Dietary Protein to Support Periodontal Health: An Update

Dietary Protein, Canada’s Food Guide and Health

We all know that dietary protein is integral for our health, keeping our muscles strong. But what about our oral health? Does dietary protein have a role in the health of our gums and teeth? Does the source of the protein matter? The question around protein source, plant versus animal, has a heightened interest as the latest version of Canada’s Food Guide (CFG) – published in 2019 – states that we should “choose protein foods that come from plants more often” for overall health.¹

The focus on plants is evidence-based. There is strong scientific evidence that consuming higher intakes of plant-based foods – including fruit, vegetables, nuts, seeds, legumes and tofu – is linked with reduced risk of cardiovascular disease, colon cancer, and type 2 diabetes.^2-7 The reduced risk of diseases may be mediated by improvements in blood lipid profile and higher fibre intake, though the precise mechanisms continue to be studied. Increasing our intake of plants and other whole foods also encourages a more healthful dietary pattern by lowering the consumption of processed foods via displacement.

Moreover, the reasons for incorporating more plant foods in our diet can go beyond Canada’s Food Guide, as consuming more plants may also have environmental benefits by conserving soil, water, and air compared to other food production.^8-11 Plant-based diets are also gaining popularity due to the various ethical concerns related to the preparation of animal-based foods.¹²

Protein and Periodontal Health

Studies investigating the relationship between protein and oral or periodontal health are less in number compared to studies that have demonstrated positive associations between plants or plant-based foods and the risk of chronic diseases discussed earlier in this article. However, several recent studies have investigated the relationship between protein and oral and periodontal health. These studies have shown that consuming protein at the recommended or higher than recommended intake level is associated with better periodontal health.^13-17 This is not surprising given that dietary protein is a building block for bone and the periodontium and plays a role in the protection and repair of the periodontal tissue.

In a study of American adults, more natural teeth were positively associated with protein intake, while having fewer natural teeth was associated with lower diet quality that included lower protein intake.¹⁴ Thus, individuals with fewer teeth may be at risk of insufficient protein intake, further challenging oral health status. Two cross-sectional studies that included large groups of individuals (N=12,689 adults aged ≥ 19 years, and N=7935 aged ≥ 40 years) showed that individuals with periodontal disease (defined as the presence of periodontal pocket depths ≥ 4 mm) consumed less protein, including meat, fish, eggs, and legumes compared to individuals without periodontal disease.^15,18 These findings demonstrate the interconnectedness between sufficient protein intake and oral health. It is also interesting to note that dietary protein intake in childhood may be an important indicator of adolescent oral health. In a retrospective cohort study of adolescents (12-19 years of age), protein-energy malnutrition in early childhood was related to poor periodontal status as adolescents.¹⁹ In contrast, higher protein consumption may benefit healing after treatment for periodontal disease. A study in patients who underwent non-surgical periodontal therapy (sanative therapy) demonstrated a positive association between patients who had higher intakes of protein (>1 g protein/kg body weight/day versus ≤1 g protein/kg body weight/day) and fewer periodontal probing depths greater than 4 mm by 8 to 12 weeks post-procedure.¹⁷ Notably, this relationship was observed in patients who were non-smokers, whereas no association was observed among current smokers. Determining cause and effect and studying this relationship in larger cohorts is warranted to more fully elucidate the role of dietary protein for healing after periodontal procedures.

Plant-Based Protein and Periodontal Health

When considering the health benefits of plant-based protein food sources, it is relevant to consider what specific plant components may contribute. For example, fruits and vegetables, whole grains, nuts and seeds contain polyphenols and fibre, which can play a role in reducing oxidative stress and inflammation.²⁰ Protein also helps to increase our body’s ability to absorb calcium, an essential building block for both tooth and bone health – and, in terms of oral health, helps support the mineralization of jaw bone. Dietary protein also increases the production of insulin-like growth factor-1, which favourably stimulates bone cell activity and increases collagen and other bone matrix proteins. These key components interact with minerals for strong bone. Consuming recommended dietary protein levels may support periodontal and bone health through these mechanisms (Fig. 1).

