A randomized, double-blind, placebo-controlled multicenter study for evaluating the effects of fixed-dose combinations of vitamin C, vitamin E, lysozyme, and carbazochrome on gingival inflammation in chronic periodontitis patients

Background

To evaluate gingival inflammation from fixed-dose combinations of vitamin C, vitamin E, lysozyme and carbazochrome (CELC) in the treatment of chronic periodontitis following scaling and root planing.

Methods

One hundred patients were randomly assigned to receive CELC (test) or placebo (control) for the first 4 weeks at a 1:1 ratio, and both groups received CELC for the remaining 4 weeks. Primary outcome was the mean change in the gingival index (GI) after 4 weeks. Secondary outcomes included mean change in GI after 8 weeks and plaque index, probing depth, clinical attachment level, and VAS at 4 weeks and 8 weeks.

Results

Ninety-three patients completed the study. The GI in the test group significantly decreased after 4 weeks (p < 0.001) and 8 weeks (p < 0.001). The mean change from baseline in GI significantly decreased in the test group compared to the control group after 4 weeks (p = 0.015). In the GEE model adjusting for age, gender and visits, the test group showed 2.5 times GI improvement compared to the control group (p = 0.022).

Conclusions

Within the study, CELC showed a significant reduction in gingival inflammation compared with a placebo. Other parameters, however, were similar between groups.

Trial registration

KCT0001366 (Clinical Research Information Service, Republic of Korea) and 29 Jan 2015, retrospectively registered.

Review: modulation of the oral microbiome by the host to promote ecological balance

The indivisible relationship between the human host and its oral microbiome has been shaped throughout the millennia, by facing various changes that have forced the adaptation of oral microorganisms to new environmental conditions. In this constant crosstalk between the human host and its microbiome, a bidirectional relationship has been established. The microorganisms provide the host with functions it cannot perform on its own and at the same time the host provides its microbes with a suitable environment for their growth and development. These host factors can positively affect the microbiome, promoting diversity and balance between different species, resulting in a state of symbiosis and absence of pathology. In contrast, other host factors can negatively influence the composition of the oral microbiome and drive the interaction towards a dysbiotic state, where the balance tilts towards a harmful relationship between the host and its microbiome. The aim of this review is to describe the role host factors play in cultivating and maintaining a healthy oral ecology and discuss mechanisms that can prevent its drift towards dysbiosis.

Effects of Chicory Leaf Extract on Serum Oxidative Stress Markers, Lipid Profile and Periodontal Status in Patients With Chronic Periodontitis

AIM

The aim of present study was to evaluate the effects of chicory leaf extract on serum oxidative stress markers, lipid profile, and periodontal status in patients with chronic periodontitis.

METHODS

In this double-blind, randomized controlled clinical trial 40 patients with chronic periodontitis were allocated to intervention and control groups. The intervention group received a 1-gram chicory leaf methanolic extract capsule twice daily for 8 weeks. In the control group, participants received a placebo capsule (containing 1 gram wheat flour) twice daily for 8 weeks. All participants had nonsurgical periodontal therapy during the study. Anthropometric measurements, dietary intake, total antioxidant capacity (TAC), malondialdehyde (MDA), uric acid, lipid profile (total cholesterol [TC], triglycerides [TG], low-density lipoprotein cholesterol [LDL-C], and high-density lipoprotein cholesterol [HDL-C]), and pocket depth (PD) were assessed before and after intervention.

RESULTS

The results showed that mean serum TAC, uric acid, and HDL-C increased and mean serum MDA, TG, LDL-C, and TC decreased significantly in the intervention group compared to their baseline and the control group post-intervention. A significant difference was observed in mean PD between the two groups.

CONCLUSION

Chicory leaf extract as an adjunct nutritional approach with nonsurgical periodontal therapy may be helpful in controlling periodontal status.

The Relationship between Vitamin D and Periodontal Pathology

Osteoporosis and periodontal diseases are common problems among the elderly population. Vitamin D is a secosteroid hormone that is either synthesized by human skin cells under the effect of UV radiation or consumed through diet. Deficiency in vitamin D leads to reduced bone mineral density, osteoporosis, the progression of periodontal diseases and causes resorption to occur in the jawbone. Sufficient intake of vitamin D can decrease the risk of gingivitis and chronic periodontitis, as it has been shown to have immunomodulatory, anti-inflammatory, antiproliferative effects and initiates cell apoptosis. In addition, vitamin D is also important for bone metabolism, alveolar bone resorption and preventing tooth loss. It increases antibacterial defense of gingival epithelial cells and decrease gingival inflammation, improves postoperative wound healing after periodontal surgery and is an important supplement used as prophylaxis in periodontology. This publication aims to update the recent advances, stress the clinical importance, and evaluate vitamin D in the prevention of periodontal diseases to reach a successful outcome of conservative and surgical treatment. An analysis of the literature shows that vitamin D plays a significant role in maintaining healthy periodontal and jaw bone tissues, alleviating inflammation processes, stimulating post-operative healing of periodontal tissues and the recovery of clinical parameters. However, further research is needed to clarify the required vitamin D concentration in plasma before starting periodontal treatment to achieve the best outcome.

Serum vitamin D levels and chronic periodontitis in adult, Caucasian population-a systematic review

The aim of this systematic review was to explore the relationship between serum vitamin D levels and periodontal disease. The review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The focused PICO question was: Are serum vitamin D levels (I) associated with gingivitis or periodontitis (C) in healthy humans (P)? PubMed (Medline), Embase, Science Direct, the Cochrane library, and grey literature were searched up to 31 July 2017. Two reviewers independently selected studies and extracted data. Quality, risk of bias, and heterogeneity of the studies were assessed using the Newcastle-Ottawa Scale. In total, 365 studies were identified and 24 were analyzed. Seven studies fulfilled the inclusion criteria. Four case-control studies showed an influence of vitamin D and its metabolites on periodontal health status/disease. One interventional study suggested the proposed anti-inflammatory role of vitamin D. Two cross-sectional studies failed to show a relationship between vitamin D and periodontal condition. The literature on the effect of serum vitamin D levels on periodontal status remains scarce and controversial. Some data, however, support a "perio-protective" role for vitamin D. There is a need for well-designed randomized clinical trials to explore the possible anti-inflammatory effect of vitamin D on periodontal health.

