The importance of nutrition to dental health has been common knowledge for a long time. Several studies demonstrate this close correlation and highlight the circuitous relationship between malnutrition, infectious disease (such as periodontal disease), and the immune system. Infections promote malnutrition and malnutrition elicits auto-immune dysfunction; this impaired immunity, in turn, intensifies the infectious disease.1
At the practical level, however, knowing the important role that vitamins, minerals, antioxidants and cofactors play in tooth development and oral health has not culminated in dentists recommending that their patients eat more spinach or take their vitamins. The profession has been content to simply limit its counseling to sugar reduction. Some track record: in the 1800s the per capita consumption of sugar (sucrose) was about 5.5 kilograms per year. Today, consumption exceeds 134 kilograms per person per year.
THE OLD PARADIGM
For decades the concept of nutritional supplementation was disregarded as frivolous and unnecessary. In the early 80s, the Journal of the American Medical Association’s comprehensive review of vitamins concluded that people of normal health did not need to take a multivitamin; they could instead meet all their nutritional needs through diet. The review supported the contention that the Recommended Dietary Allowances (RDAs), established by the U.S. National Academy of Sciences, were sufficient to provide the necessary daily intake of vitamins, minerals and trace elements.
The problem is, the RDAs were based on the minimum criteria necessary to avoid acute disease states such as scurvy, pellagra and rickets, caused by nutritional deficiencies. They do not reflect the level of nutrient intake required for optimal health and the avoidance of chronic degenerative diseases, so much a part of our modern lifestyle. The RDAs are not age-related or gender-related; they do not consider physiological status (e.g. pregnancy) or concurrent disease states. They are simply levels that are unlikely to cause harm.2
Twenty years later, the AMA has completely reversed its previous anti-vitamin stance and now encourages all adults to supplement with a multiple vitamin. This “sea change” is a result of a landmark review of 38 years of scientific evidence by Harvard researchers, Dr. Robert Fletcher and Dr. Kathleen Fairfield. In two reports, published in the June 19, 2002 edition of JAMA, the authors conclude that the current North American diet is simply inadequate to support optimal health.3,4 The authors state that sub-optimal levels of vitamin intakes, even well above those causing deficiency syndromes, are risk factors for chronic diseases, such as cardiovascular disease, cancer and osteoporosis.
Based on these remarkable findings, the AMA now concludes that, given today’s diet, supplementation with a multiple vitamin is a prudent preventive measure.
Like our medical colleagues, dentistry stands today on the edge of what promises to be one of the most rewarding times in preventive care. Some dentists will seize the opportunity to embrace the concept of optimal health and a more holistic approach to wellness. Others will back away, content with the status quo and the technical discipline of disease repair. Until now, the second option has really been our only choice and our efforts in perfecting it have been commendable. It is worth noting that the second option has also been economically rewarding. The old paradigm was appropriate, based on the information available at the time; but this does not excuse us from embracing the new.
WHAT’S CHANGED?
The confluence of several recent events has served to create a major shift in our evolving perspective of healthcare delivery:
First, with the growing ability of scientific research to probe new frontiers, from cell biology to immunology to mapping the human gene, science has entered a whole new realm of discovery. With each discovery comes a renewed understanding of the marvels of the human body, the “connectedness” of its systems, and the need to approach prevention and treatment from a more holistic dimension.
Second, there has been a shift in focus from the traditional pharmaceutical approach of diagnosis/ treatment/cure to the recognition of the incredible potential of the body to heal itself–given the nutritional “tools” to do so. The following three examples demonstrate the efficacy of the use of natural biological factors in the prevention and mitigation of chronic disease states:
Harmful levels of blood homocysteine, the “Darth Vader” of cardiovascular disease, have been found to respond effectively to supplementation with three inexpensive vitamins: B6, B12 and folic acid.5-7
The antioxidant vitamins, A, C, E, coenzyme Q10, the antioxidant element selenium and the endogenous antioxidant glutathione have each proved effective in mitigating the risk of cancer.8-12
Diabetes and its metabolic precursor, insulin resistance, are found to respond well to supplementation with several micronutrients, including: a-lipoic acid, biotin, L-carnitine, chromium, magnesium, N-acetyl-cysteine, vitamin C, and vitamin E, as well as several herbal remedies.13-16
As well, new research into the biological properties of reactive oxygen species, or free radicals, has opened our eyes to the linkages between oxidative stress and degenerative disease. Free radicals are extremely reactive molecular fragments with an unpaired electron. They are produced endogenously by our cells and are also inflicted upon us by our increasingly polluted environment. While oxidation is a natural biological process within the cell, uncontrolled oxidative stress eventually damages the machinery of the cell and accelerates the aging process.
