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Nutrition and Oral Health: A Review
Article in Indian Journal of Applied Research · November 2015
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Research Paper Medical Science Volume : 5 | Issue : 11 | November 2015 | ISSN - 2249-555X
Nutrition and Oral Health: A Review
oral health, nutrition, diet, malnutrition, dental caries, cariogenic, periodontal disease,
Keywords dental erosion, oral cancer,
Dr. Abhishek Ghosh Dr. Pallavi SK
BDS, MDS, Assistant Professor, Dept. of Public Health BDS, MDS, Associate Professor, Dept. of Public Health
Dentistry, Mithila Minority Dental College & Hospital, Dentistry, VS Dental College & Hospital, VV Puram,
Mansukh Nagar, Darbhanga, Bihar, India Bengaluru-560004, Karnataka, India
Dr. Bhuvan Nagpal Dr. Usha Hegde
BDS, (MDS), Post Graduate Student, Dept. of Oral
BDS, MDS, Professor & Head, Dept. of Oral Pathology
Pathology & Microbiology, JSS Dental College &
& Microbiology, JSS Dental College & Hospital, JSS
Hospital, JSS University, Mysuru- 570015, Karnataka,
University, Mysuru- 570015, Karnataka, India
India
Dr. Archana S Mrs. Jyoti Nagpal
BDS, (MDS), Post Graduate Student, Dept. of Oral
B. Sc., M. Sc. (Foods & Nutrition), Associate Professor
Pathology & Microbiology, JSS Dental College &
& Head, Dept. of Home Science, M. M. PG College,
Hospital, JSS University, Mysuru- 570015, Karnataka,
Fatehabad - 125050, Haryana, India
India
ABSTRACT Oral health is related to diet in many ways; e.g. influence of nutrition on craniofacial development, infec-
tious diseases of the oral cavity and oral cancer. Oro-dental diseases impact considerably on self-esteem
and quality of life and are expensive to treat. Nutrition affects the teeth as well as oral cavity during development and
malnutrition may exacerbate periodontal and oral infectious diseases. Diet plays an important role in the prevention of
oro-dental diseases including dental caries, dental erosion, developmental defects, oral mucosal diseases and periodon-
tal diseases. However, the most significant effect of nutrition on teeth is the local action of diet in the mouth on the de-
velopment of dental caries and dental erosion. The objective of this paper is to review the evidence for an association
between nutrition, diet and dental diseases and to present dietary recommendations for their prevention.
Introduction through the anaerobic metabolism of sugars found in the
Nutrition can be considered as a core pillar of human de- diet.5 The evidence linking dietary sugar to caries comes
velopment.1 In the last two centuries, there has been a from a number of different types of study, namely; human
general improvement in the health of people worldwide intervention studies, human observational studies, animal
attributed largely to changes in nutrition, hygiene and studies, enamel slab experiments, plaque pH experiments
public health. Nutrition can be defined as the study of nu- and incubation experiments. Collected evidence from each
trients in food, how the body uses nutrients, and the rela- study type gives an overall picture of the cariogenic poten-
tionship between diet, health and disease and how food tial of sugars and other foods.6
affects the body. It is the adequate provision of vitamins,
minerals, fiber, water and other food components to cells Numerous cross-sectional studies attempting to indicate a
and organisms, to support life.2 World Health Organiza- relationship between sugar consumption and dental caries
tion (WHO) defines malnutrition as the cellular imbalance have been carried out, of which Rugg-Gunn in 1993 has
between supply of nutrients and energy and the body’s presented a comprehensive summary. The experimental
demand for them to ensure growth, maintenance, and spe- design varies widely between cross sectional studies and
cific functions. Malnutrition can either be over-nutrition or often only the correlation coefficient and not the absolute
under-nutrition.3 Nutrition is an integral component of oral dental caries experience is reported. Even when significant
health. There is a continuous synergy between nutrition relationships have been found, absolute differences in den-
and the integrity of the oral cavity in health and disease. tal caries experience have sometimes been small. In other
Nutrition affects oral health, and oral health affects nutri- studies, large differences in absolute values for decayed,
tion. This interdependent relationship sees good nutritional missing and filled deciduous teeth have been found be-
health, promoting good oral health and vice versa.4 tween high and low sugar consumers but numbers have
been insufficient for statistical significance.7
Nutrition and Dental Caries
Dental caries is demineralization of the inorganic part of Granath et al. found a significant relationship between sug-