Nonsurgical and surgical treatment of periodontitis: how many options for one disease?

Treatment of periodontitis aims at preventing further disease progression with the intentions to reduce the risk of tooth loss, minimize symptoms and perception of the disease, possibly restore lost periodontal tissue and provide information on maintaining a healthy periodontium. Therapeutic intervention includes introduction of techniques to change behavior, such as: individually tailored oral-hygiene instructions; a smoking-cessation program; dietary adjustment; subgingival instrumentation to remove plaque and calculus; local and systemic pharmacotherapy; and various types of surgery. No single treatment option has shown superiority, and virtually all types of mechanical periodontal treatment benefit from adjunctive antimicrobial chemotherapy. Periodontal treatment, because of the chronic nature of periodontitis, is a lifelong commitment to intricate oral-hygiene techniques, which, when properly implemented, will minimize the risk of disease initiation and progression.

Nutraceuticals in Periodontal Health: A Systematic Review on the Role of Vitamins in Periodontal Health Maintenance

Periodontal disease, a relevant public health problem worldwide, is generally considered a common pathology of elderly people. In this respect, there is agreement about that nutritional status may be a modifying factor in the progression and healing of the periodontal tissues. Vitamins have been recommended as nutraceuticals for prevention and treatment of some pathological conditions, such as cardiovascular diseases, obesity or cancer. Thus, a systematic approach to determining how the different vitamin type could ameliorate periodontal risks or improve periodontal health is necessary to further the understanding of the potential benefits and risks of vitamins supplementation use. For this, a systematic review of English-written literature in PubMed until February 2018, which included both human and animal research on the relationship of each vitamin with periodontal disease, was conducted. Among all the analyzed vitamins those with antioxidant capacity and effects on immune system seem to be useful for prevention or improvement of periodontal disease, as well as those implicated in bone metabolism. In the first case, there are quite information in favor of various vitamins, mainly vitamin C, that is the most studied. In the second case, vitamin D seems to have the most relevant role.

The effect of twice daily kiwifruit consumption on periodontal and systemic conditions before and after treatment: A randomized clinical trial

BACKGROUND

To assess the nutraceutical effects of twice/daily intake of kiwifruit on periodontal parameters and systemic health before and after initial periodontal treatment (IPT).

METHODS

At baseline, participants were randomly assigned to test and control group, and either consumed two kiwifruits/day for 5 months or no kiwifruit. In the first 2 months, no periodontal treatment was delivered (2 M). Subsequently, a session of full-mouth IPT within 24 hours was performed. Participants were then re-assessed after 3 months (5 M). Blood samples, evaluating systemic biomarkers and vital signs, were also collected atbaseline, 2 M, and 5 M.

RESULTS

Groups were balanced at baseline. At 2 M no within-groups differences could be detected for any parameter but the bleeding score, which decreased significantly in the kiwifruit group by 6.67% ± 11.90% (P < 0.01). Comparison of test and control group showed that 2 months of kiwifruit consumption resulted in significant lower values of bleeding, plaque, and attachment loss. After IPT both groups demonstrated substantial significant clinical benefits however the control group showed significant greater reductions of bleeding, plaque and attachment loss than the test group. Systemic biomarkers and vital signs did not show clinically relevant differences between test and control group.

CONCLUSIONS

Kiwifruit consumption reduces gingival inflammation despite the lack of any periodontal instrumentation or patient's behavioral changes. No adjunctive effect to periodontal treatment of dietary intake of kiwifruit was noted. (NCT NCT03084484).

A Comparative Assessment of Serum Vitamin C and Serum Lead Among Periodontitis and Diabetic Patient

Background and Aims: Pre and post-operative nutritional status are not often tested on a consistent basis when patients are analyzed and diagnosed with Type 2 Diabetes Mellitus (T2DM) or have chronic periodontitis. Thus, this study pursues to evaluate the predictive value of serum vitamin C and lead levels in this population at baseline and after periodontal treatment.

Materials and Methods: In an interventional study setting we enrolled 120 subjects which were later categorized into four sub-groups: set 1 – individuals with chronic periodontitis, set 2 – individuals with T2DM, set 3 – individuals with T2DM and chronic periodontitis respectively set 4 - healthy individuals as control group. Scaling and root planing was performed only to individuals with periodontitis and T2DM. At baseline and 21 days after periodontitis treatment blood was obtained from the subjects and analysis of serum vitamin C and serum lead was done and data obtained was statisticaly analysed.

Results: ANOVA test showed baseline values of both the parameters to be statistically significant different between groups and within groups (p<0.001). Alteration was seen in the parameters postoperatively regarding serum vitamin C was increased and lead level decreased; paired t-test showed statistically significant difference (p<0.001).

Conclusion: Serum Vitamin C can be considered a key biomarker. Increased lead level can be a risk factor for commencement and progression of T2DM and chronic periodontitis.

Serum levels of 25-hydroxyvitamin D are associated with periodontal disease

OBJECTIVES

Vitamin D plays an essential role in bone metabolism as well as in immunity. Hence, it might affect the development and extent of periodontal disease. The aim of this study was the assessment of 25-hydroxyvitamin D (25(OH)D) status in periodontal disease.