Fig. 1

A study from the US showed that a high dietary quality was associated with a lower risk of severe periodontitis. Specifically, the high nutritional quality included a higher consumption of fruit and whole grains associated with less severe periodontal disease.²¹ Another study showed that higher consumption of nuts was associated with a lower mean probing depth and risk of periodontal disease.¹⁸ These associations may be partly mediated by the presence of these plant-specific components: polyphenols and fibre.

The Mediterranean diet – characterized by a high intake of plant-based foods (vegetables, fruit, nuts, whole grains, legumes, olive oil) and fish – has been associated with better periodontal health.^22-24 In one study, low adherence to the Mediterranean diet and physical inactivity markedly increased the risk of periodontal disease.²⁵ A four-week randomized clinical trial investigating dietary protein sources and periodontal health concluded that a diet rich in vegetables, legumes, nuts, and seeds was more beneficial to oral health than an omnivorous, high-carbohydrate diet.²⁵ There was a favourable effect on periodontal probing depth and clinical attachment loss.²⁵ Another study showed that a higher intake of red meat was positively associated with greater periodontal probing depth and bleeding on probing.²¹ Similarly, a lower consumption of red and/or processed meat was associated with a reduced probability of developing periodontitis.²¹

While Canada’s Food Guide recommends that a quarter of each meal be protein, there is also a dietary reference intake to calculate adequate protein intake based on body weight (0.8 g of protein per kg of body weight per day). This level of protein does not differ by sex or adult age. So, an individual weighing 73 kg (or 160 pounds) should consume approximately 58 g of protein daily to meet basic physiological needs. What foods could be consumed to meet this amount of protein? Two cooked eggs in the morning, one serving of Greek yogurt, 2 ounces (two small handfuls) of nuts at lunch or as snacks, and a salmon filet for dinner equates to approximately 58 g of protein (Fig. 2). As shown in Figure 2, additional protein can come from many other foods, including vegetables and whole-grain foods that are part of meals throughout the day. There is growing interest in whether the level of 0.8 g of protein per kg body weight per day is appropriate for all ages for optimal health. In particular, there is interest in whether higher levels of dietary protein may help to attenuate loss of muscle mass and strength with aging. This remains an active area of study.

Fig. 2

Individuals consuming a more plant-based diet is increasing.²⁶ Global sales of plant-based meat foods have increased 8% annually since 2010.²⁷ About 40% of Canadians are incorporating more plant-based foods into their diets, and according to Leger Research from 2021, 67% of Canadians consume plant-based foods frequently.²⁷ The impact of these trends on health remains to be seen.

Considerations for Consuming Plant-Based Protein Foods

As shown in Figure 2, the amount of protein per serving size is relatively less in plant-based protein foods compared to dairy products (animal-based protein food) or animal protein (eggs, meats, fish). Thus, to ensure the daily recommended intake for protein is met, a wide variety of plant-based protein foods should be consumed. Also, it is essential to consider other differences in nutrient levels that are important for bone and tooth health, such as vitamin D and calcium. For example, dairy products such as cow’s milk and yogurt are excellent sources of calcium and vitamin D, and arguably, it can be more challenging to meet the recommended intake of these nutrients if not consuming these foods. Plant beverages, often fortified with calcium and vitamin D to be at the levels in cow’s milk, can also contribute calcium and vitamin D to the diet. The yellow boxes on the food images shown in Figure 2 identify specific plant sources with higher levels of calcium and/or vitamin D. In periodontal health, calcium is essential for maintaining and forming the calcified tissues of the teeth.²⁸ While it is still unclear whether serum vitamin D levels directly affect periodontal health, vitamin D enhances calcium absorption, which can, in turn, positively affect bone and tooth health.²⁸

Tips:

• A healthy diet and adequate protein consumption are associated with positive overall and oral health. As per Canada’s food guide, aim for a quarter of each meal to contain protein and choose plant sources more often.
• More information about Canada’s food guide for healthy eating can be found at: https://food-guide.canada.ca/en/. This website provides detailed guidance about healthy food choices and healthy eating habits, essentially ‘what to eat’ and ‘how to eat.’
• Subscribe to e-mail updates about Canada’s Food Guide, including recipes, at: https://www.canada.ca/en/health-canada/services/canada-food-guide/subscribe.html
• A helpful resource to check the nutrient content and profile of a food is the Canadian Nutrient File (CNF): https://food-nutrition.canada.ca/cnf-fce/?lang=eng
• For general bone health, ensure adequate calcium and vitamin D intake, particularly if not regularly consuming dairy foods or plant-based beverages fortified with calcium and vitamin D.

