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Nutrition Concepts - Part II

Nutrition and Oral Health

Poor nutrition can hinder proper development of the oral hard and soft tissues as well as contribute to tooth decay and periodontal conditions in the established oral environment.  The relationship between diet and dental caries has been known for some time.   But certain changes and conditions that manifest in the oral soft tissues can also be related to deficiencies in the diet.

Dental Caries

 Fermentable Carbohydrates

That sugar intake is directly related to the development of tooth decay has been well established.    Simple sugars, including monosaccharides and disaccharides, are referred to as “fermentable carbohydrates”.  Fermentable carbohydrates can be broken down in the mouth by salivary amylase and are easily metabolized by oral bacteria, especially Streptococcus mutans and Lactobacillus.   When this metabolism of simple sugars occurs, acid is produced in the mouth, causing the pH of the plaque to drop to 5.5 or lower.  A pH of 5.5 is the critical level at which demineralization of the enamel begins to occur.  Fermentable carbohydrates can thus be defined as those foods that cause the pH of the oral environment to drop to 5.5, beginning the process of enamel demineralization.  Complex carbohydrates, or polysaccharides, are not metabolized by oral bacteria and therefore do not contribute to tooth decay as the simple sugars do. 

Studies have shown that there are other factors besides simply the presence of fermentable carbohydrates that contribute to caries formation.  Some of these factors are: whether or not the sugar is eaten with a meal, the place of the carbohydrate within the meal, the frequency of ingestion, the retentiveness of the carbohydrate, and the effects of saliva.

A fermentable carbohydrate that is eaten as part of a meal is less damaging to the teeth than a carbohydrate that is eaten between meals as a snack.   The other foods that are part of the meal tend to offset the effects of the fermentable carbohydrate.  This is especially true if the carbohydrate is followed during the meal by a fat or protein food.  Proteins and fats are considered to be anticariogenic because they do not lower the pH of the oral environment.  A fat or protein food that is eaten after a fermentable carbohydrate will help to neutralize the acidic effects of the carbohydrate.   Dairy foods like cheese, milk, and yogurt, especially, are cariostatic and good choices for ending a meal.

When a fermentable carbohydrate is consumed over a period of time (for instance, sipping on a sugared drink for an hour or two), the oral environment is continuously exposed to the acid produced by the bacterial metabolism of the carbohydrate.   This continuous exposure does not allow the saliva to do its job of neutralizing and buffering.    Therefore, consuming a fermentable carbohydrate over time is much more damaging to the teeth than eating it within a few minutes.   Another factor to consider is the retentiveness of the fermentable carbohydrate.   “Sticky” foods, of course, are more damaging because they tend to adhere to the teeth and are not cleared from the mouth easily by the saliva.   



Saliva is an important factor affecting the rate of caries formation.    One of the actions of saliva is to clear the mouth of food debris; therefore it’s necessary to have a sufficient amount of saliva to wash away debris successfully.    Studies show that a reduced flow or absence of saliva is associated with an increased presence of caries.   Xerostomia, which is the reduction or absence of saliva, can be related to certain systemic conditions. 

 Xerostomia, in varying degrees, also occurs at higher rates in the elderly population.   This fact helps explain why root caries are often a problem for elderly people.   The recession that can occur in the older population, along with reduced salivary flow, combine to cause caries on the exposed root surfaces.  Root caries can be particularly destructive and fast-moving due to the lack of protective enamel on the root surface and the thinner structure of the root itself.

In addition to physically clearing the oral environment, saliva contains buffering and antimicrobial properties.  The pH of saliva is normally in the neutral range of about 6.5 to 7.5.   This neutral pH means the saliva works to buffer the acidic pH caused by fermentable carbohydrates and bring the pH of the oral environment back into a more neutral state.   As for saliva’s antimicrobial properties, the main antibody in saliva is Immunoglobulin A.  Immunoglobulin A has been shown to act against S mutans and other oral bacteria associated with the presence of caries.