MATERIALS AND METHODS

Twenty-nine patients with severe periodontal disease and 29 healthy volunteers were recruited in this case-control-study. Serum 25(OH)D levels, Periodontal Probing Depth (PPD), Clinical Attachment Level (CAL), Bleeding on Probing (BOP), Body Mass Index (BMI), and current smoking status and smoking history (packyears) were assessed in all participants. Serum 25(OH)D levels were compared between controls and cases. Multivariable logistic regression was used to determine the odds ratio (OR) and 95 % confidence interval (CI) for periodontal disease in 25(OH)D deficient probands.

RESULTS

Patients with periodontal disease presented a significantly higher proportion of deficient 25(OH)D levels (i.e., <50 nmol/l) compared to healthy controls (48 vs. 14 % respectively). The adjusted OR for periodontal disease with vitamin D deficiency was 1.5 (95 % CI, 1.13-1.98). No correlation between serum 25(OH)D levels and CAL, PPD, and BOP in the group with periodontal disease was found.

CONCLUSIONS

In this case-control-study 25(OH)D deficiency is significantly associated with periodontal disease.

CLINICAL RELEVANCE

The assessment of vitamin D levels in patients presenting with periodontal disease seems advisable, as vitamin D deficiency might be involved in the onset and progression of periodontal disease.

The association of dietary vitamin C intake with periodontitis among Korean adults: Results from KNHANES Ⅳ

Backgrounds

The association of dietary vitamin C (vit C) on periodontitis requires more valid evidence from large representative samples to enable sufficient adjustments. This study aimed to evaluate the association between dietary vit C intake and periodontitis after controlling for various confounders in the representative Korean adult population

Method

A total of 10,930 Korean adults (≥19 years) from the fourth Korean National Health and Nutrition Examination Survey data set were included in this cross-sectional study. Periodontitis was defined as community periodontal index score of 3 or 4. Dietary vit C intake was estimated from a 24-hour dietary record, and categorized into adequate and inadequate according to the Korean Estimated Average Requirement value. Potential confounders included age, sex, income, frequency of tooth brushing, use of floss, dental visit, drinking, smoking, diabetes, hypercholesterolemia, hypertension, and obesity. A multivariable logistic regression analysis and stratified analysis were applied.

Results

Those with inadequate dietary vit C intake were more likely by 1.16 times to have periodontitis than those with adequate dietary vit C intake (adjusted odds ratio [aOR] = 1.16, 95% confidence interval = 1.04–1.29). Lowest and middle-low quartile of dietary vit C intake, compared to highest quartile of dietary vit C intake, showed significant association (aOR = 1.28 and 1.22 respectively), which was in a biological-gradient relationship (trend-p <0.05).

Conclusions

Our data showed that inadequate dietary vit C intake was independently associated with periodontitis among Korean adults. Hence, adequate intake of dietary vitamin C could be substantially important on the promotion of periodontal health among Korean adults.

Antioxidant Micronutrients and Oxidative Stress Biomarkers

Chronic inflammatory diseases are the major causes of mortality in humans and recent research has improved our understanding of the major impact of life-style factors upon inflammatory diseases and conditions. One of the most influential of these is nutrition, which may drive both pro-inflammatory as well as anti-inflammatory cascades at molecular and cellular levels. There are a variety of model systems that may be employed to investigate the impact of micronutrients and macronutrients upon inflammatory pathways, many of which operate through oxidative stress, either at the level of controlling the redox state of the cell and downstream redox-regulated gene transcription factors, and other acting as free radical generating or scavenging agents. This chapter focuses upon biological sample preparation prior to assay and details methods for analyzing certain antioxidant micronutrients and biomarkers of oxidative stress.

A Comparative Evaluation of Serum Magnesium in Diabetes Mellitus Type 2 Patients with and without Periodontitis - A Clinico-biochemical Study

INTRODUCTION

Magnesium is an essential cation playing a crucial role in many physiological functions and its imbalance is associated with greater number of pathological situations. Oxidative stress is usually increased due to decreased essential nutrients. Hence, any imbalance of essential nutrients like serum magnesium can significantly play a role in the pathobiology of periodontitis in the presence of diabetes, as diabetes and chronic periodontitis are two chronic diseases that have been biologically linked.

AIM

To evaluate the association of serum magnesium in type 2 diabetes mellitus and chronic periodontitis patients, also to evaluate and associate the influence of serum magnesium on periodontal health.

MATERIALS AND METHODS

A single blinded, randomized study was conducted that comprised of 120 subjects divided into four groups. Individuals with periodontitis and type 2 diabetes mellitus formed the test group. Subjects with chronic periodontitis diagnosed clinically according to 1999 American Academy of Periodontology classification, without any medical history and drug history were included as the study subjects. Gingival Index and Plaque Index were scored for all the groups at baseline and after 21 days of scaling and root planing. Scaling and root planing was done only in the test group. Blood was drawn from the patients at baseline and 21 days after scaling and root planning and estimation of serum magnesium level was done using semi-autoanalyzer. Data obtained was statistically analyzed using the paired t-test, one-way ANOVA, post-hoc test.

RESULTS

The result of the present study showed that mean serum magnesium among healthy was 1.40±0.565mmol/l as compared to 1.01±0.287mmol/l among subjects with periodontitis, 0.920±0.23mmol/l among diabetics with periodontitis and 0.93±0.29mmol/l among diabetics without periodontitis. Serum magnesium was significantly decreased in chronic periodontitis and diabetic patients with and without chronic periodontitis as compared to controls.

CONCLUSION

Imbalance of serum magnesium level was seen in patients with chronic periodontitis and type 2 diabetes mellitus. Hence, it can be a biomarker which can predict the occurrence of type 2 diabetes mellitus and chronic periodontitis.