It is now recognized that 80 to 90 degenerative diseases are linked to oxidative stress. For example, while infectious in nature, periodontal disease is associated with a growing list of chronic disease processes, such as heart disease and type II diabetes, in which oxidative stress plays a central role. Recent research confirms that the gram-negative bacteria produced in periodontal disease spill into the blood to incite a cascade of deleterious events, including the release of inflammatory cytokines (which elevate the risk of heart disease) and a potent toxin called LPS (which blocks the action of insulin and creates a chronic state of insulin resistance in the body).17,18 Enhancement of immune defenses against tooth decay and periodontal disease, in concert with preventive measures to reduce the level of oxidative stress, may prove a novel and rewarding avenue of treatment for such disease processes.
Third, we now have the ability to respond with a totally different level of nutritional supplementation than in the past. It is becoming more evident that the “a la carte” method of taking “some of this vitamin for this” or “a bit of that mineral for that” not only is ineffective, but can prove to be counter-productive.19 Today’s leading manufacturers formulate their multi-vitamin/mineral complexes at potencies that often exceed the minimalistic RDA levels. Furthermore, they enhance the effectiveness of their formulations by including a wide spectrum of previously known as well as newly discovered antioxidants, many of which function synergistically. At the time the RDAs were originally developed, the importance of several of these newly discovered nutrients, such as the bioflavonoids and polyphenolic compounds, was not yet known. It is this new level of scientifically designed products (more appropriately referred to as nutraceuticals, rather than food supplements) that is garnering the attention of the scientific community and the American Medical Association.
Having exceptional quality is one thing; recognizing it is another. The Comparative Guide to Nutritional Supplements, by Canadian author and biochemist, Lyle MacWilliam,20 is the recognized compendium for professionals and consumers alike. Independently researched and written, the guide offers an objective and scientifically based revie
w of the North American nutritional market, allowing the reader to quickly and easily identify quality nutritional products, based on 14 referenced selection criteria. It will, hopefully, become the standard nutritional supplement reference guide in every dental office in Canada. Just as the VQA designation has helped consumers identify better quality wine, the Comparative Guide to Nutritional Supplements allows us to identify and choose better quality supplements.
Fourth, the explosive potential of the Internet has created a way to enhance the ability of researchers to share ideas and discoveries, for manufacturers to compare and improve products, and for professionals and laymen to become better informed about matters of nutritional science. The massive survey of over 1,000 Canadian and American nutritional supplements undertaken in the writing of the Comparative Guide to Nutritional Supplements would not have been possible before the advent of the Internet.
Last but not least, the public “about face” of the American Medical Association, in its recent declaration that supplementation is now deemed important to your health, underscores the strength of the scientific evidence that now prevails. As summarized by Dr. Robert Fletcher, co-author of the two studies that convinced the AMA to re-write its policy guidelines, “All of us grew up believing that if we ate a reasonable diet, that would take care of our vitamin needs. But, the new evidence,
much of it in the last couple of years, is that vitamins also prevent the usual diseases we deal with every day–heart disease, cancer and birth defects.” Like the AMA’s “conversion on the road to Damascus,” if dentistry is truly pursuing the path of evidence-based treatment, enlightenment with regard to the virtues of nutritional supplementation could take place very quickly.
THE NEW PARADIGM
The new frontier of nutrition will have a profound effect on all of us. Dentists, team members, their families and clients/patients will all benefit from nutritional supplementation. Let’s look at a few scenarios of how nutritional science will impact on areas of dentistry.
Diabetes mellitus is a classic example. Dentistry has long been aware of the co-relationship of uncontrolled periodontal disease to an increased need for insulin. We have been content, however, to limit our therapies to repair-mode tactics to facilitate healthy gums, rather than face the cause. Yesterday’s paradigm would have dictated that the problem with diabetes is in the pancreas and to make any nutritional recommendations would be akin to practicing medicine without a license.
Not so anymore. Dentists who approach periodontal disease as an infectious disease think nothing of prescribing doxycycline, metronidazole and other drugs with a systemic impact. Will we similarly prescribe a specific vitamin or mineral to stimulate a therapeutic response in the periodontium? Evidence is mounting that we would be better to encourage immune system support with a broad-spectrum vitamin/mineral/ antioxidant supplement, fully cognizant of the fact that it will have a “whole-person” effect.
Can we continue to ignore the fact that, as insulin resistance increases, so too does the incidence of periodontal disease? Will we fail to act on the emerging evidence confirming that the relationship with periodontal disease and diabetes cuts both ways? Research shows that periodontal disease may make it more difficult for those with diabetes to control their blood sugar, and poorly controlled diabetics are, in turn, significantly more prone to periodontal disease. Oral bacteria escaping from the gums incite the release of inflammatory cytokines, which are believed to overstep their role and attack the pancreatic -cells. This compromises the ability of the -cells to manufacture insulin and initiates a vicious and damaging cycle. The eventual onset of frank diabetes brings with it a host of other complications, including the development of advanced glycation end products (AGEs), responsible for the yellowing of teeth and accelerated aging in diabetics. Herein lies a classic example of “connectedness” and the realization that we cannot continue to treat only the symptom; instead, we must consider the whole person.