Saliva also has been shown to have remineralization properties.   Ions in the saliva, including fluoride and phosphate, promote remineralization of the enamel, thereby helping to reverse the demineralization caused by fermentable carbohydrates.


Sugar Alcohols

Sugar alcohols, also called polyols and non-nutritive sweeteners, are often used in foods to replace sucrose, glucose, and other simple sugars.    These non-nutritive sweeteners are called sugar alcohols because their molecular structures resemble both that of sugar and of an alcohol.   Mannitol, sorbitol, and xylitol are widely used sugar alcohols.  They are considered noncariogenic because they are fermented in the mouth much more slowly than simple sugars.   They also are lower in calories than sugars.   Sugar alcohols are not easily digested or absorbed by the body, so they do not cause the rise in blood sugar that simple sugars do.

Sugar alcohols occur naturally in fruit and other plant foods, but they are also commercially produced and used in other foods.   The use of sugar alcohols has a long history, but their use in foods has increased in recent years with new techniques available.   Sugar alcohols are a good sugar substitute for people with diabetes The anticariogenic effects of xylitol were discovered in the 1970’s with studies done in Finland.

Most of the sugar alcohols have only 35--75% of the sweetness of sugar.  Xylitol, however, has the same sweetness level as sugar.  Studies show that xylitol, like the other sugar alcohols, is anticariogenic, increases salivary flow (thus aiding in clearance of the oral environment), and acts as a buffer.   With these characteristics, and its sweetness equaling that of sucrose, xylitol is a popular choice as a sweetener in chewing gums, candies, and mints. Xylitol is also available as a sugar substitute which can be used as table sugar is used---for baking, sweetening coffee or tea, etc.   It is suggested that for the most effectiveness at preventing caries, six to ten grams of xylitol per day should be consumed.

Very recent studies suggest that xylitol may assist with wound healing and be effective against ear and nose infections and even osteoporosis.  Research is ongoing in these fields, but the oral benefits of xylitol are unquestioned.   

Non-nutritive sweeteners (sugar alcohols) and artificial sweeteners (such as saccharin and aspartame) are not the same.   Artificial sweeteners contain zero calories or carbohydrates, while non-nutritive sweeteners contain an average of 2.6 calories per gram and do contain some carbohydrates.   Neither will contribute to caries as sugar does.   The most common drawback to consuming sugar alcohols is that because they are not completely digested and absorbed by the body, they can cause bloating and diarrhea when consumed in large amounts.


Water and Fluoride

A popular practice related to nutrition that is of some concern is the increased consumption of bottled water instead of tap water.   Many communities fluoridate their tap water, which has helped to reduce decay rates over the past 30 to 40 years.   Bottled water often contains no fluoride, so there is some concern that the widespread substitution of bottled water for tap water may reverse this downward trend in tooth decay.

(Continued from page 1 )


Periodontal Diseases

The role of diet as a cause of periodontal disease is not as clear as the relationship between fermentable carbohydrates in the diet and dental caries.  But research has established a definite relationship between nutrition and periodontal disease.  Individuals who have poor nutritional habits tend to have more periodontal disease and other oral diseases than those people who maintain a healthy diet.   A healthy diet sufficient in vitamins and minerals seems to help protect the body’s tissues, including oral tissues.

The relationship between poor nutrition and oral disease can be a vicious cycle.  Poor nutrition in general, and especially deficiencies of certain vitamins, can lead to oral conditions (like gingivitis) that produce pain that makes it difficult to eat.  This difficulty in eating exacerbates the poor nutrition, and so the cycle repeats itself.   This cycle is especially applicable when systemic diseases, such as cancer or HIV/AIDS are present.

Nutritional deficiencies often produce symptoms in the oral environment, so the dental professional is in a unique position to recognize these symptoms and help the patient.  Both dental and dietetic professionals are realizing the benefit to patients of working together to improve patients’ nutritional health.   In cases of extremely poor nutrition or after periodontal surgery, especially when poor nutrition has played a part in the periodontal disease process, a nutritionist or dietician may be called upon to counsel the dental patient in proper nutrition to promote healing.   This teamwork approach is becoming more common in the health professions as understanding of the relationship between nutrition and healing increases.