Impact of micronutrients supplementation on bone repair around implants: microCT and counter-torque analysis in rats

The use of natural substances and micronutritional approaches has been suggested as a therapeutic alternative to benefit the bone healing associated with no side effects. Nevertheless, the influence of micronutritional interventions with therapeutic proprieties on the bone repair has yet to be intensely evaluated, and no evidence is available exploring the impact of micronutrient supplementation on the peri-implant bone healing.

OBJECTIVE

This study investigated the effect of micronutrients supplementation on the bone repair around implants.

MATERIAL AND METHODS

One screw-shaped titanium implant was inserted in each tibia of each rat, which were assigned to: daily administration, for 30 d, of the placebo solution (Placebo group-n:18) or micronutrients supplementation (Micronutrients group-n:18), based on calcium, magnesium, zinc, and vitamin D3 intake. After, the animals were sacrificed. One of the implants was removed by applying a counter-torque force to evaluate the force to rupture the bone-implant interface. The other implant was evaluated by microcomputed tomography (CT) examination to determine the bone-to-implant contact (BIC) and the bone volume (BV/TV).

RESULTS

No statistically significant differences were observed between the groups for both counter-torque values and microCT parameters (p>0.05).

CONCLUSION

Within the limits of this study, micronutrients supplementation did not provide additional benefits to the bone healing around dental implants.

A Systematic Review on the Implication of Minerals in the Onset, Severity and Treatment of Periodontal Disease

Periodontal disease is an inflammatory disease with high prevalence in adults that leads to destruction of the teeth-supporting tissues. Periodontal therapy has been traditionally directed at reduction of the bacterial load to a level that encourages health-promoting bacteria and maintenance of oral-hygiene. The role of nutrition in different chronic inflammatory diseases has been the subject of an increasing body of research in the last decades. In this sense, there has been an important increase in the volume of research on role of nutrition in periodontitis since the diet has known effects on the immune system and inflammatory cascades. Minerals play a key role in all these processes due to the multiple pathways where they participate. To clarify the role of the different minerals in the establishment, progression and/or treatment of this pathology, a systemically review of published literature cited in PubMed until May 2016 was conducted, which included research on the relationship of these elements with the onset and progression of periodontal disease. Among all the minerals, calcium dietary intake seems important to maintain alveolar bone. Likewise, dietary proportions of minerals that may influence its metabolism also can be relevant. Lastly, some observations suggest that all those minerals with roles in immune and/or antioxidant systems should be considered in future research.

The Role of Nutrition in Periodontal Health: An Update

Periodontal health is influenced by a number of factors such as oral hygiene, genetic and epigenetic factors, systemic health, and nutrition. Many studies have observed that a balanced diet has an essential role in maintaining periodontal health. Additionally, the influences of nutritional supplements and dietary components have been known to affect healing after periodontal surgery. Studies have attempted to find a correlation between tooth loss, periodontal health, and nutrition. Moreover, bone formation and periodontal regeneration are also affected by numerous vitamins, minerals, and trace elements. The aim of this review is to critically appraise the currently available data on diet and maintenance of periodontal health and periodontal healing. The effects of nutritional intervention studies to improve the quality of life and well-being of patients with periodontal disease have been discussed.

An oral health optimized diet can reduce gingival and periodontal inflammation in humans - a randomized controlled pilot study

BACKGROUND

The aim of this pilot study was to investigate the effects of four weeks of an oral health optimized diet on periodontal clinical parameters in a randomized controlled trial.

METHODS

The experimental group (n = 10) had to change to a diet low in carbohydrates, rich in Omega-3 fatty acids, and rich in vitamins C and D, antioxidants and fiber for four weeks. Participants of the control group (n = 5) did not change their dietary behavior. Plaque index, gingival bleeding, probing depths, and bleeding upon probing were assessed by a dentist with a pressure-sensitive periodontal probe. Measurements were performed after one and two weeks without a dietary change (baseline), followed by a two week transitional period, and finally performed weekly for four weeks.

RESULTS

Despite constant plaque values in both groups, all inflammatory parameters decreased in the experimental group to approximately half that of the baseline values (GI: 1.10 ± 0.51 to 0.54 ± 0.30; BOP: 53.57 to 24.17 %; PISA: 638 mm(2) to 284 mm(2)). This reduction was significantly different compared to that of the control group.

CONCLUSION

A diet low in carbohydrates, rich in Omega-3 fatty acids, rich in vitamins C and D, and rich in fibers can significantly reduce gingival and periodontal inflammation.

TRIAL REGISTRATION

German Clinical Trials Register; https://www.germanctr.de (DRKS00006301). Registered on 2015-02-21.

Role of Lipids in the Onset, Progression and Treatment of Periodontal Disease. A Systematic Review of Studies in Humans

The risk of different oral problems (root caries, tooth mobility, and tooth loss) can be increased by the presence of periodontal disease, which has also been associated with a growing list of systemic diseases. The presence of some bacteria is the primary etiology of this disease; a susceptible host is also necessary for disease initiation. In this respect, the progression of periodontal disease and healing of the periodontal tissues can be modulated by nutritional status. To clarify the role of lipids in the establishment, progression, and/or treatment of this pathology, a systematic review was conducted of English-written literature in PubMed until May 2016, which included research on the relationship of these dietary components with the onset and progression of periodontal disease. According to publication type, randomized-controlled trials, cohort, case-control and cross-sectional studies were included. Among all the analyzed components, those that have any effect on oxidative stress and/or inflammation seem to be the most interesting according to current evidence. On one hand, there is quite a lot of information in favor of a positive role of n-3 fatty acids, due to their antioxidant and immunomodulatory effects. On the other hand, saturated fat-rich diets increase oxidative stress as well the as intensity and duration of inflammatory processes, so they must be avoided.

