On Sunday, February 25, 2007, a 12-year-old Maryland boy died of an untreated tooth infection that had migrated to his brain.1 This tragedy underscores the warning of the Surgeon General of the United States, that America is in the midst of an oral health crisis.2 Despite great advances in the last 50 years in oral health awareness, improved dental treatments, and fluoridation of municipal water supplies, dental problems continue to persist-especially in underserved populations.3-5

Today, dental caries (tooth decay) is still the most prevalent disease of children, affecting nearly 80% of children by age 17 years (see Table 1 for definitions of commonly used terms).2 The incidence of dental caries in children's primary teeth is also increasing6 as is the incidence in teenagers' permanent teeth.7,8 Twenty-six percent of American adults older than 20 years have had severe destructive periodontal disease.2 Nearly 68% of elder Americans between the ages of 80 and 90 years have some form of periodontal disease, a condition that often leads to tooth loss2 and may be associated with an increased risk of cardiovascular disease.9 In the elderly, tooth loss is still a major contributor to poor health and malnutrition.10,11 Yet despite the evidence, the importance of oral health to overall health is often underrecognized or underappreciated.

Table 1. Dental Definitions

Oral health can affect and be affected by nutrition, dietary patterns, and food choices. 2 Relationships between dietary factors and dental caries have been noted for centuries. More than 200 years ago, Aristotle recognized that figs caused teeth to rot. In l746, Pierre Fauchard, the "father of dentistry," reported that sugary foods contributed to tooth destruction.12 In past centuries, the wealthiest people, who had the greatest access to costly refined sugars, also had the greatest amount of dental caries. Today, many people are aware that somehow sugar causes dental caries, but are unaware of the complex factors that contribute to caries development.

Oral health can have significant effects on the food choices, which ultimately affect nutritional status.11,13 Mouth pain and discomfort-whether from dental caries, gum disease, infection, or ill-fitting dentures-can lead to food avoidances through a lack of desire and/or ability to eat.12-14 In children, caries-related pain and discomfort can result in reduced caloric intake and/or inappropriate food choices that may ultimately contribute to failure to thrive.7,8

The dietary effects of compromised dentition (including edentulism) on mastication have been well established.11,13,15 The prevalence of edentulism in Americans adults older than 60 years is about 25%, with rates of edentulism increasing with advanced age.16 Poor dentition has been independently associated with a low body mass index, a decreased fiber intake, poor diet variety, lower intake of vitamins A and C, and low scores on the Healthy Eating Index.13 This may occur because, in the face of mastication challenges, people may gravitate toward foods that are easy to chew but are low in nutritional quality, such as cakes and pastries rather than fresh fruits and high-fiber grains.17 These choices are often high in fat, carbohydrate, or calories, which can increase risk for developing chronic diseases such as cardiovascular disease, diabetes, and some forms of cancer. Older adults have the greatest edentulism rates and are also at risk for developing these chronic diseases.18,19

How Systemic Nutrition Affects the Oral Cavity

The mouth is a sensitive early indicator of nutritional and general health status. The soft tissue in the oral cavity has a more rapid turnover rate than other body tissues.20-24 For this reason, clinical signs and symptoms of health problems, including nutrient deficiencies or toxicities, often appear first in the oral cavity before becoming clinically evident elsewhere in the body.20 For example, the earliest clinical signs of vitamin C deficiency may be gingival bleeding and redness. Cracks in the corners of the mouth are associated with B-complex deficiencies, and excess vitamin A can interfere with oral-tissue healing after surgery.

Nutritional adequacy is important for optimal development of hard and soft oral tissues beginning in utero. After birth, when teeth have erupted into the oral cavity, the effects of systemic nutrition on the teeth are minimal (other than through effects on saliva). However, the other oral tissues, such as the alveolar bone (jawbone), mucous membranes (eg, gums and lips), and soft and hard palates, undergo continuous remodeling and regeneration throughout life and thus rely on diet adequacy throughout the life span.2,14,20

Systemic nutrition may also play a pivotal role in oral diseases such as periodontal disease and oral infections. Periodontal disease results from bacterial infection of the gingiva (tissues surrounding the teeth).25 Initially, the gums become swollen, red, and puffy and bleed readily. As the infection progresses, the tooth-supporting alveolar bone can recede, causing the tooth to become loose. Although nutritional factors do not necessarily cause periodontal disease, they can play an important role in its prevention, initiation, progression, severity, and response to treatment. Malnutrition can exacerbate the susceptibility to periodontal infection by reducing host resistance, undermining tissue repair, and facilitating inflammation and periodontal tissue destruction.26 Dietary factors such as deficiencies in calcium, phosphorous, and vitamin D are associated with alveolar bone loss as well as long bone osteoporosis and can contribute to tooth mobility and eventual tooth loss.10,27,28

Conversely, optimal nutrition helps to promote immune function, increase tissue resistance to periodontal pathogens, and promote periodontal healing and tissue integrity.14,28,29 Nutrient toxicities, although rare, can also have oral implications. Excessive vitamin A intake can cause xerostomia (dry mouth), impaired tooth formation, and impaired tissue healing.30Although rarely seen in humans, vitamin D toxicity can cause pre-eruptive enamel hypoplasia and defective calcification of the tooth pulp in children.31

