Your guide to a healthy smile

Flashing a warm, friendly smile goes a long way in today’s fast-paced life. Modern research indicates, however, that there is a lot more lurking behind that friendly smile than a welcoming personality. There is now a body of evidence linking teeth and gum health to serious conditions such as metabolic syndrome, which includes heart disease, diabetes and obesity, as well as major depressive disorder and even erectile dysfunction. Achieving optimal dental health involves far more than regular brushing and the occasional floss.

Gums a-blazing

Some people lavish regular attention on their pearly whites while others obliviously skip through life doing the bare minimum. Oral health and hygiene refer not only to healthy teeth but also to healthy gums. Some of the markers of poor oral health include dental cavities, tooth loss, inflammation of the gums, poor saliva composition/flow and periodontal disease.

Periodontal disease is a particular focus in much of the current research and refers to a group of common chronic infections that produce an exaggerated inflammatory response to the “bad” bacteria found in the mouth. This chronic infection affects the attachment of connective tissue and bone around the teeth. If left untreated, it can be serious enough to lead to loss of the affected tooth or teeth. We now know that the body as a whole is being adversely affected long before reaching this end stage.

For a long time, periodontal disease was viewed as a local infection with no further health implications. More recent research suggests that inflamed gums form an easy entry point for bacteria and that these bacteria can directly and indirectly cause health issues. We know bacteria themselves can cause infection and subsequent inflammation but we have more recently discovered that these bacteria also release poisons called endotoxins as well as all kinds of local immune mediators that, once in circulation, can affect distant organ systems. Common oral bacteria have been found in arterial plaques, for example. Once a link was suggested between oral health and systemic health, the body of research around these fields blossomed.

Metabolic syndrome

Metabolic syndrome, rampant in the Western world, is associated with obesity, increased waistline measurement and an increased risk of cardiovascular disease and type 2 diabetes. What is interesting is the link now being made with this group of conditions and oral health.

Obesity is central to metabolic syndrome, with high waist circumference being a predominant feature. Research now tells us there is a close relationship between obesity and oral health. Obesity coexists with a greater risk for dental cavities, reduced salivation levels and periodontal disease. All these risks have the potential to increase loss of teeth, which may in turn alter food selection and contribute further to obesity. Poor dental health affects food choices with an unhealthy diet often comprising softer or more highly processed foods that are perceived as easier to chew.

Obesity also goes hand in hand with an inflammatory state in the body. Far from being inert, fat cells release adipokines, which trigger the development of inflammation in the body. This inflammatory state leads down the path of chronic disease, including cardiovascular disease, which is now understood to be an inflammatory disease rather than one of “bad fats”. As both obesity and oral health are affected by nutrition, it was suggested in the Journal of the Canadian Dental Association that oral health may reflect the inflammatory state coexisting with obesity.

Periodontal disease, which involves inflammation of the gums, has been associated with almost every feature of atherosclerosis. It has long been established that cardiovascular disease and treatment affect oral health and numerous studies have linked oral diseases such as cavities, low salivation, periodontal diseases and tooth loss to most elements of metabolic syndrome.

Studies have shown that successful treatment of periodontal disease has beneficial effects on diabetes, suggesting that oral inflammation that does not respond to routine dental procedures may indicate undiagnosed or uncontrolled type 2 diabetes. A Cochrane review found evidence suggesting a small but significant improvement in blood-sugar control from treating pre-existing gum disease in people with type 2 diabetes. It also seems that periodontal treatment leads to clinically relevant improvements in systemic inflammation and should be carried out as early as possible for optimal health.

Depression

A seemingly unlikely candidate with a link to oral health is major depressive disorder. Major depressive disorder involves impaired mood, thoughts and behavioural patterns and is characterised by a marked sadness or a loss of pleasure in daily activities along with a range of other symptoms.

A study in the Journal of the American Dental Association concluded that major depressive disorder is associated with a disinterest in daily routines such as oral hygiene, poor diet, reduced salivary flow, rampant dental cavities and advanced periodontal disease. This is of heightened concern with the known links between poor oral health and other systemic diseases, as already discussed.

Erectile problems

Few men would think that the health of their teeth and gums might be linked to erectile function yet it seems this may be the case. Both chronic periodontal disease and erectile dysfunction are associated with cardiovascular disease and diabetes. One population study set out to discover if there was a direct link between erectile dysfunction and chronic periodontal disease and concluded that there did appear to be a direct association.

While more studies are necessary, these findings concur with our current understanding of both erectile dysfunction and poor oral health linked to systemic inflammation, endothelial dysfunction (affecting the interior lining of blood vessels) and atherosclerosis.

Protecting your gums

In the interests of achieving the best possible dental health we need to take a holistic approach, starting with a generally healthy diet and lifestyle. We have seen that there is a significant relationship between obesity and dental health, so the starting point is weight normalisation. To achieve this, a low-energy diet and regular physical activity are required. It’s interesting to note that increased physical activity has been associated with reduced periodontal disease, regardless of weight.

