Both macronutrients and micronutrients are essential for life and overall health. Multiple factors can cause micronutrient deficiencies such as, medications, malabsorption, lifestyle factors, systemic disorders, pregnancy and certain surgeries. Micronutrient requirements vary depending on age, gender, growth, body composition and genetics. Micronutrient’s role in the onset, progression and maintenance of periodontal disease has been studied for years. In a recent review published in 2018 in the journal Periodontology 2000 the authors aimed to assess the results from multiple studies to determine the effect of micronutrient malnutrition on periodontal disease and periodontal therapy.1
Vitamin A deficiency in developed countries is rare. A nutritional study on more than 21,000 people concluded that “populations with high scores for periodontal disease tended to be deficient in vitamin A.” However, in the Third US National Health and Nutrition Examination Survey, this result could not be confirmed for vitamin A. The role of vitamin A in periodontal therapy has not yet been reported, this could be due to the fact that high levels of vitamin A can cause liver toxicity leading to concerns about safety of conducting a trial using a monovitamin supplement.
Patients receiving a supplement with vitamin B complex showed improved clinical attachment levels when compared to patients receiving a placebo. However, no differences were found regarding bleeding on probing or microbiological outcomes. A double-blind placebo-controlled study evaluated the efficacy of a folate containing mouth rinse in patients with gingivitis and periodontal disease. The results showed a decrease in bleeding on probing and less gingival redness in the folate mouth rinse group. More studies are needed to determine the role of vitamin B12 and folate in the onset and as a possible treatment of periodontal disease.
Vitamin C has long been associated with reduced gingival inflammation, primarily due to its role in the onset of scurvy. Interestingly, vitamin intake results in increased levels of serum vitamin C levels in nonsmokers but did not show an increase in serum vitamin C levels in smokers. Additionally, increased serum vitamin C was resulted in less bleeding in patients with gingivitis, patients with diabetes mellitus, and chronic periodontitis. Though a reduction in bleeding was noted, the increased serum vitamin C levels did not affect the extent of periodontitis-related tissue destruction.
In a study based on the US National Health and Nutrition Examination Survey, patients with high vitamin D levels had less alveolar bone loss. However, the effect was independent of bone density and was not associated with periodontal disease. This points to the importance of the anti-inflammatory properties of vitamin D and not necessarily the osteogenic properties. Another study evaluated how vitamin D levels affected bone augmentation. The results showed no difference between the placebo group and vitamin D group regarding graft resorption and bone formation. However, more osteoclasts were found around graft particles in the vitamin D group.
In animal studies calcium deficiency was associated with periodontal disease, however, follow up studies in humans were inconclusive. The Third US National Health and Nutrition Examination Survey concluded “low dietary calcium intake results in more severe periodontal disease.” Another important point was that participants with high intakes of dairy as a source of calcium were 20% less likely to have periodontal disease than those with lower intakes. Studies evaluating the efficacy of calcium and vitamin D supplements on the outcome of periodontal therapy, there was a modest, positive effect.
No effect was seen in studies evaluating vitamin E, magnesium, iron and copper. Low levels of potassium may increase blood pressure and affect periodontal inflammation. Another emerging issue regarding micronutrients is specific gene polymorphisms that can affect the efficacy of nutritional transporters leading to deficiencies. Several of these single nucleotide polymorphisms have been associated with aggressive periodontitis.
The authors conclude by stating, “the data available suggest that micronutrients are important in the prevention and treatment of periodontal disease but further research I required to define mechanism, risk groups, and potential intervention strategies. In the meantime, a pragmatic approach to the provision of nutritional advice seems to be in keeping with the recommendations of the World Health Organization for high-risk individuals for periodontitis, whilst the evidence base continues to emerge.”
- Dommisch H, Kuzmanova D, Jönsson D, Grant M, Chapple I. Effect of micronutrient malnutrition on periodontal disease and periodontal therapy. Periodontol 2000. 2018 Oct;78(1):129-153. doi: 10.1111/prd.12233. PMID: 30198127.