COMMONWEALTH ASSOCATION FOR
EDUCATION, ADMINISTRATION AND
MANAGEMENT
VOLUME 2 ISSUE 1
ISSNO NO 2322-0147
JANUARY
2014
IMPACT OF MICRONUTRIENTS ON ORAL HEALTH
Excellence International Journal of Education and
Research (Multi- subject journal)
Excellence International Journal Of Education And Research
VOLUME 2
ISSUE 1
ISSN 2322-0147
IMPACT OF MICRONUTRIENTS ON ORAL HEALTH
BY
Dr Neha Bansal
Junior Resident ( MDS),
Dept. of Periodontics & Community Dentistry,
Z.A.Dental College, A.M.U., Aligarh.
Email id- nehabansal2k5@gmail.com
mobile 9897517350
Dr N.D. Gupta
Professor, MDS
Dept. Of Periodontics & Community Dentistry,
Z. A. Dental College, A.M.U., Aligarh.
Email id- ndguptaligarh@gmail.com
Mobile- 9412817009
Office- 0571 - 2721184
Dr. Afshan Bey
Professor and chairperson, MDS
Periodontics & Community Dentistry
Deptt. Of Periodontics & Community Dentistry,
Dr. Z.A. Dental College, AMU, Aligarh
Email ID: afshanbey@gmail.com
Telephone number: (R) 0571-2720133 (O) 0571-2721184
mobile- 9837231654
Dr Vivek kumar sharma
Associate Professor, MDS
Periodontics & Community Dentistry
Deptt. Of Periodontics & Community Dentistry,
Dr. Z.A. Dental College, AMU, Aligarh
Email id- yeahlifehai@yahoo.com
mobile- 9411491571
ABSTRACT
Nutrients play an important regulatory role in preserving the health of the human body and of all
metabolically active tissues. Micronutrients, vitamins and antioxidants are essential for constant
regenerative processes, for coping with oxidative stress, and also for adequate immune
responses. 1, 2 Increased productions of reactive oxygen species, resulting in high oxidative stress,
is one of the major pathological patterns for destruction of tooth supporting structures including
periodontal, ultimately causing tooth loss if not treated well on time. In recent years, the
beneficial effects of micronutrients against various chronic disorders induced by oxidative stress
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have received much attention. This review is intended to provide a critical summary of impact of
micronutrients in the prevention of oral disease.
Key words: Micronutrients, Periodontium, Oxidative Stress, Malnutrition
INTRODUCTION:
A sound nutritional habits and a sufficient supply of essential vitamins and minerals are of
considerable importance for general and oral health. Several studies reported various degrees of
association between nutritional supplement and periodontal status, and others have reported
possible positive influences of nutritional supplementation on therapeutic outcomes.
3
Since
nutrient supplementation shows minimal or no side effects, it could be used to enhance response
to therapy and may prove valuable in producing more predictable treatment outcomes.
Many oral diseases like periodontitis are regarded as an inflammatory lesion mediated by hostparasite interactions. Due to stimulation by bacterial antigens, polymorph nuclear leukocytes
(PMN) produce reactive oxygen species (ROS) during phagocytosis. Mediation of the
inflammatory response has been successful with a variety of naturally occurring, safe nutritional
supplements that neutralize the reactive oxygen species produced in the presence of periodontal
pathogens. Acute-phase protein response plays a key role in promoting healing, and its deficit in
malnutrition is due to impairment in the production and cellular action of the cytokines. 4
There is, however, insufficient evidence to justify treatment with vitamin and mineral
supplementation in the adequately nourished individual. Future research should focus on an
evaluation of which nutrients may help to prevent the onset and the progression of oral diseases.
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The aim of this article is to provide an overview of the impact of various micronutrients in oral
health and disease.