Nutrition and Periodontal Disease

The identification of inflammatory periodontal disease and education in local and systemic risk factors and their management forms the foundation of the treatment of this disease. Nutrition is potentially a modifiable risk factor that could drive or abrogate the underlying oxidative stress in periodontitis. As research in this area is still in its infancy, clinical guidance on the delivery of dietary advice for susceptible patients is scarce. This paper will explain the possible mechanisms linking nutrition and periodontal disease, as well as the guidelines currently available to the dental profession. CPD/CLINICAL RELEVANCE: With a growing evidence base, an appreciation of the links between nutrition and inflammatory periodontal disease can help guide clinicians in educating patients on this potentially important modifiable risk factor.

Effects of 1,25-dihydroxyvitamin D3 on Macrophage Cytokine Secretion Stimulated by Porphyromonas gingivalis

Vitamin D is known to be closely associated with periodontitis; however, its exact mechanisms remain to be clarified. The present study aimed to investigate the influence of 1,25-dihydroxyvitamin D₃ (1,25(OH)₂D₃) on Porphyromonas gingivalis (Pg)-stimulated cytokine production and the involved signaling pathways in macrophages. The main observation was that 1,25(OH)₂D₃ inhibited Pg-induced interleukin (IL)-6 cytokine expression but up-regulated the expression of anti-inflammatory cytokine IL-10. Further analyses showed that 1,25(OH)₂D₃ decreased p38 mitogen-activated protein kinase (MAPK) and extracellular signal regulated kinase (ERK)1/2 phosphorylation. Inhibited phosphorylation of p38 MAPK and ERK1/2 was associated with decreased level of IL-6 expression, but was not related to increased level of IL-10 expression in macrophages stimulated with Pg. These results suggest that 1,25(OH)₂D₃ might exert its anti-inflammatory effects on Pg-stimulated macrophages partly through its inhibitory effect on the p38 MAPK and ERK1/2 signaling pathway.

Dietary antioxidants and their indispensable role in periodontal health

Periodontitis is an increasing area of interest due to its global prevalence. This inflammatory condition results due to the loss of the critical balance between the virulence factors produced by microorganisms and the inflammatory host response. A number of efforts have been made in the past to address this condition and regain periodontal health. Targeting the root cause by nonsurgical debridement has been considered the gold standard. However, research has shown the possible effects of nutrient deficiency and an imbalanced diet on the periodontium. Therefore, an effort toward the maintenance of optimal conditions as well as improvement of the oral health necessities the introduction of adjunctive nutritional therapy, which can benefit the patients. Antioxidants in the diet have some remarkable benefits and valuable properties that play an irreplaceable role in the maintenance of periodontal health. These have emerged as excellent adjuncts that can enhance the outcomes of conventional periodontal therapy. The aim of this review article is to highlight some of these dietary antioxidants that can make a notable difference by striking a balance between health and disease.

Nutrigenomics: the role of nutrients in gene expression

Improved understanding of the mechanism behind periodontal tissue destruction, the potential protective role of nutrients and the advent of modern genomic measurement tools has led to an increased interest in the association between nutrition and periodontal disease. To date, evidence for a direct link between periodontal disease and nutrition has come mainly from large observational cross-sectional studies or very small double-blind randomized supplementation trials, with a large proportion finding no significant association between the nutrient being analyzed and markers of periodontal disease status. The advent of the 'genomic era' has introduced the concept of nutrigenomic studies, which aim to reveal the relationship between nutrition and the genome to provide a scientific basis for improved public health through dietary means. Used alongside relatively inexpensive high-throughput technology, this will allow the effect of diet on the etiology of periodontal disease to be studied in greater detail. As it is extremely likely that interactions between genotype and diet are important in determining the risk of the most common complex diseases, it is highly probable that these interactions will be important in determining periodontal disease risk. Numerous nutritional genetic studies where the outcome measures have been markers of disease risk, most notably cardiovascular disease and cancer, provide proof of principle, highlight the importance of understanding these interactions and illustrate where the effect of dietary modification on periodontal disease progression may have been overlooked previously by observational studies.

Defining periodontal health

Assessment of the periodontium has relied exclusively on a variety of physical measurements (e.g., attachment level, probing depth, bone loss, mobility, recession, degree of inflammation, etc.) in relation to various case definitions of periodontal disease. Periodontal health was often an afterthought and was simply defined as the absence of the signs and symptoms of a periodontal disease. Accordingly, these strict and sometimes disparate definitions of periodontal disease have resulted in an idealistic requirement of a pristine periodontium for periodontal health, which makes us all diseased in one way or another. Furthermore, the consequence of not having a realistic definition of health has resulted in potentially questionable recommendations. The aim of this manuscript was to assess the biological, environmental, sociological, economic, educational and psychological relationships that are germane to constructing a paradigm that defines periodontal health using a modified wellness model. The paradigm includes four cardinal characteristics, i.e., 1) a functional dentition, 2) the painless function of a dentition, 3) the stability of the periodontal attachment apparatus, and 4) the psychological and social well-being of the individual. Finally, strategies and policies that advocate periodontal health were appraised.

I'm not sick but I'm not well,

and it's a sin to live so well.

Flagpole Sitta, Harvey Danger

What is the Contribution of Genetics to Periodontal Risk?

This review addresses the multicausal etiology of periodontitis, in which genetic factors play a role. The various proposed causes for periodontitis always work simultaneously, but the relative contribution of each of these varies from case to case. We are still at an early stage to identify the genes involved, in comparison with other chronic diseases. To date, the genetic variations firmly and repeatedly associated with periodontitis in some populations are found within the following genes: ANRIL, COX2, IL1, IL10, DEFB1, whereas many other proposed periodontitis candidate genes have not been firmly proven or replicated.