the tooth with the dissolution of the organic substance ar consumption between meals and dental caries, which
due to a multifactorial etiology. The demineralization of was independent of fluoride intake or oral hygiene prac-
the enamel and of the dentine is caused by organic acids tices.8 Children with low sugar intake between meals had
that form in the dental plaque because of bacterial activity, significantly fewer caries than children with high sugar con-
546 X INDIAN JOURNAL OF APPLIED RESEARCH
Research Paper Volume : 5 | Issue : 11 | November 2015 | ISSN - 2249-555X
sumption between meals. Studies of older children have
7
of current interest and further research into the role of free
found the relationships between oral hygiene, water fluori- radicals and dietary antioxidants in relation to periodontal
dation, Streptococcus mutans and dental caries to be more disease is expected. Vitamin A is intimately involved in ep-
important than the relationship between sugar intake and ithelial maintenance and so deficiency is likely to influence
dental caries.5 Human intervention studies in the field of the gingiva. In 1962, Shaw reviewed the evidence from
diet and dental caries are rare owing to ethical problems animal studies on the relationship between vitamin A de-
and the difficulty of placing groups of people on strict die- ficiency and periodontal disease and found that gingivitis,
tary regimens for long periods of time. The only two stud- gingival hypoplasia, proliferation of crevicular epithelium
ies from which conclusive evidence can be drawn are the and resorption of alveolar bone were all associated with
Vipeholm study9 and the Turku study.10 deficiency of vitamin A. Evidence exists from early animal
studies which has shown that deficiency of nicotinic acid,
Frequency of sugar consumption is undoubtedly an im- pantothenic acid, riboflavin and folic acid results in gingival
portant factor in the etiology of dental caries, but there inflammation.14 An epidemiological study by WHO done
is also evidence that amount of sugar consumed influ- in Sri Lanka investigated the relationship between vitamin
ences dental caries development independently of fre- deficiencies and periodontal diseases, has shown that de-
quency, suggesting that both factors are important. ficiency of vitamin B complex were associated with lower
Rugg-Gunn and Mikx et al. carried out a study in which resistance to bacterial irritants. Deficiency of most B com-
five groups of rats received diets of varying sugar concen- plex vitamins is rare in modern society and the only B vi-
tration and found a significant positive correlation between tamin which is of current interest in relation to periodon-
the sucrose concentration and the incidence of dental car- tal disease is folic acid. Owing to its high cellular turnover
ies.7,11 rate gingival epithelium is especially vulnerable to folic
acid deficiency, which reduces the ability of this tissue to
Animal studies have compared the relative cariogenic- function as a barrier against bacterial insults.15
ity of different sugars. A theory existed that sucrose was
uniquely cariogenic because consumption resulted in dex- Vitamin C has well established functions in the mainte-
tran formation and increased plaque volume.5 Studies done nance of periodontal tissues. It has a key role in collagen
on rats have shown sucrose to be more cariogenic than synthesis which is important for the maintenance of the
fructose, maltose, lactose or glucose but the rats were su- periodontal ligament, gingiva, alveolar bone and blood
perinfected with Streptococcus mutans which preferentially vessel walls. The immunological role of vitamin C is also
take up and utilize sucrose.5,11 The cariogenicity of un- important in determining host resistance to plaque micro-
cooked starch is very low but this is seldom consumed by organisms. Animal studies have demonstrated that acute
humans. Finely ground and heat treated starch can cause vitamin C deficiency results in oedema and haemorrhage
dental caries but to a much lesser extent than sucrose. in the periodontal ligament, osteoporosis of the alveolar
There is little evidence to show that cooked staple foods bone, tooth mobility and degeneration of the collagen fi-
such as rice, potatoes, and bread are cariogenic as con- bres of the gingivae.16 Epidemiological studies in humans
sumed by humans.12 Manufactured foods, in which starch is have failed to demonstrate a relationship between vitamin
heat treated and hydrolyzed and especially if mixed with C and gingival health or disease.17 This is probably be-
sugars, form a potential threat to teeth. The addition of cause gingivitis and periodontitis are of multifactorial etiol-
sugar greatly increases the cariogenicity of cooked starch- ogy. Patients with severe scurvy can have healthy gingivae,