Much attention has also been focused on the relationship of periodontal disease to cardiovascular and cardiac health. The old paradigm encouraged us to take a passive role and offer oral therapies only. Conveniently, we would wash our hands of systemic responsibility. We can no longer afford to play such a passive role: the way to approach periodontal disease must be through systemic support of the immune system and optimization of the biological systems for removal of toxins, including excess free radical species. Vitamin E and magnesium are intimately involved in cardiac support, as is coenzyme Q10 (CoQ10). Reported in the dental literature as having a beneficial effect on periodontal health, CoQ10 has also proved effective in reversing mitral valve prolapse, with relapse rarely occurring in patients who had taken CoQ10 supplementation for over three months.21 How many people do we have in our practices who presently take their two grams of amoxicillin before their appointment, when CoQ10 deficiency may be the real problem?
Like diabetes, osteoporosis has also become an epidemic of global dimensions. Not long ago, conventional medical wisdom held that osteoporosis was an age-related disease–an irreversible process caused by the sudden reduction of estrogen in postmenopausal women and consequent loss of calcium from the bone. Today, we know that osteoporosis is a chronic degenerative disease that is pediatric in origin and one that will strike without consideration of gender. It is also a disease largely of our own making; we have brought it about through poor diet, a lack of regular exercise and exposure to pharmaceutical drugs used in the treatment of other disease processes.22 While there is no cure for osteoporosis, the good news is that the disease is almost entirely preventable. A simple combination of fresh air, exercise and optimal nutrition, including supplementation, could save millions of people the agony of osteoporosis and billions of dollars for our beleaguered healthcare systems.
The dawning of the nutritional frontier involves more than simply feeding the body macronutrients, the proteins, fats and carbohydrates needed to sustain our cellular structures and fuel our energy needs. It also involves supplementation with micronutrients, the vitamins, minerals, trace elements and antioxidants needed to “lubricate” our biochemical systems and defend against toxic free radical species.
Vitamin A, vitamin C, vitamin E, beta-carotene, coenzyme Q10, selenium, zinc, l-glutathione, alpha-lipoic acid, n-acetyl-cysteine, proanthocyanidins, bioflavonoids and other free radical fighters work in concert with each other as the front line of our cellular defense systems. As research continues to uncover more evidence of the ravages of stress and free radical production, we are becoming more aware of the benefits of antioxidant support for the immune system. In a very short time, recommending antioxidants through supplementation will be as common in the dental office as recommending floss.
Here is another example of how therapy may change. Presently, we employ numerous dental therapies to treat temporomandibular joint dysfunction (TMD). From splints to occlusal equilibration and from trigger-point therapy to myomonitors, dentistry treats TMD as a mechanical dysfunction. Some may even engage their clients/patients in biofeedback and stress management. However, recent evidence shows that arthritic joints are full of free radicals and that treatment with antioxidants can suppress the development of arthritis.23 Could the temporomandibular joint (TMJ) be that different than other joints in the same body? Concurrently, evidence is mounting that glucosamine, in synergy with other micronutrients, can preserve cartilage, and in some cases, regenerate some of it. In a recent study, elite athletes with cartilage damage of the knee
were given 1500mg of glucosamine sulphate daily for 40 days, followed by 750mg for 100 days. Seventy-six percent had complete disappearance of their symptoms and resumed full athletic activity; a 12-month follow-up revealed no signs of cartilage damage in any of the athletes.24,25 Perhaps there is a therapeutic role for antioxidants and glucosamine in the treatment of TMD.
As another example, leukoplakia, a stubborn and possibly pre-cancerous lesion, has been shown to respond well to antioxidant therapies. It has been reported that supporting the immune system through supplementation with antioxidants can reduce the white lesions in 55 percent of cases.26
SUMMARY
Albert Szent Gyorgi, Nobel Laureate in Physiology and Medicine and one of the greatest scientific minds of the 20th century, once stated: “Vitamins, if properly understood and applied, will help us to reduce human suffering to an extent which the most fantastic human mind would fail to imagine.”
That said, the impact of nutritional supplementation on dentistry and health care in general may well be beyond our imaginations. Dentistry has a proud history of leadership among health professions in championing preventive measures to enhance wellness. With this enviable position as its launch pad, dentistry is perfectly positioned to explore this new frontier. Carpe diem doctor–seize the day!
Ken Southward is a general dentist in Beamsville, ON.