VITAMIN C:
The importance of ascorbic acid, better known as vitamin C, for periodontal health has long been
known. Insufficient consumption of vegetables and fruits, the two major sources of vitamin C,
can lead to depletion or deficiency states for the vitamin. The most appropriate sources of
vitamin C are natural fruits such as kiwi fruit. Green kiwi fruit contains 93 mg vitamin C/100 g
fruit whereas e.g. Oranges contain 53 mg/100 g fruit. 5 Other dietary sources are Red and Green
Hot Chili Peppers, Guavas, Oranges and citrus fruits, Dark Leafy Greens (Kale, Mustard Greens,
garden cress), Broccoli, Cauliflower, Brussels Sprouts, Papayas and Strawberries.6
Vitamin C is a powerful antioxidant radical scavenger within the aqueous phase. It is a co-factor
for lysyl and prolyl hydroxylase, involved in post-translational modification involved in
stabilization of the collagen triple helix.7 It has been suggested that high ascorbic acid levels
achievable in leukocytes contribute to the ability of these cells to react to inflammatory stimuli. 8
Ascorbic acid was not only shown to enhance chemotaxis of normal PMNLs but also to correct
in vivo and in vitro the abnormal chemotaxis and lysosome degranulation in PMN from patients
with Chediak–Higashi syndrome.9
Leggott et al.10 studied the effect of a rotating 7day diet, adequate in all nutrients except vitamin
C, on periodontal health. The results suggested that ascorbic acid may influence early stages of
gingivitis, particularly crevicular bleeding. However, in subsequent studies, no significant effect
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of vitamin C on plaque accumulation, probing pocket depth, or attachment level were noted.11
On the basis of the NHANES III survey, Chapple et al. found a strong and consistent inverse
association between serum vitamin C concentrations and the prevalence of periodontitis.12
It is however important to remember that high doses of vitamin C may generate toxicity due to
the formation of vitamin C radicals. In 2000 the recommended guidelines for Recommended
Dietary Allowance (RDA) of vitamin C was increased by the Food and Nutrition Board from 60
to 90 mg daily for men to 75 mg daily for women. 13
VITAMIN E:
Vitamin E falls into the class of conventional antioxidants which generally consist of phenols or
aromatic amines. α-tocopherol is the most biologically active form of vitamin E, can be found
most abundantly in wheat germ oil, sunflower, and safflower oils. 14, 15 Other dietary sources are
Tofu, Spinach, Nuts (Almonds) , Shellfish, Broccoli, Turnip Greens, Wheat etc.. 16 According to
new guidelines updated in 2000, RDA of vitamin E was increased to 15 mg/day or 22 IU for men
and women (old RDA: 10 and 8 mg/day alpha-tocopherol equivalents, respectively, for men and
women) 17
Vitamin E can help to control oral disease through its ability to prevent inflammation. As a fatsoluble antioxidant, it helps in prevention of chronic inflammatory diseases like periodontitis and
delay aging process. Taking vitamin E might helps in controlling diabetes thereby help in
reducing the side effects of the diabetes including the development of oral disease.
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A study done in 2007 found that epilepsy patients with periodontal disease displayed abnormally
low levels of vitamin E and other antioxidants in their mouths and saliva.
18
Till date, studies
done on vitamin E showed Mixed Results. Therefore data do not provide sufficient support for
the treatment of inflammatory periodontal disease with vitamin E and more researches are
needed in this area.
CAROTENOIDS:
Carotenoid antioxidants (alpha carotene, beta carotene, crytoxanthin, lutein, lycopene,
zeanxantin) are a group of colored pigments, usually yellow, red or orange, that are widespread
in plants.
19
It's not just orange vegetables that are rich in carotenoids, some green ones have
high quantities too. Good choices are kale, turnip greens, mustard greens, collard greens,
dandelion greens, Swiss chard, watercress, beet greens, and spinach. Broccoli is another green
vegetable that has respectable quantities of carotenoids. Fruits are also good sources of
carotenoids. These include apricots, mangos, cantaloupe, guava, and goji berries. 20
Carotenoids are powerful antioxidants. 21 They have protective effects on vitamins C and E. Also
β -carotene is the main source of provitamin A in the diet. When the carotenoid levels are
diminished, the rest of the antioxidant network begins to unravel. Svilaas et al demonstrated that
carotenoids are predictors of overall antioxidant status. 22
High intakes of carotenoid-rich fruit and vegetables have been shown to decrease in systemic
inflammation as indicated by a reduction in C-reactive protein (CRP).
23
Linden et al.
investigated the association between periodontal health and serum levels of various antioxidants.
Levels of α and β carotene, β Cryptoxanthin, and zeaxanthin were significantly lower both in the
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moderate and severe periodontitis group. 24 In a 2-year longitudinal study inverse relationship is
found between α- and β-carotene and total carotenoids and interleukin-6 (an indicator of
systemic inflammation). 25
β-Cryptoxanthin has an anabolic effect on bone metabolism. It stimulates bone formation and
inhibits bone resorption in a tissue culture model of bone. 26 It also suppresses gene expression of
enzymes that are involved in bone resorption in osteoclasts. A recent epidemiological study
suggested that a high intake of fruit and vegetables containing β-Cryptoxanthin could reduce the
risk of osteoporosis. 27 Therefore β-Cryptoxanthin could be relevant to periodontal destruction,
given its potential to inhibit osteoclastic bone resorption and stimulate osteogenesis rather than
through its activity as an antioxidant.