es. Less refined starchy foods contain protective factors but a deficiency of vitamin C can exacerbate an existing
and it has been suggested that their fibrous nature may gingivitis. Another study reported that a daily supplement
aid removal of plaque and food from the mouth, although of 70 mg ascorbic acid for six weeks produced marked
only from exposed surfaces.13 changes in the ultrastructure of the epithelium and con-
nective tissue of the periodontium. Desmosomal junctions
Nutrition and Periodontal Disease between epithelial cells became longer and the contact
One of the oldest observations on nutrition and periodon- surface between cells increased.18 Dachi et al. found that
tal health is James Lind’s account of scurvy in the first con- vitamin C supplementation was unable to reduce gingival
trolled therapeutic trial conducted in 1747. Before Loe et sulcus depth in healthy dental students, but it is unlikely
al. published their work on the bacterial causation of gin- that these subjects were deficient.19 Vitamin C and other
givitis in 1965, nutritional and other systemic factors were antioxidant nutrients may be important in protection of the
assumed to be virtually exclusively responsible for peri- gingiva from oxidative damage. It has also been suggest-
odontal diseases, even though it had become clear that ed that free radicals play a role in collagen destruction in
vitamin C deficiency could only explain a small segment of periodontitis by Asman et al.20
the problem. Periodontitis is a ubiquitous chronic inflam-
matory disease affecting the supporting structures of the There exists a relationship between calcium intake and
teeth and if not promptly recognized and correctly man- periodontal diseases. This may be due to calcium’s role
aged can ultimately lead to tooth loss resulting in reduced in building density in the alveolar bone that supports the
masticatory function and subsequent alterations in dietary teeth. Calcium is necessary for healthy bones, teeth, mus-
intake and nutritional status. Periodontal disease evolves cle contractions and other functions. The ratio of calcium
more quickly in undernourished populations. The pathol- to phosphorus in the diet is also important since secondary
ogy starts in the gingiva and could involve the periodontal hyperparathyroidism causes marked loss of alveolar bone.
ligament up to the alveolar bone. The most important risk The composition of the diet can affect the amount and
factor in the development of periodontal disease is repre- consistency of plaque. Sugar consumption can increase
sented by inadequate oral hygiene.14 the volume of plaque - the major etiological agent in peri-
odontal disease. Reduction in sugar consumption is not,
Role of vitamins have been extensively researched in re- however, a pragmatic approach to plaque control, because
lation to periodontal diseases. Deficiencies of vitamin A, the maximum practical reduction in dietary sugar is not ca-
C, E and folate have detrimental effects on periodontal pable of preventing gingivitis. Likewise consumption of fi-
health. The role of folate in the prevention of gingivitis is brous foods is not a substitute for tooth brushing.20
INDIAN JOURNAL OF APPLIED RESEARCH X 547
Research Paper Volume : 5 | Issue : 11 | November 2015 | ISSN - 2249-555X
Another study found that supplementing the diet with su- Poor salivary flow or saliva deficiency is thought to make
crose increased plaque volume and this was not observed some individuals more susceptible to acid challenges. Low
when the diet was supplemented with glucose. In studies salivary flow rate or inadequate buffering capacities are
of human experimental gingivitis, higher bleeding scores factors that exacerbate dental erosion. Intrinsic acids are
have been shown to occur on high carbohydrate rich diet from vomiting and regurgitation of acid from stomach to
compared to low carbohydrate rich diet and frequent sug- oral cavity. The extrinsic acids are from the diet i.e. citric
ar intake increased gingival inflammation. However, the acid, phosphoric acid, ascorbic acid, malic acid, tartaric
maximum reduction in sugar in the diet within the limits acid and carbonic acids found in fruits and fruit juices, car-
of practicality is not capable of preventing gingivitis.21 Ac- bonated soft drinks and still, some herbal teas, dry wines
cording to one retrospective cohort study which was con- and vinegar containing foods. The critical pH of enamel is
ducted to examine whether an exposure to Early Child- 5.5 and therefore, any drink or food with a lower pH may
hood Protein-Energy Malnutrition (ECPEM) was related to cause dental erosion.6
a worsened periodontal status in the permanent dentition