Lyle MacWilliam is an author, educator and biochemist. A consultant and public advocate for the natural healthcare industry, he is the author of The Comparative Guide to Nutritional Supplements.
Oral Health welcomes this original article.
REFERENCES
1.Enwonwu CA, Phillips, RS and Falkler, WA Jr. Nutrition and Oral Infectious Diseases, State of the Science , Compend Cont Educ Dent. 2002;23(5):431-438.
2.Wooltorton E. Too much of a Good Thing? Toxic effects of vitamin and mineral supplements. CMAJ. 2003 Jul;169(1):47-48
3.Fairfield KM and Fletcher RH. Vitamins for chronic disease prevention in adults: scientific review. JAMA. 2002 Jun;287(23):3116-26.
4.Fletcher RH and Fairfield KM. Vitamins for chronic disease prevention in adults: clinical applications. JAMA. 2002;287(23):3117-29.
5.Boushey CJ, Beresford SA, Omenn GS, et al. A quantitative assessment of plasma homocysteine as a risk factor for vascular disease. Probable benefits of increasing folic acid intakes. JAMA. 1995;274(13): 1049-1057.
6.Firshein R. The Nutraceutical Revolution. New York, NY: Riverside Books; 1998.
7.MacWilliam L. Comparative Guide to Nutritional Supplements. 3rd ed. Vernon, BC: Northern Dimensions Pub; 2003.
8.Kummet T and Meyskins F. Vitamin A: a potential inhibitor of human cancer. Semin Oncol. 1983;10(3): 281-289.
9.Ames BN. Dietary carcinogens and anticarcinogens. Oxygen radicals and degenerative diseases. Science. 1983;221(4617): 1256-1264.
10.Smigel K. Vitamin E reduces prostate cancer rates in Finnish trial: U.S. considers follow-up. J Natl Cancer Inst. 1998;90(6):416-417.
11.Clark LC, Dalkin B, Drongrad A, et al. Decreased incidence of prostate cancer with selenium supplementation: results of a double-blind cancer prevention trial. Br J Urol. 1998;81(5):730-734.
12.Warholm M, Guthenberg C, Mannervik B, et al. Purification of a new glutathione S-transferase (transferase mu) from human liver having high activity with benzo(alpha) pyrene-4,5-oxide. Biochem Biophys Res Comm. 1981;98(2):512-519.
13.Segala M, ed. Disease Prevention and Treatment. expanded 4th ed. Hollywood, FL: Life Extension Media; 2003.
14.Murray, MT. Encyclopedia of Nutritional Supplements. Rocklin, CA: Prima Publishing; 1996.
15.Murray MT. Healing Power of Herbs. 2nd edition. Rocklin, CA: Prima Publishing; 1995.
16.Diabetes Type II and the Syndrome X Connection. Life Extension Foundation website. Available at: http://www.lef.org/protocols/prtcls-text/t-prctl-042.html. Accesssed Jan 27, 2004.
17.Baker L. Bacteria from Gum Infections Associated with Diabetes, Chronic Lung Disease, UB Studies Find. 1999. Buffalo, NY: University of Buffalo school of Dental Medicine. Available at: http://www.sdm.buffalo.edu.news/19990313_diab.html.
18.Diabetes Type II and the Syndrome X Connection. Life Extension Foundation website. Available at: http://www.lef.org/protocols/prtcls-text/t-prctl-042.html. Accesssed Jan 27, 2004.
19.Wooltorton E, Too much of a Good Thing? Toxic effects of vitamin and mineral supplements. CMAJ. 2003 July;169(1):47-48
20.MacWilliam L. Comparative Guide to Nutritional Supplements. 3rd ed. Vernon, BC: Northern Dimensions Pub; 2003.
21.Oda T and Homomota K. Effect of Coenzyme Q10 on the Stress-Induced Decrease of Cardiac Performance in Pediatric Patients with Mitral Valve Prolapse. Japan Circ J. 1984;48:1387.
22.Sellem S. Osteoporosis – the Bones of Contention. Nexus Magazine. Nov 1998:5(6).
23.Sakaii A, et al. Large dose ascorbic acid administration suppresses the development of arthritis in adjuvant-infected rats. Arch Orthop Trauma Surg. 1999;119(3-4):121-6.
24.Bohmen D, et al. Treatment of chondropathia patellae in young athletes with glucosamine sulphate. Current Topics in Sports Medicine. Bracht N, Prokop L eds. Vienna: Urban and Schwarzenberg; 1984.
25.Colgan M. Glucosamine: Optimal Healing for Young and Old. Colgan Chronicles. 1997;1(1):1-3.
26.Kaugers GE, et al. A Clinical trial of antioxidant supplements in the treatment of oral leukoplakia. Oral Surg Oral Med Oral Pathol. 1994 Oct;78(4):462-8.