FLAVONOIDS :
Flavonoids are substances with antioxidant properties found in fruits, vegetables, and certain
beverages. Dietary intake of flavonoids is quite high compared to other dietary antioxidants like
vitamins C and E. They have aroused considerable interest recently because of their potential
beneficial effects on human health. They have antioxidant, antiviral, antifungal, anti-allergic,
antiplatelet, hepatoprotective, antiulcer, antidiabetic, anti-inflammatory and antitumor activities.
28
Synergistic relationships between flavonoids and vitamin C has also been established. 29 High-
flavonoid foods help to protect blood vessels from rupture or leakage, protect cells from oxygen
damage, and prevent excessive inflammation throughout the body. 30
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Green tea has flavonoid components called catechins that may reach 1 gram per cup. Cocoa,
apples, apricots, blueberries, pears, raspberries, strawberries, black beans, onions, parsley, pinto
beans, and tomatoes are also a rich source of flavonoids. 30
The possible role of flavonoids in relation to periodontal disease may be supported by an animal
study that 31 showed that although experimental periodontitis was induced in the rats fed a cocoa
enriched diet, they did not show impairments in serum reactive oxygen metabolite levels and the
GSH ratio was maintained within gingival tissues. Kushiyama et al. showed that the intake of
green tea was inversely correlated with mean pocket depth, mean clinical attachment level, and
bleeding on probing.
32
In a study by Tominari et al, Nobiletin ( a flavonoid) was shown to
restore the alveolar bone mass in a mouse experimental model for periodontitis by inhibiting
LPS-induced bone resorption.
33
Flavonoids may therefore provide a new therapeutic approach
for periodontal bone loss.
POLYUNSATURATED FATTY ACIDS (PUFA):
Adequate dietary intake of omega-3 polyunsaturated fatty acids (n-3 PUFAs) increases tissue
concentrations of the types of fatty acids (e.g. Eicosapentaenoic acid and docosahexaenoic Acid)
that downregulate inflammation.
34, 35
Studies suggest that n-3 PUFA metabolites may serve as
‘‘stop signals’’ for preventing neutrophil-mediated tissue damage.
36, 37
Studies in animals have
suggested a positive, modulating effect of n-3 PUFAs on gingival inflammation through
biomarker analysis,
38, 39
and there are also reports of reduced bone loss in a P. gingivalis
ligature-induced model of periodontitis.
40
Improved outcomes are attributed to the primary
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metabolites of omega-3 DHA). People with low DHA intake had an approximately 1.5 times
higher incidence rate ratio of periodontal disease progression. 41
DIETARY CALCIUM:
Calcium is the most abundant mineral in the human body. An adequate supply of vitamin D and
Calcium is essential for optimal skeleton growth. A continuous exchange of calcium exists
between the skeleton, blood, and other parts of the body, and is closely controlled by specific
hormones. Metabolites of vitamin D are important in this process by increasing the reabsorption
of calcium by the bones. 42 Vitamin D is needed for the absorption of dietary calcium . In adults,
calcium deficiency may lead to osteomalacia and osteoporosis. Animal as well as human studies
of calcium intake, bone mineral density, and tooth loss provide a rationale for hypothesizing that
low dietary intake of calcium is a risk factor for periodontal disease. 43, 44
ZINC:
Zinc is the second most abundant trace metal in the human body and is present in all living cells
and body secretions. 45 Zinc can support the body’s antioxidative defense system in several ways.
For instance, it can bind to proteins, making them less vulnerable to oxidative processes.
46
By
displacing reactive iron and copper ions from proteins and lipids, zinc can reduce the formation
of oxygen radicals. Further, zinc increases the activity of the catalase enzyme and functions as a
co - factor in copper/zinc superoxide dismutase, both of which are important enzymes in the
antioxidant defense system. Clinical studies have provided evidence that low plasma zinc
concentrations in older study participants are associated with higher concentrations of markers
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for oxidative stress and for pro-inflammatory cytokines.
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This could be corrected by targeted
dietary supplementation with zinc.
Rats and mice fed a zinc-deficient diet develop parakeratosis of normally orthokeratinized oral
mucosa.
48
In a study done it was found that oral health was better in a group of rats who fed
with a zinc containing diet than those fed with a zinc-deficient diet. Hence, zinc deficiency can
be a potential risk factor for oral and periodontal diseases. 49
CONCLUSION:
There are compelling evidences that a diet rich in fruits and vegetables is good for a healthy
lifestyle. Oral and general health cannot be looked independently. For prevention of oral disease,
diet should be supplemented natural antioxidants. Specific foods and combinations of various
micronutrients can be used to improve the response to therapies and can complement treatment
concepts. To correctly evaluate the relationship of dietary antioxidants and periodontal health,
further controlled clinical studies are needed.
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