during adolescence, revealed that ECPEM was related to The evidence for an etiological role of diet in the devel-
a poorer periodontal status. Because ECPEM is likely to af- opment of dental erosion comes from clinical trials, human
fect the developing immune system, a person’s ability to observational studies, experimental clinical studies, animal
respond to the colonization with the periodontal patho- studies, case reports and experiments in vitro. Thomas
gens may be adversely affected permanently.22 showed that students who consumed either grapefruit
juice, orange juice or cola daily for 6 weeks had signs of
Malnutrition and Oral Health dental erosion on the labial surface of incisors and that this
Malnutrition is a multifactorial disease that can have an was greatest with grapefruit juice.5 In a case–control study
early onset during the intrauterine life or childhood or it done by Jarvinen et al., it was found that the dietary prac-
can occur during an individual’s lifetime as a result of poor tices associated with dental erosion were consumption of
nutrition. Malnutrition appears to have multiple effects on citrus fruits twice or more per day, consumption of soft
the oral tissues and the subsequent oral disease develop- drinks once per day and consumption of vinegar or sports
ment. It affects the development of the oral cavity and drinks more than once a week. Other risk factors includ-
the progression of the oral diseases through altered tissue ed are eating disorders which are largely due to effect of
homeostasis, a reduced resistance to the microbial biofilm intrinsic acids on vomiting, gastro-esophageal reflux dis-
and a reduced tissue repair capacity.4 ease and a low salivary flow rate.25 The United Kingdom
National Diet and Nutrition Survey on young people aged
Teeth are affected during their formation by nutrition. De- 4–18 years showed that the prevalence of dental erosion
ficiency of nutrients can result in defective enamel forma- increased with age in high, moderate and low amount
tion (enamel hypoplasia) which has aesthetic disadvantages of soft drink consumption. The age-related increase was
and which may increase the susceptibility to dental caries. greatest in the highest amounts of soft drink consump-
Malnutrition can also increase the risk of dental caries by tion.4 Experimental clinical studies have shown that con-
affecting the salivary glands so that the flow rate is re- sumption of, or rinsing with acidic beverages significantly
duced and the composition of saliva changed. In poorly lowers the pH of the oral fluids and this is most marked
nourished communities where sugar is available, malnutri- with grapefruit juice. Miller made the important observa-
tion may increase caries risk by causing defective enamel tion that fruit juices were 3–10 times more destructive than
development and salivary gland atrophy. Defective enamel whole fruit in rats. However, due to differences in drinking
appears to stem from hypocalcaemia associated with mal- technique and salivary flow and composition, there are dif-
nutrition and is also caused by vitamin D deficiency. De- ficulties in extrapolating the findings of these studies to
ficiency of vitamin D and vitamin A and Protein Energy humans.26
Malnutrition (PEM) have been associated with the enamel
hypoplasia. PEM and vitamin A deficiency are also associ- Most of the reports on diet and dental erosion have been
ated with salivary gland atrophy, which subsequently re- single case reports and have shown that extensive dental
duces the defense of the oral cavity against infection and erosion has been associated with sucking lemon wedges,
its ability to buffer the plaque acids.6 drinking cola continuously or holding cola in the mouth,
addition of baby fruit juices to comforters or reservoir
It was found that malnutrition was an etiological factor in feeders, or mega doses of chewable vitamin C. In-vitro
dental hypoplasia which resulted in increased susceptibil- experiments supplement the clinical evidence for an as-
ity to caries. Despite a general consensus that malnutrition sociation between diet and dental erosion but vary wide
increased defective enamel formation, the mechanism for in methodology. However, in general such studies have
this was uncertain.23 It was not until 1981 that Nikiforuk & shown that beverages with a high acidity or a pH 4 can
Fraser showed hypoplasia to be associated with hypocal- lead to dental erosion. Fruit juices have also been shown
caemia, which is a common occurrence in malnutrition due to be more erosive than pulped fruits. Citric, malic and tar-
to chronic diarrhea.24 While dental caries occurs in afflu- taric acids are particularly erosive and carbonic acid is the
ent communities with a good nutritional status, it is rare least erosive.6
in many communities in which malnutrition is widespread.