Vitamin C

The relationship between vitamin C deficiency and scurvy is one example of how the lack of good nutrition can contribute to oral diseases of soft tissues.  Scurvy can be described as very severe gingivitis, with extremely painful and bleeding gingiva.   In the days of sailing vessels that were at sea for months at a time, scurvy was common among the sailors who became deficient in vitamin C due to the lack of fresh fruits and vegetables.  Eventually this link between lack of fruit (especially citrus) and scurvy became known, and in 1867, the Merchant Shipping Act required the Royal Navy to supply limes and lemons on all their sailing ships.   Later research established that it was vitamin C in the citrus fruit that prevented scurvy.

Although scurvy itself is rare today, especially in developed countries, a deficiency of vitamin C can still be associated with increased gingival bleeding.     Vitamin C is necessary for the production and healing of collagen, so it is important in the healing of wounds or after surgery.  Other nutrients involved in the healing process include vitamin A, zinc, and protein.      

Food sources of vitamin C include most fruits and vegetables, especially citrus fruits, cantaloupe, kiwi fruit, berries, broccoli, red and green peppers, spinach, and other fruits and vegetables.  Some cereals are fortified with vitamin C.   The best sources are raw or uncooked fruits and vegetables; cooking reduces the vitamin C content in foods.   Vitamin A food sources include dairy products, liver, fish, and fortified cereals.   Protein can be obtained in meats, milk, fish, eggs, beans, legumes, and some grains.


The B Vitamins

Along with vitamins C and A, the B vitamins are very important in maintaining the health of the oral soft tissues.   Vitamin B is actually a complex of vitamins including thiamin, riboflavin, niacin, folic acid (folate), pantothenic acid, biotin, and vitamins B6 and B12.   Deficiencies in the B vitamins can result in oral soft tissue changes, including glossitis, cheilosis, burning or furrowed tongue, aphthous ulcers, and cracked lips, among other changes.   Cheilosis and glossitis are two symptoms of riboflavin (vitamin B2)deficiency.   A mild deficiency of niacin (vitamin B3) can result in cankersores (aphthous ulcers); a severe of niacin causes pellagra.   Symptoms of pellagra include dermatitis, edema, and skin and oral lesions as well as psychological symptoms.  Pellagra is often described by the “four D’s”: diarrhea, dermatitis, dementia, and death.   The classic oral symptom of pellagra is a swollen, bright red (“beefy red”) tongue.   

A severe deficiency of thiamine (vitamin B1) causes beriberi, which also has oral symptoms similar to those described for the other B vitamins.   Deficiencies of most of the B vitamins are rare; deficiency of vitamin B12 is the most common deficiency of the B vitamins.   Vitamin B12 deficiency is most often seen in vegans and some vegetarians because the most reliable sources of B12 are meat and dairy products.  It’s recommended that vegans, particularly, consider taking vitamin B12 supplements.

Folic acid (folate is the term for the naturally-occurring form in the body) is another B vitamin.  Folate deficiency is rare in the United States, but it is very important that pregnant women get enough folic acid especially early in the pregnancy to prevent neural tube defects in the fetus.  Some recent studies suggest that good levels of folic acid can reduce the risks for certain cancers, but the evidence is conflicting and research is ongoing.

Deficiencies of the B vitamins, particularly thiamine, niacin, and folic acid, are also related to alcoholism.  This is partly due to the poor diet of many alcoholics and also to the fact that alcohol abuse impairs the absorption capabilities of the gastrointestinal tract.   The brain damage that occurs with long-term alcohol abuse is often due to severe deficiencies of thiamine and niacin.

Food sources for the B vitamins include whole grains, potatoes, beans, turkey, tuna, liver.  Unprocessed foods are a good source of vitamin B; processing of flour and other foods tends to reduce the levels of vitamin B.   Vitamin B12 is obtained mostly from meat and dairy products.


