1. CHAPTER 18 NUTRITIONAL ASPECTS OF GINGIVITIS AND PERIODONTAL DISEASE Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

2. 2 Introduction Nutrient deficiencies, excesses, or imbalances do not initiate periodontal disease nor do megadoses of supplements cure or prevent periodontal disease Nutrient deficiencies, excesses, or imbalances do not initiate periodontal disease nor do megadoses of supplements cure or prevent periodontal disease However, nutrition may alter development, resistance, and/or repair of the periodontium However, nutrition may alter development, resistance, and/or repair of the periodontium From Bird DL, Robinson DS: Torres and Ehlrlich Modern Dental Assisting, ed 9. St. Louis: Saunders, 2009.

3. DEFINITIONS Gingivitis Periodontal Disease Present: Inflammation Swelling plaque accumulation possible calculus accumulation bleeding on probing Not present: attachment loss, connective tissue loss bone loss Chronic inflammation Chronic inflammation Communicable infection Communicable infection Loss of connective tissue Loss of connective tissue Bone loss Bone loss Gingival bleeding Gingival bleeding Pain Pain Supppuration Supppuration Leading cause of tooth loss in adults over 35 years 3Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

4. PERIODONTAL DISEASE AS A HEALTH RISK Causes increased risk for: Causes increased risk for: 1. Cardiovascular disease 2. Stroke 3. Premature births 4. Respiratory infections 5. Diabetic problems High glucose levels with uncontrolled diabetes High glucose levels with uncontrolled diabetes 4Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

5. 5 Physical Effects of Food on Periodontal Health An imbalance of one or more nutrients can be a factor in disruption of tissue integrity and immune response An imbalance of one or more nutrients can be a factor in disruption of tissue integrity and immune response Normal growth and development of periodontal and oral tissues need: Normal growth and development of periodontal and oral tissues need: Vitamin A Vitamin A (salivary glands, epithelial tissue) Vitamin C Vitamin C (collagen, connective tissue) Vitamin B-complex Vitamin B-complex (epithelial, connective tissue) Calcification of bone and cementum requires: Calcification of bone and cementum requires: Amino acids, calcium, phosphorus, vitamin D, and magnesium Amino acids, calcium, phosphorus, vitamin D, and magnesium Maintenance of oral tissues, immunity and repair responses requires: Maintenance of oral tissues, immunity and repair responses requires: Vitamins A, C, and D Vitamins A, C, and D Proteins Proteins Carbohydrates Carbohydrates Calcium Calcium Iron Iron Zinc Zinc Folic acid Folic acid

6. 6Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Physical Effects of Food on Periodontal Health Food consistency Food consistency Chewing firm, coarse, and fibrous foods, such as raw fruits and vegetables, stimulates saliva flow Chewing firm, coarse, and fibrous foods, such as raw fruits and vegetables, stimulates saliva flow The increase in saliva will enhance oral clearance of food and reduce food retention The increase in saliva will enhance oral clearance of food and reduce food retention Plaque biofilm is not physically removed by eating firm foods, Plaque biofilm is not physically removed by eating firm foods, but soft, sticky foods may increase accumulation of food.

7. 7Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Nutritional Considerations for Periodontal Patients Increased nutrients and energy are required by periodontal patients experiencing: Increased nutrients and energy are required by periodontal patients experiencing: Stress Stress Tissue catabolism Tissue catabolism Infection Infection Medical and social history can indicate Medical and social history can indicate whether patient at risk for nutrient deficiencies i.e.; alcoholism, anorexia i.e.; alcoholism, anorexia Dietary counseling of all periodontal patients enhances: Dietary counseling of all periodontal patients enhances: Tissue repair and wound healing Tissue repair and wound healing Resistance to infection Resistance to infection Reduction in number/severity of complications Reduction in number/severity of complications

8. 8Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Gingivitis Gingivitis may develop with the combination of local factors and systemic factors. Gingivitis may develop with the combination of local factors and systemic factors. Systemic factors: Systemic factors: Immunocompromised system (AIDS) Immunocompromised system (AIDS) Medications Medications Hormonal changes (pregnancy, puberty) Hormonal changes (pregnancy, puberty) Vitamin C deficiency Vitamin C deficiency A lack of nutrients does not cause gingival inflammation but may be a predisposing factor in that it disrupts the process of tissue repair A lack of nutrients does not cause gingival inflammation but may be a predisposing factor in that it disrupts the process of tissue repair Encourage vitamin C–rich foods and well-balanced, nutrient- dense diet using MyPyramid as a guide Encourage vitamin C–rich foods and well-balanced, nutrient- dense diet using MyPyramid as a guide