However, when developing countries are exposed to sugar To summarize, dental erosion appears to be an increas-
in the diet, the level of dental caries is greater than ex- ing problem in industrialized countries and is related to
pected from experience in developed countries. This ob- extrinsic and intrinsic acids. Factors such as salivary flow,
servation has led to the suggestion that malnutrition en- fluoride, calcium and phosphate may protect against den-
hances the cariogenic effect of sugar.6 tal erosion although there is no consensus as to how ef-
fective these factors are in prevention. Overall, there is a
Nutrition and Dental Erosion need for more comprehensive population-based studies on
Dental erosion is progressive irreversible loss of dental tis- the prevalence of dental erosion using a standard index of
sues which are chemically eroded by extrinsic and intrinsic measurement. The longitudinal patterns of the dental ero-
acids through a process that does not involve bacteria. sion in populations need to be monitored and related to
548 X INDIAN JOURNAL OF APPLIED RESEARCH
Research Paper Volume : 5 | Issue : 11 | November 2015 | ISSN - 2249-555X
changes in dietary factors. 4
In a recent research it is shown that lycopene can exert
protective effects against 4-nitroquinoline-1-oxide induced
Nutrition and Oral Cancer tongue carcinogenesis through reduction in cell prolif-
The association between nutrition and oral cancer is ex- eration and enhanced cellular adhesion, suggesting a new
tremely serious. Oral cancer is a pathology that is diag- mechanism for the anti-invasive effect of lycopene.27 In a
nosed in three hundred thousand new cases in the world recent report which has shown that diets rich in animal or-
every year and presents the greatest incidence in peo- igin and animal fats are positively, and those rich in fruit
ple who smoke, chew tobacco, and consume alcohol. and vegetables and vegetable fats inversely related to oral
The use of tobacco can alter the distribution of nutrients and pharyngeal cancer risk.28
such as antioxidants, which develops protective action to-
wards the cells. The study on the incidence of oral cancer Malnutrition also interferes negatively with humoral and
has underlined the possibility that diet and nutrition can cellular immune competence and with tissue and repara-
represent an important etiological factor for oral carcino- tive functions. In addition, the alteration of the liver func-
genesis. Vitamins A, E, C, and Beta Carotene have anti- tion can change the way drugs are metabolized. Therefore,
oxidant properties. They neutralize metabolic products, malnutrition can interfere with oncological therapy and in-
interfere with the activation of pro-carcinogens, inhibit crease the severity of the collateral effects4.
chromosomal aberrations and potentially inhibit the growth
of potentially malignant lesions.4 Conclusion
Nutrition is a major modifiable determinant of chronic dis-
The mechanism that connects smoke to this disease has ease, with scientific evidence increasingly supporting the
not been discovered but some progress has been made. view that alterations in diet have strong effects, both posi-
Smoke modifies the distribution of protective substances tive and negative, on health throughout life. Most impor-
such as folic acid and some antioxidants. A rebalancing tantly, dietary adjustments may not only influence present
of nutrients obtained through diet can modify the altered health, but may determine whether or not an individual
distribution caused by the consumption of tobacco. In an will develop such diseases as cancer, cardiovascular dis-
unbalanced diet, there is a depletion of antioxidant nutri- ease and diabetes much later in life. However, these con-
ents. Fruit and vegetables have, vice versa, important an- cepts have not led to a change in policies which are prac-
tioxidant properties. Many micronutrients, vitamins in par- ticed. In many developing countries, food policies remain
ticular are used in chemoprevention programs formulated focused only on under-nutrition and are not addressing
by the US National Cancer Institute.6 The National Cancer the prevention of chronic diseases. There is an increasing
Institute and the American Cancer Society have estab- need to prevent and control the public health problems
lished some prudential dietary recommendations for the of chronic diseases by promoting appropriate diets and
choice of food; maintain a desirable body weight, eat a healthy lifestyles.
varied diet, include a new variety of fruits and vegetables
in the daily diet, consume a greater quantity of foods rich
in fibre, decrease the total intake of fats (30% less than the
total calories), limit the consumption of alcohol, limit the
consumption of salted foods or foods preserved with ni-
trates.5
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