Oral Health welcomes this original article.

References

1. Canada’s Food Guid e. (2023, June 8). Food guide snapshot, healthy eating recommendations, recipes, tips and resources. Government of Canada. https://food-guide.canada.ca/en/
2. Hartley, L., Igbinedion, E., Holmes, J., Flowers, N., Thorogood, M., Clarke, A., … & Rees, K. (2013). Increased consumption of fruit and vegetables for the primary prevention of cardiovascular diseases. Cochrane Database of Systematic Reviews, (6).
3. Koushik, A., Hunter, D. J., Spiegelman, D., Beeson, W. L., Van Den Brandt, P. A., Buring, J. E., … & Smith-Warner, S. A. (2007). Fruits, vegetables, and colon cancer risk in a pooled analysis of 14 cohort studies. Journal of the National Cancer Institute, 99(19), 1471-1483.
4. Li, M., Fan, Y., Zhang, X., Hou, W., & Tang, Z. (2014). Fruit and vegetable intake and risk of type 2 diabetes mellitus: meta-analysis of prospective cohort studies. BMJ open, 4(11), e005497.
5. Quek, J., Lim, G., Lim, W. H., Ng, C. H., So, W. Z., Toh, J., … & Chew, N. W. (2021). The association of plant-based diet with cardiovascular disease and mortality: a meta-analysis and systematic review of prospect cohort studies. Frontiers in cardiovascular medicine, 1389.
6. Richter, C. K., Skulas-Ray, A. C., Champagne, C. M., & Kris-Etherton, P. M. (2015). Plant protein and animal proteins: do they differentially affect cardiovascular disease risk?. Advances in nutrition, 6(6), 712-728.
7. Vieira, A. R., Abar, L., Chan, D. S. M., Vingeliene, S., Polemiti, E., Stevens, C., … & Norat, T. (2017). Foods and beverages and colorectal cancer risk: a systematic review and meta-analysis of cohort studies, an update of the evidence of the WCRF-AICR Continuous Update Project. Annals of Oncology, 28(8), 1788-1802.
8. Reynolds, A. N., Mhurchu, C. N., Kok, Z. Y., & Cleghorn, C. (2023). The neglected potential of red and processed meat replacement with alternative protein sources: Simulation modelling and systematic review. Eclinicalmedicine, 56, 101774.
9. González, N., Marquès, M., Nadal, M., & Domingo, J. L. (2020). Meat consumption: Which are the current global risks? A review of recent (2010–2020) evidences. Food Research International, 137, 109341.
10. Machovina, B., Feeley, K. J., & Ripple, W. J. (2015). Biodiversity conservation: The key is reducing meat consumption. Science of the Total Environment, 536, 419-431.
11. Reynolds, C. J., Buckley, J. D., Weinstein, P., & Boland, J. (2014). Are the dietary guidelines for meat, fat, fruit and vegetable consumption appropriate for environmental sustainability? A review of the literature. Nutrients, 6(6), 2251-2265.
12. Parlasca, M. C., & Qaim, M. (2022). Meat consumption and sustainability. Annual Review of Resource Economics, 14, 17-41.
13. Choowong, P., Wali, J. A., Nguyen, A. T. M., Jayasinghe, T. N., & Eberhard, J. (2022). Macronutrient-induced modulation of periodontitis in rodents—a systematic review. Nutrition Reviews, 80(5), 1160-1178.
14. Zhu, Y., & Hollis, J. H. (2014). Tooth loss and its association with dietary intake and diet quality in American adults. Journal of dentistry, 42(11), 1428-1435.
15. Hwang, S. Y., & Park, J. E. (2022). The Relationship Between Periodontal Disease and Nutrient Intake in Korean Adults: The Korea National Health and Nutrition Examination Survey (KNHANES VII) from 2016–2018. Oral Health Prev. Dent, 20, 313-320.
16. Jayasinghe, T. N., Harrass, S., Erdrich, S., King, S., & Eberhard, J. (2022). Protein Intake and Oral Health in Older Adults—A Narrative Review. Nutrients, 14(21), 4478.