9. 9Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Chronic Periodontitis Initiation and progression of periodontitis do not occur unless plaque biofilm is present Initiation and progression of periodontitis do not occur unless plaque biofilm is present Excess glucose and sucrose also results in an increased rate of bacterial growth in early stages of biofilm development Excess glucose and sucrose also results in an increased rate of bacterial growth in early stages of biofilm development Certain types of food (soft, retentive, and/or a fermentable carbohydrate) can enhance food retention and severity of gingival inflammation Certain types of food (soft, retentive, and/or a fermentable carbohydrate) can enhance food retention and severity of gingival inflammation Nutritional status determines the immunocompetence of the periodontium Nutritional status determines the immunocompetence of the periodontium Intake of nutrients beyond the recommended amount does not improve or speed up healing and may be detrimental Intake of nutrients beyond the recommended amount does not improve or speed up healing and may be detrimental Maintain nutritional diet; avoid retentive foods Maintain nutritional diet; avoid retentive foods

10. 10Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Chronic Periodontitis: Periodontal Surgery Preoperative Immunological competency is important for optimal healing Immunological competency is important for optimal healing Conduct preliminary assessment of patient for adequate nutrient reserves Conduct preliminary assessment of patient for adequate nutrient reserves An elective surgery may need to be postponed for 1 or 2 weeks to allow nutritional status to be improved in a patient with poor nutrition An elective surgery may need to be postponed for 1 or 2 weeks to allow nutritional status to be improved in a patient with poor nutrition Medically compromised patient should be referred to a registered dietitian Medically compromised patient should be referred to a registered dietitian Patient should be given tailored meal plan listing nutrient- dense foods and beverages (e.g.;Ensure) to choose/consume during recovery Patient should be given tailored meal plan listing nutrient- dense foods and beverages (e.g.;Ensure) to choose/consume during recovery

11. 11Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Chronic Periodontitis: Periodontal Surgery Postop Adequate nutrient intake by the patient is required, following periodontal surgery, due to: Adequate nutrient intake by the patient is required, following periodontal surgery, due to: Blood loss Blood loss Increased catabolism, tissue regeneration Increased catabolism, tissue regeneration Host defense activities Host defense activities Dietary intake can be influenced by complications of anorexia, nausea, dysphagia, and oral discomfort Dietary intake can be influenced by complications of anorexia, nausea, dysphagia, and oral discomfort Full-liquid diet Full-liquid diet If patient is unable to chew (by cup-no straw) If patient is unable to chew (by cup-no straw) Mechanical soft diet (p. 358, Box 18-3) Mechanical soft diet (p. 358, Box 18-3) If chewing is compromised If chewing is compromised For Perio dressing, no hard, sticky, or brittle foods, soft diet For Perio dressing, no hard, sticky, or brittle foods, soft diet for 1-2 days, cool liquids for 1 st 24 hrs to harden dressing

12. 12Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Necrotizing Periodontal Diseases Nutrient deficiencies, such as protein or Vitamin C and/or B- complex deficiency, are contributing factors to NUG because of lowered host resistance Nutrient deficiencies, such as protein or Vitamin C and/or B- complex deficiency, are contributing factors to NUG because of lowered host resistance Those with NUG may lose the desire to eat because of pain or may choose soft foods that are easier to eat Those with NUG may lose the desire to eat because of pain or may choose soft foods that are easier to eat Tissue infection and destruction increase requirements for all nutrients Tissue infection and destruction increase requirements for all nutrients When fever is present, a 12% increase in energy and nutrients is recommended for each degree above normal body temperature When fever is present, a 12% increase in energy and nutrients is recommended for each degree above normal body temperature Severity of NUG determines initial dietary recommendations Severity of NUG determines initial dietary recommendations Liquid nutrition supplements may be Liquid nutrition supplements may be needed until a regular diet can be resumed From Perry DA, Beemsterboer P: Periodontology for the Dental Hygienist, ed 2. St. Louis: Saunders, 2007.

13. 13Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Necrotizing Periodontal Diseases Dental hygiene considerations Dental hygiene considerations While ulcerations are present, encourage bland, soothing foods (such as gelatin, pudding) and avoidance of spicy and acidic foods (such as citrus fruits and tomatoes) While ulcerations are present, encourage bland, soothing foods (such as gelatin, pudding) and avoidance of spicy and acidic foods (such as citrus fruits and tomatoes) A liquid diet may be needed initially with advancement to a mechanical soft diet followed by a regular diet, depending on the patient’s tolerance and comfort A liquid diet may be needed initially with advancement to a mechanical soft diet followed by a regular diet, depending on the patient’s tolerance and comfort Cooler-temperature foods are more soothing when ulcerations are present Cooler-temperature foods are more soothing when ulcerations are present Referral to an RD may be indicated Referral to an RD may be indicated