Nutrient supplementation may adversely affect maternal oral health--a randomised controlled trial in rural Malawi

Nutritional supplementation during pregnancy is increasingly recommended especially in low-resource settings, but its oral health impacts have not been studied. Our aim was to examine whether supplementation with multiple micronutrients (MMN) or small-quantity lipid-based nutrient supplements affects dental caries development or periodontal health in a rural Malawian population. The study was embedded in a controlled iLiNS-DYAD trial that enrolled 1391 pregnant women <20 gestation weeks. Women were provided with one daily iron-folic acid capsule (IFA), one capsule with 18 micronutrients (MMN) or one sachet of lipid-based nutrient supplements (LNS) containing protein, carbohydrates, essential fatty acids and 21 micronutrients. Oral examination of 1024 participants was conducted and panoramic X-ray taken within 6 weeks after delivery. The supplement groups were similar at baseline in average socio-economic, nutritional and health status. At the end of the intervention, the prevalence of caries was 56.7%, 69.1% and 63.3% (P = 0.004), and periodontitis 34.9%, 29.8% and 31.2% (P = 0.338) in the IFA, MMN and LNS groups, respectively. Compared with the IFA group, women in the MMN group had 0.60 (0.18-1.02) and in the LNS group 0.59 (0.17-1.01) higher mean number of caries lesions. In the absence of baseline oral health data, firm conclusions on causality cannot be drawn. However, although not confirmatory, the findings are consistent with a possibility that provision of MMN or LNS may have increased the caries incidence in this target population. Because of the potential public health impacts, further research on the association between gestational nutrient interventions and oral health in low-income settings is needed.

The epigenetic paradigm in periodontitis pathogenesis

Epigenome refers to “epi” meaning outside the “genome.” Epigenetics is the field of study of the epigenome. Epigenetic modifications include changes in the promoter CpG Islands, modifications of histone protein structure, posttranslational repression by micro-RNA which contributes to the alteration of gene expression. Epigenetics provides an understanding of the role of gene-environment interactions on disease phenotype especially in complex multifactorial diseases. Periodontitis is a chronic inflammatory disorder that affects the supporting structures of the tooth. The role of the genome (in terms of genetic polymorphisms) in periodontitis pathogenesis has been examined in numerous studies, and chronic periodontitis has been established as a polygenic disorder. The potential role of epigenetic modifications in the various facets of pathogenesis of periodontitis is discussed in this paper based on the available literature.

Oxidative Stress and Dietary Fat Type in Relation to Periodontal Disease

Oxidative stress is one of the main factors studied to explain the pathophysiological mechanisms of inflammatory conditions, such as periodontitis. In this respect, nutrition may be of great importance. Actually, research on nutrients' effects on periodontal diseases has expanded to include those influencing the redox status, which correlates to the inflammatory process. Dietary fat or lipids are often blamed as the major source of excess energy. Consequently, when caloric intake exceeds energy expenditure, the resultant substrate-induced increase in citric acid cycle activity generates an excess of reactive oxygen species (ROS). In addition, dietary fatty acid intake influences in relative fatty acid composition of biological membranes determining its susceptibility to oxidative alterations. From this standpoint, here, we reviewed studies analyzing the dietary fat role in periodontal disease. Research data suggest that periodontal health could be achieved by main dietary strategies which include substitution of saturated fats with monounsaturated fatty acids (MUFA) and polyunsaturated fatty acids (PUFA), particularly n-3 PUFA. Maybe in the future, we should analyze the diet and provide some advice to periodontitis patients to improve treatment outcomes.

SLC23A1 polymorphism rs6596473 in the vitamin C transporter SVCT1 is associated with aggressive periodontitis

AIM

Identification of variants within genes SLC23A1 and SLC23A2 coding for vitamin C transporter proteins associated with aggressive (AgP) and chronic periodontitis (CP).

MATERIAL AND METHODS

Employment of three independent case-control samples of AgP (I. 283 cases, 979 controls; II. 417 cases, 1912 controls; III. 164 cases, 357 controls) and one sample of CP (1359 cases, 1296 controls).

RESULTS

Stage 1: Among the tested single-nucleotide polymorphisms (SNPs), the rare allele (RA) of rs6596473 in SLC23A1 showed nominal significant association with AgP (p = 0.026, odds ratio [OR] 1.26, and a highly similar minor allele frequency between different control panels. Stage 2: rs6596473 showed no significant association with AgP in the replication with the German and Dutch case-control samples. After pooling the German AgP populations (674 cases, 2891 controls) to significantly increase the statistical power (SP = 0.81), rs6596473 RA showed significant association with AgP prior to and upon adjustment with the covariates smoking and gender with padj  = 0.005, OR = 1.35. Stage 3: RA of rs6596473 showed no significant association with severe CP.

CONCLUSION

SNP rs6596473 of SLC23A1 is suggested to be associated with AgP. These results add to previous reports that vitamin C plays a role in the pathogenesis of periodontitis.

Ascorbic acid: new role of an age-old micronutrient in the management of periodontal disease in older adults

To review the new role of an age-old micronutrient - ascorbic acid - in the management of periodontal disease. Articles pertaining to the topic were searched in PubMed and other search engines from year 1974 to April 2014 with the following key words: "ascorbic acid," "ascorbate," "vitamin C," "periodontal disease," "gingivitis," "periodontitis," "anti-oxidants" and "elderly." Balanced nutrition is an essential factor in the elderly. Modification of nutritional requirement is important to overcome the effect of an unbalanced diet in older individuals as a result of several external and internal host-associated factors. Micronutrient requirements as aging advances could change, and require due attention. Ascorbic acid and its relationship with periodontal disease are very well known. However, recent changes in the concept of understanding the pathogenicity has led to a new path of therapeutic intervention with ascorbic acid in many chronic diseases. Oxidative stress with its associated burden might alter the disease process. In the era of "periodontal medicine," the impact of remote tissue changes on systemic disease has to be taken into serious consideration. Deficiency of nutritional impact on the host, with micronutrient vitamin C detailed in this review with sources, absorption, interaction and its relationship with systemic disease, and thereby the impact on periodontal disease. Ascorbic acid plays an important role in the aging process, and in the maintenance of periodontal health in the elderly.