Vitamin D and Calcium

Vitamin D, in addition to having cardiovascular and immunity effects, contributes to bone health.  Vitamin D and calcium work together.  Studies show that 99% of the calcium in the body is in the bones and teeth; only 1% of calcium is located in the blood.   A deficiency of vitamin D can lead to poor absorption of calcium, resulting in inadequate bone levels or loss of bone.   This can lead to osteoporosis, and it can also affect periodontal bone health.  There is some evidence that magnesium and vitamin K also contribute to bone health.

Vitamin D is naturally present in very few foods.   Fatty fish, such as salmon, tuna, and mackerel, are good sources.  In the United States, most milk is fortified with vitamin D.   Exposure to sunlight is a main source of vitamin D for most people; generally, it’s recommended to have 5 to 30 minutes of exposure to the sun twice a week.   People who don’t get sufficient sun exposure need to be certain that they get enough vitamin D through the diet.   Dark green leafy vegetables and nuts are good sources of magnesium.  Green leafy vegetables also have vitamin K, but the main source of vitamin K is synthesis by bacteria in the large intestine.


Other Nutrients

Other vitamins and minerals that affect oral health are vitamin E, which contributes to healing of the oral tissues, and zinc, a lack of which can alter the senses of taste and smell.   A deficiency of iron can lead to anemia, symptoms of which often are seen first in the oral soft tissues as unusual paleness of the gingiva.

Vitamin E can be obtained from eating nuts, seeds, vegetable oils, fortified cereals, and green leafy vegetables.  Zinc is present in a variety of foods; oysters contain more zinc than any other food.  Zinc is also present in beans, nuts, dairy products, meat, poultry, and whole grains.   Sources of iron include dried beans and fruits, egg yolks, iron-fortified cereals, meat, poultry, salmon, tuna, and whole grains.

Recent research has suggested that certain omega-3 and omega-6 fatty acids can act against periodontal disease.  These polyunsaturated fatty acids in the diet act as antioxidants to reduce the effects of inflammation.   Omega-3 fatty acids seem to have the most effect; one study demonstrated an inverse relationship between periodontal disease and omega-3 fatty acids.    These fatty acids benefit the entire body as well as the oral environment.

Foods high in omega-3 fatty acids include whole grains, fresh fruits and vegetables, fish, olive oil, and garlic.  Omega-6 fatty acids can be obtained mostly from vegetable oils.

Evidence is mounting that consuming enough fruits and vegetables can help prevent oral cancer.   Some studies demonstrate an inverse relationship between fruit and vegetable consumption and the occurrence of oral cancer.  Fruit, especially, seems to have the most effect on oral cancer rates.   There is some evidence that consumption of whole grains may also be protective against oral cancer, but the evidence is not as strong for whole grains as it is for fruits and vegetables. 



Most experts agree that the best and most effective way to consume sufficient macro- and micronutrients is through the diet rather than through supplements.   Some studies do suggest that in certain situations (for instance, after periodontal surgery), supplementation may be warranted to aid healing, but ordinarily it’s recommended that most people should aim to get their nutrients from a well-balanced diet.

Systemic conditions, including nutritional deficiencies, often show symptoms first in the oral tissues.  For this reason, it is imperative that dental professionals be able to recognize changes that occur in the oral mucosa, and be prepared to address those changes, either with educational measures and proper dental treatment or by referring the patient to the appropriate health professional.


Related Reading:

  1. http://www.ncbi.nlm.nih.gov/pubmed/14972061
  2. http://www.ajcn.org/content/78/4/881S.full
  1. http://www.ynhh.org/about-us/sugar_alcohol.aspx
  2. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3320731/?tool=pmcentrez
  3. http://www.health.harvard.edu/press_releases/vitamin_b12_deficiency
  4. http://www.mayoclinic.com/health/folate/NS_patient-folate/DSECTION=evidence
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