There is strong evidence that a diet rich in fruit, vegetables, wholegrains, nuts, fish and unsaturated fats, together with regular exercise, contributes greatly to overall health, including dental health. A dental-friendly diet should be low in refined sugars, sugar-containing foods, saturated fats and trans fats. Beverages should comprise water (around one-and-a-half litres a day) and unsweetened herbal teas. Fruit juices, soft drinks and sweetened milk drinks should be avoided. Overweight and obesity are a significant problem with respect to dental health and evidence does not support low-fat diets; rather, attention should be devoted to an overall lowering of caloric intake.

Vitamin C

Research indicates that antioxidants reduce the inflammatory processes of periodontitis. Vitamin C, in particular, has been shown to reduce severity of periodontitis in one study while another noted that higher levels of vitamin C in the blood predicted a lower incidence of periodontitis. Good sources of vitamin C include citrus fruit, kiwifruit and capsicum.

Omega-3 fatty acids

The anti-inflammatory effects of omega-3 fatty acids have been demonstrated in many disease conditions. Preliminary findings for omega-3 fatty acids and oral health are promising. Omega-3 fatty acids have been shown to improve human gingivitis in one study, while another study of periodontitis showed that omega-6 fatty acids in the form of borage oil were more helpful than omega-3s. The Journal of the American Dietetics Association published a population study that found that higher levels of DHA and, to a lesser degree, EPA (both found in fish oil) were associated with a lower prevalence of periodontitis.

Vitamin D

It seems that the more research is done on vitamin D the more promise it holds for human health and vitality. This seems to also be the case with oral health. Studies have linked geographical variations in dental health and tooth loss to sun exposure. Research conducted in the 1920s found that vitamin D stimulated the calcification of teeth in dogs; subsequent research found a beneficial relationship between the prevention of dental caries in children and vitamin D supplementation.

Low serum levels of vitamin D have been associated with gingivitis and periodontal disease and a clinical trial of vitamin D and calcium supplementation showed increased tooth retention in elderly people.

It’s thought that vitamin D is beneficial to oral health through its relationship with calcium metabolism as well as the fact that it induces cathelicidin, which is an antimicrobial peptide that attacks oral bacteria linked to dental caries.

Vitamin D is the sun vitamin, so 15–20 minutes of morning or afternoon sun exposure three to four times a week is generally advised or supplementation with a high-quality D3 supplement at 1000IU per day or higher if frank deficiency is found via a blood test by your doctor. Vitamin D can also be found in cod liver oil, salmon, mackerel, sardines, eggs and fortified foods.

Calcium

Another more obvious nutrient with a significant role in dental health is the mineral calcium. Low dietary levels of calcium are associated with increased levels of periodontal disease. The recommended intake is 840mg a day for adults and increases to 1100mg a day for women over 50 and men over 70 years of age. Good sources of calcium include fish with soft bones that you eat, including tinned salmon and sardines, as well as whitebait, kale, broccoli, Chinese cabbage, most grains and fortified foods.

Probiotics

An exciting area currently under investigation for potential benefits to oral health is that of probiotics and prebiotics. Probiotics are the large group of bacteria that exert a positive effect on the body of which Lactobacillus acidophilus is the most commonly known. Prebiotics refers to the “food” these bacteria like to eat. More than 700 species of oral bacteria have been found in the human mouth and these micro-organisms work actively to improve our oral health.

Some of the work these micro-organisms perform in your mouth that you may not even be aware of includes the blocking of colonisation by bad bacteria, improvement of cell structure and function, development of the immune system and the normalisation of inflammation levels. Various studies have shown specific strains of probiotics to improve oral health, reduce dental caries and inhibit plaque formation. As for whether probiotics can become a viable treatment option for oral health, more research is required but studies to date are promising.

Shiitake mushroom

Other avenues have been explored in the search for natural immune support and medicinal mushrooms, such as shiitake, have shown promise in their exertion of antimicrobial effects. One study compared the effectiveness of shiitake mushroom extract with the active component in the leading gingivitis mouthwash, containing chlorhexidine. The results indicated that shiitake mushroom extract lowered the numbers of some “bad” bacteria without affecting the bacteria associated with health, unlike chlorhexidine, which was found to lower bacteria associated with both health and disease.

Flossing and brushing

Finally, we cannot forget simple good oral hygiene in the form of regular flossing and brushing and six-monthly checkups with your dentist. A Cochrane review in 2009 found electric toothbrushes to be superior to manual toothbrushes for removal of plaque and reduction of gingivitis. A brushing time of approximately two minutes is recommended and the ideal pressure is around 150g, which is about the weight of an orange. If you are uncertain about brushing technique, talk to your dentist or dental hygienist.

In summary, dental health goes far beyond simply achieving a dazzling smile. Research now links poor oral hygiene to obesity, cardiovascular disease, type 2 diabetes and possibly even erectile dysfunction and major depressive disorder. It also seems that improving your oral Health may improve the prognosis of any of these existing disorders and vice versa. This further highlights that oral health reflects your systemic health.

Healthy teeth and gums require more than regular sessions in the dentist’s chair; they also requires healthy eating, regular exercise, weight normalisation and a comprehensive health plan for any existing metabolic disorders.

References available on request.

Kate Mirow is a naturopath, nutritionist, herbalist and homœopath practising at Your Health in Manly, NSW. She specialises in fertility and weight loss while also seeing myriad other health conditions. T: (02) 9977 7888.