lycopene
supplementation may enhance the improvement of
periodontal health .
 To date, the exact mechanism of action of lycopene in the
periodontium has not been established.

Chandra, R.V.; Prabhuji, M.; Roopa, D.A.; Ravirajan, S.; Kishore, H.C. Efficacy of lycopene in
the treatment of gingivitis: A randomised, placebo-controlled clinical trial. Oral Health Prev.
Dent. 2007, 5, 327
Melatonin
 Melatonin is a potent antioxidant secreted by various organs of the
human body.
 Although melatonin is not classified as a major nutrient, it has been
suggested that, in supplement form, the antioxidative properties of
melatonin are more potent than those of Vitamin E .
 Topical forms of melatonin may be used as an adjunct to surgical
and non-surgical periodontal therapy.

Pieri, C.; Marra, M.; Moroni, F.; Recchioni, R.; Marcheselli, F. Melatonin: A peroxyl radical
scavenger more effective than vitamin E. Life Sci. 1994, 55, PL271–PL276
 Melatonin acts as an ROS scavenger at the site of
implant placement to reduce inflammation and
stimulates the proliferation of osteoblasts .
 Although melatonin has been approved by the FDA as
a dietary supplement for treating sleep disorders, the
effect of systemic melatonin on periodontal health
and post-surgical healing has not been researched to
date.
 Calcium is required for the normal functioning of muscles and body
systems.
 Additionally, calcium is essential for the maintenance and formation
of calcified tissues such as bone and teeth.
 Dietary sources of calcium are dairy products, leafy vegetables,
nuts, and seeds.
 A lack of calcium (hypocalcemia) may lead to cardiac arrhythmias,
conclusions, tetany, and numbness and/or tingling in hands, feet
and round the lips.
 A study conducted on older Danish patients indicated that a higher
intake of dairy products decreases the severity of periodontitis in
later life [122
 Co-supplementation of calcium and vitamin D is commonly used
and has a positive effect on outcomes of periodontal therapy [121
 It has been established that local delivery of calcium, in the form of
hydroxyapatite, enhances the osseointegration of dental implants
[123
 Magnesium is required for cell metabolism and maintenance and
formation of bone.
 The deficiency of magnesium interfered with the parathyroid
hormone and directly affects the bone resulting in osteoporosis [128]
 Magnesium supplements have been shown to reduce incidences of
fractures in osteoporotic patients, indicating their positive effect on
the maintenance of bones.
 So far, only one study has suggested a positive effect of
magnesium-rich diets on non-surgical periodontal therapy [124]
 Iron is mainly required for synthesis of proteins, including hemoglobin
and enzymes.
 Foods such as red meat, spinach, fish (tuna and salmon), and beans
are rich sources of iron.
 Iron deficiency leads to anemia and related symptoms. Oral
manifestations of anemia include recurrent ulceration, pale
mucosa, and burning of the mouth.
 Indeed, a study indicates that iron-deficiency anemia leads to a
reduction in antioxidant enzymes, leading to an increased oxidative
stress and worsening of periodontal diseases [125]
 Zinc is second to iron as the most abundantly found trace mineral in
the human body [133]
 it modulates the processes of auto-debridement and keratinocyte
migration during wound repair [134].
 it also exerts an antioxidative effect by scavenging ROS in addition
to neutralizing bacterial toxins [135
 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 [137]
a systematic review by Pushparani has further supported the importance of zinc in preventing
diabetes-related periodontitis by exerting an anti-oxidant effect.

zinc is an important component of periodontal dressings [136].

enhancement of osseointegration has been reported around zinc-coated dental implants in

osteoporotic rats [139],
 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
[140].
 Fluoride supplementation of 0.25 to 1 mg per day is recommended depending up on the ppm F
already present in drinking water [144].
 Additionally, fluoride supplementation may also reduce root resorption caused by orthodontic
movement of teeth [145]
Nutrients, Periodontal Health, and
Specific Conditions

 A number of factors are involved in reducing the serum level of micronutrients such as genetic or
gastrointestinal disorders (affects absorption and bioavailability), poor diet, or lifestyle [147].
Certain physiological changes such as pregnancy and aging may affect the daily requirement of
various nutrients.
Pregnancy

 Pregnancy is a physiological condition that results in a number of transitory changes in female

body organs including the oral cavity.
 In terms of periodontal health, pregnant women are more prone to periodontitis, gingivitis and
gingival hyperplasia.
 the increased secretion of estrogen has been linked to periodontal diseases during pregnancy [149]
 As pregnancy needs special consideration, proper diet and nutritional advice can
be vital for the prevention and management of periodontal conditions.
 increasing fiber and reducing refined sugar can be advised as preventive measures
[147]
 Patients should be educated in oral hygiene maintenance as better oral hygiene
potentially reduces the amount of oxidants.
Ageing Population and Role of Diet
Nutrition
 According to an adult dental health survey, a majority of patients (85%) reporting
periodontitis were 65 years or older [153]. Numbers of natural teeth are reduced in
older age [154], which exposes remaining teeth to higher masticatory stresses.
This evidence suggests that the number of older people requiring periodontal
treatment is likely to increase in the future.
 polypharmacy and reduced body metabolism results in the impairment of
nutritional status in old age.
 the risk of folic acid deficiency and related complications has been associated with
the elderly population in the USA [157]
 In older people The masticatory efficiency is compromised due to the presence of
dentures and implants, the lack of natural teeth, and xerostomia.
 Patients’ masticatory efficiency and choices should be considered while discussing
nutritional options
 Considering the role of nutrition for oral and periodontal health, nutritional advice
can be very helpful for the prevention and management of periodontal diseases.
Regular and timely nutrition consultation during dental practice can improve the
quality of life, hence benefitting the elderly [161,162
Dietary recommendations for periodontal
disease management
 The recommendations of the 2011 European workshop on Periodontology26 suggest that the
dental team should consider including advice to all patients on increasing levels of fish oils, fibre,
fruit and vegetables and to reduce levels of refined sugars as part of a periodontal
prevention/treatment regime and a general health benefit message.
CONCLUSIONS

 some studies suggest that improving nutrition and supplementation of vitamins and minerals,
particularly vitamin C, may contribute to improvement of periodontal health.
 The reported treatment effects are too small to indicate the magnitude of therapeutic supplements
when used as an adjunct to periodontal therapy. Hence, well-designed, long-term studies are
needed to ascertain the direct effects of dietary supplements on the outcomes on periodontal
diseases.