Severe periodontitis is inversely associated with coffee consumption in the maintenance phase of periodontal treatment

This cross-sectional study addressed the relationship between coffee consumption and periodontitis in patients during the maintenance phase of periodontal treatment. A total of 414 periodontitis patients in the maintenance phase of periodontal treatment completed a questionnaire including items related to coffee intake and underwent periodontal examination. Logistic regression analysis showed that presence of moderate/severe periodontitis was correlated with presence of hypertension (Odds Ratio (OR) = 1.99, p < 0.05), smoking (former, OR = 5.63, p < 0.01; current, OR = 6.81, p = 0.076), number of teeth present (OR = 0.89, p < 0.001), plaque control record ≥20% (OR = 1.88, p < 0.05), and duration of maintenance phase (OR = 1.07, p < 0.01). On the other hand, presence of severe periodontitis was correlated with smoking (former, OR = 1.35, p = 0.501; current, OR = 3.98, p < 0.05), coffee consumption (≥1 cup/day, OR = 0.55, p < 0.05), number of teeth present (OR = 0.95, p < 0.05), and bleeding on probing ≥ 20% (OR = 3.67, p < 0.001). There appears to be an inverse association between coffee consumption (≥1 cup/day) and prevalence of severe periodontitis in the maintenance phase of periodontal treatment.

Micronutrients and superoxide dismutase in postmenopausal women with chronic periodontitis: a pilot interventional study

Purpose

The study was aimed at investigating changes in periodontal parameters and superoxide dismutase activity triggered by root surface debridement with and without micronutrient supplementation in postmenopausal women.

Methods

Forty-three postmenopausal chronic periodontitis patients were divided into two groups: group 1 (n=22) were provided periodontal treatment in the form of scaling and root planing (SRP) and group 2 (n=21) patients received SRP along with systemic administration of micronutrient antioxidants. Patients in both groups were subjected to root surface debridement. Group 2 patients also received adjunctive micronutrient antioxidant supplementation. Serum and salivary superoxide dismutase (SOD) activity along with periodontal parameters were recorded at baseline and 3 months after therapy.

Results

Salivary and serum SOD values significantly (P<0.05) improved with periodontal treatment. Improvement in systemic enzymatic antioxidant status along with reduction in gingival inflammation and bleeding on probing (%) sites was significantly greater in group 2 as compared to group 1.

Conclusions

Adjunctive micronutrient supplements reduce periodontal inflammation and improve the status of systemic enzymatic antioxidants in postmenopausal women.

Graphical Abstract

Psidium guajava: A review on its potential as an adjunct in treating periodontal disease

Plants for thousands of years have been used to enhance health and for medicinal purposes. Psidium guajava is one which has an enormous wealth of medicinal value. It for long has been known for its anti-inflammatory, antimicrobial, antioxidant, antidiarrheal, antimutagenic properties. Despite of its widespread biologic uses there is a dearth of information on its therapeutic effect in the treatment of periodontal disease. Hence, this review is an attempt to highlight the potential of P. guajava in the treatment of periodontal disease. Internet databases PubMed, Google Scholar were searched and the most relevant articles were considered for review.

Mass spectrometry-based metabolomic profiling identifies alterations in salivary redox status and fatty acid metabolism in response to inflammation and oxidative stress in periodontal disease

Periodontal diseases represent the most common chronic inflammatory diseases in humans and a major cause of tooth loss. Combining mass spectrometry-based ionomics and targeted lipidomics on fatty acid metabolites, we identified significant alterations in redox status and fatty acid metabolism in saliva in response to chronic inflammation and oxidative stress in periodontal disease in a cohort of nonsmoker subjects with chronic periodontitis. For the first time, ionomic profiling of around 30 ions in saliva revealed significantly decreased levels of redox-active metal ions including Mn, Cu, and Zn in the periodontal group, which is consistent with decreased levels of superoxide dismutases in saliva and serum. A targeted lipidomic approach was employed to monitor the major metabolites of arachidonic acid and linoleic acid in saliva. We observed increased levels of cyclooxygenase products including PGE2, PGD2, and PGF2α and TXB2, but decreased level of PGI2 in the periodontal group. A unique pattern of the lipoxygenase products of arachidonic acid and linoleic acid was observed with increased level of 5-HETE but decreased levels of 13-HODE and 9-HODE. Levels of salivary F2-isoprostanes, free radical lipid peroxidation products, and a gold standard for oxidative stress in vivo were also significantly elevated. Taking these data together, our study using multiple powerful omics techniques demonstrates that local redox alteration contributes significantly to periodontitis through the modulation of fatty acid metabolism in response to inflammation and oxidative stress. This study highlights the importance of redox status in periodontitis and provides a rationale for preventing periodontal disease by dietary interventions aiming to restore redox balance.

A comparative clinical evaluation of diet intake and effect of various nutritions on aggressive periodontitis patients

AIM

The aim of this study is to investigate the effect various dietary nutrients in aggressive periodontitis patients.

MATERIALS AND METHODS

A total of 85 patients were selected and divided into two groups, 45 patients are with aggressive periodontitis and 40 patients are healthy. Periodontal parameters such as oral hygiene index, Russels periodontal index and radiograph were taken. The food consumption survey was conducted in all the households of subjects both in control and experimental group. The individual of food intake of the subjects was assessed by the oral questionnaire (24 hours recall) method. The quantity of raw foods used for various preparations and volumes of cooked quantities of such preparations in terms of standardized cups were noted. Body measurements were taken on all the subjects, standing height using a height measuring rod and weight in standard weighing machine.