17. Dodington, D. W., Young, H. E., Beaudette, J. R., Fritz, P. C., & Ward, W. E. (2021). Improved Healing after Non-Surgical Periodontal Therapy Is Associated with Higher Protein Intake in Patients Who Are Non-Smokers. Nutrients, 13(11), 3722.
18. Lee, M. R. (2023). Relationship between Diet Quality and Periodontal Disease in South Korean Adults Aged ≥ 40 Years. International Journal of Environmental Research and Public Health, 20(6), 5039.
19. Russell, S. L., Psoter, W. J., Jean-Charles, G., Prophte, S., & Gebrian, B. (2010). Protein‐energy malnutrition during early childhood and periodontal disease in the permanent dentition of Haitian adolescents aged 12–19 years: a retrospective cohort study. International journal of paediatric dentistry, 20(3), 222-229.
20. Ginwala, R., Bhavsar, R., Chigbu, D. G. I., Jain, P., & Khan, Z. K. (2019). Potential role of flavonoids in treating chronic inflammatory diseases with a special focus on the anti-inflammatory activity of apigenin. Antioxidants, 8(2), 35.
21. Salazar, C. R., Laniado, N., Mossavar-Rahmani, Y., Borrell, L. N., Qi, Q., Sotres-Alvarez, D., Morse, D. E., Singer, R. H., Kaplan, R. C., Badner, V., & Lamster, I. B. (2018). Better-quality diet is associated with lower odds of severe periodontitis in US Hispanics/Latinos. Journal of clinical periodontology, 45(7), 780–790.
22. Bartha, V., Exner, L., Schweikert, D., Woelber, J. P., Vach, K., Meyer, A. L., … & Wolff, D. (2022). Effect of the Mediterranean diet on gingivitis: A randomized controlled trial. Journal of Clinical Periodontology, 49(2), 111-122.
23. Iwasaki, M., Ennibi, O. K., Bouziane, A., Erraji, S., Lakhdar, L., Rhissassi, M., … & Miyazaki, H. (2021). Association between periodontitis and the Mediterranean diet in young Moroccan individuals. Journal of periodontal research, 56(2), 408-414.
24. Marruganti, C., Traversi, J., Gaeta, C., Ferrari Cagidiaco, E., Parrini, S., Discepoli, N., & Grandini, S. (2022). Adherence to Mediterranean diet, physical activity level, and severity of periodontitis: Results from a university‐based cross‐sectional study. Journal of Periodontology, 93(8), 1218-1232.
25. Eberhard, J., Ruiz, K., Tan, J., Jayasinghe, T. N., Khan, S., Eroglu, E., … & Ribeiro, R. V. (2022). A randomized clinical trial to investigate the effect of dietary protein sources on periodontal health. Journal of Clinical Periodontology, 49(4), 388-400.
26. Zumbo, G., Costacurta, M., Zara, F., Pranno, N., Ceravolo, M., Covello, F., … & Vozza, I. (2022). Diet implications and oral health status of women in central Italy. European Journal of Dentistry, 16(03), 557-563.
27. National Research Council Canada. (2022, August 12). Plant-based protein market: global and Canadian market analysis– Executive summary. Government of Canada. https://nrc.canada.ca/en/research-development/research-collaboration/programs/plant-based-protein-market-global-canadian-market-analysis
28. Najeeb, S., Zafar, M. S., Khurshid, Z., Zohaib, S., & Almas, K. (2016). The role of nutrition in periodontal health: an update. Nutrients, 8(9), 530.

---

About the Author

Mitchell Ianiero is an MSc student in Health Sciences at Brock University, studying how polyphenols in tea affect metabolic health. Mitchell recently graduated from the Bachelor of Science in Medical Sciences program at Brock University.

Wendy Ward is a Professor and Senior Research Fellow in the Faculty of Applied Health Sciences at Brock University. Her research team investigates how diet can support bone and periodontal health.