RESULTS

Aggressive periodontitis is seen in young individual and mostly in females; majority of the patients of both groups belongs to low socioeconomic group. Body mass index which is a refection of nutritional status of an individual indicated that chronically energy defcient subjects in experimental group appeared to be higher. The average food and nutrient intake in control group was slightly better than that of experimental group.

CONCLUSION

The diet survey indicated marginal and negligible defciencies in aggressive periodontitis patients compared to controls, and this coupled with chronically energy defciency as indicated by body mass index, calls for a detailed study of this aspect of aggressive periodontitis. The present study indicates that nutritional infuences point to a needle of suspicion toward the etiology of aggressive periodontitis.

25-Hydroxyvitamin D(3)-loaded PLA microspheres: in vitro characterization and application in diabetic periodontitis models

This study aimed at the preparation of a sustained-release 25-hydroxyvitamin D(3) (25OHD) treatment for diabetic periodontitis, a known complication of diabetes. 25OHD-loaded polylactic acid (PLA) microspheres were prepared using oil-in-water emulsion-solvent evaporation method. The prepared microspheres exhibited intact surfaces, with average sizes ranging from 42.3 to 119.4 μm. The encapsulation efficiency ranged from 79.2% (w/w) to 88.5% (w/w), and the drug content was between 15.8% (w/w) and 17.8% (w/w). Drug release from the produced microspheres followed a near-to-zero-order release pattern and lasted over 10 weeks. In an in vitro model of diabetic periodontitis, the abnormal morphological changes and the decrease in the cell viability of bone marrow stromal cells could be effectively attenuated after the 25OHD-loaded microsphere application. Additionally, in a rat model of diabetic periodontitis, alveolar bone loss was inhibited and osteoid formation in the periodontium was promoted upon 25OHD-loaded microsphere treatment. In conclusion, 25OHD-loaded PLA microspheres may provide an effective approach for the treatment of this disease.

Use of dietary supplements in patients seeking treatment at a periodontal clinic

Dietary supplement use may modify the risk of periodontal disease but effects on wound healing after periodontal procedures are less clear. This study characterized dietary supplement use by male and female patients (n = 376) attending a periodontal clinic—information that is essential for evidence-based intervention studies that may improve patient outcomes after periodontal procedures. Calcium, vitamin D, multivitamin and vitamin C were most commonly used. A greater (p ≤ 0.05) number of males took no supplements compared to females, and more (p ≤ 0.05) females than males took ≥ four supplements. Females took more (p ≤ 0.05) calcium, vitamin D, fish oil, green tea, magnesium, omega 3,6,9 and B vitamin complex. Younger patients (31–50 years) had the highest (p ≤ 0.05) frequency of no supplement use compared to older age groups. Patients over age 50 had a higher (p ≤ 0.05) frequency of using ≥ four supplements including calcium and vitamin D. Supplement use was lower (p ≤ 0.05) in smokers, particularly for calcium, fish oil, green tea and vitamin D. In conclusion, females, older individuals and non-smokers have higher supplement use. Future dietary intervention studies can focus on supplements with known biological activities—anti-inflammatory, antioxidant or osteogenic activity—that may enhance wound healing after reconstructive periodontal procedures.

Mathematical modeling suggests that periodontitis behaves as a non-linear chaotic dynamical process

BACKGROUND

This study aims to expand on a previously presented cellular automata model and further explore the non-linear dynamics of periodontitis. Additionally the authors investigated whether their mathematical model could predict the two known types of periodontitis, aggressive (AgP) and chronic periodontitis (CP).

METHODS

The time evolution of periodontitis was modeled by an iterative function, based on the hypothesis that the host immune response level determines the rate of periodontitis progression. The chaotic properties of this function were investigated by direct iteration, and the model was validated by immunologic and clinical parameters derived from two clinical study populations.

RESULTS

Periodontitis can be described as chaos with the level of the host immune response determining its progression rate; the dynamics of the proposed model suggest that by increasing the host immune response level, periodontitis progression rate decreases. Renormalization transformations show the presence of two overlapping zones of disease activity corresponding to AgP and CP. By k-means cluster analysis, immunologic parameters corroborated the findings of the renormalization transformations. Periodontitis progression rates are modeled to scale with a power law of 1.3, and the mean exponential speed of the system is found to be 1.85 (metric entropy); clinical datasets confirmed the mathematical estimates.

CONCLUSIONS

This study introduces a mathematical model that identifies periodontitis as a non-linear chaotic process. It offers a quantitative assessment of the disease progression rate and identifies two zones of disease activity that correspond to the existing classification of periodontitis in the AgP and CP types.

Assessment of some biochemical oxidative stress markers in male smokers with chronic periodontitis

The present study aims to assess and compare the biochemical oxidative stress markers in male smokers and non-smokers with chronic periodontitis. One hundred thirty-four male chronic periodontitis patients and 64 apparently healthy male volunteers were recruited for the study. The periodontal status was evaluated by measuring gingival index, plaque index, papillary bleeding index and clinical attachment loss using UNC-15 probe. The biochemical markers estimated were total antioxidant capacity, RBC-superoxide dismutase, glutathione peroxidase, vitamin C, malondialdehyde and C-reactive protein. The obtained results indicate higher oxidative stress in chronic periodontitis. Smokers with chronic periodontitis show significantly higher periodontal clinical parameters and relatively higher systemic oxidative stress. Vitamin C estimation may be an important biochemical parameter in conjunction with clinical parameters for diagnosis of chronic periodontitis in smokers.