How Diet Affects the Oral Cavity

Dental caries is a complex dietobacterial disease, which, like any disease, results from the interplay of host (susceptible tooth), agent (dental plaque), and environmental factors (diet, saliva). Dental plaque is a film of colonized bacteria and salivary proteins that forms normally on tooth surfaces, especially along the gum line and on the chewing surfaces. The bacteria in plaque (Streptococcus mutans and lactobacilli) ferment dietary carbohydrates into acids. These acids, when secreted by plaque bacteria on tooth enamel surfaces, demineralize the enamel. When the demineralization has reached the dentinoenamel junction (where enamel meets the less mineralized dentin), the acid may continue the enamel destruction, and the bacteria invade and destroy the protein component of dentin (Figure 1). Topical fluorides, administered on a daily basis, play an important protective role in this process by increasing the resistance of the outer layers of dental enamel to acid demineralization and by helping to remineralize demineralized areas of enamel. Saliva also plays a variety of important protective roles in the oral cavity, which are detailed in Table 2.30,32

Table 2. Oral Functions of Saliva

Figure 1. Dental caries process simplified.

Dietary factors are essential for dental caries development. All simple carbohydrates-glucose, fructose, maltose, and, to a lesser extent, lactose, and sucrose-can be metabolized by cariogenic bacteria. Starches can also be cariogenic if they are retained in the mouth long enough to be hydrolyzed into simple sugars by the salivary enzyme amylases. It is the amount of time that any of these fermentable carbohydrates are in contact with dental plaque bacteria, rather than the total amount of sugars consumed that is most critical dietary factor for the development of dental caries.8,32 Caries risk increases as the number or length of eating or drinking occasions increases. Table 3 lists the dietary factors that increase or decrease caries risk.

Table 3.Dietary Factors That Affect Caries Risk

Food characteristics can also play an important role in their cariogenic potential. Foods that tend to be retained in the mouth for longer periods, such as slowly dissolving candies and dried fruits, increase the exposure time of teeth to bacterial acids.14 Conversely, foods that are quickly eliminated from the mouth are potentially less damaging than those that are retained longer. Nevertheless, a sugary liquid that may be eliminated quickly from the mouth when consumed rapidly becomes much more cariogenic if sipped over a longer period. Furthermore, the acid in beverages, such as sodas, diet sodas, and citrus juices, can also cause direct enamel demineralization if consumed or sipped frequently over time.33

Noncarbohydrate food constituents can also help modulate the cariogenic potential of foods. For example, calcium and phosphorus in foods help remineralize enamel. Dietary fiber can help stimulate saliva, and water can help clean the mouth, decreasing the amount of time foods remain in the mouth, and helping to counterbalance the cariogenic effects of the carbohydrates.30,34 Toothbrushing and flossing is recommended after eating to help remove food debris.

Fluoride, especially when provided consistently in drinking water or dentifrice, helps maintain a more resistant enamel surface that counteracts the effects of acids produced from bacterial metabolism of dietary carbohydrates.32 However, this protective benefit of fluoride may be overwhelmed if the dietary consumption of cariogenic foods is excessive and/or if there is a deficiency of saliva (xerostomia).14,32

In summary, numerous variables-frequency of eating, characteristics of foods, foods as snacks versus meals, amount of time foods reside in the mouth, frequency and duration of oral hygiene, access to fluoride, regular dental visits-make the actual caries risk of an individual diet difficult to determine. However, in general, the fewer the between-meal snacks and sweetened beverages the lower the caries risk.32

Life Cycle Nutrition/Oral Issues of Current Interest and Concern

Pregnancy

Maternal oral health and nutrition are important for both mother and fetus, as nutrition begins its lifelong impact on oral health in utero.27 Gingivitis during pregnancy is a common phenomenon that can lead to more severe periodontal disease. An estimated 60% to 75% of all pregnant women have gingivitis, partially resulting from increased hormonal influences on inflammation. Some research findings also suggest that periodontal disease may be a risk factor for having a preterm low-birth-weight infant.35 Adequate nutriture is essential for optimal oral development. Poor prenatal nutrition can undermine fetal oral growth and development, resulting in increased risk of dental caries later in life.27 Calcification of enamel of deciduous teeth occurs from 14 weeks in utero to about 4 months of age. Mineralization of the permanent dentition occurs from birth to around age 10 to 15 years. During these periods, deficiencies in calcium, vitamin D, vitamin A, protein, and calories all have been shown to result in oral defects.18 New data suggest that inadequate dietary intake of vitamin B₆ may be a risk factor for cleft lip and cleft palate formation.24 Throughout life, deficiencies in one or more of the B-complex vitamins can result in clinical oral changes such as glossitis (inflammation and soreness of the tongue) and mucositis (inflammation of oral soft tissues), and angular cheilosis (cracks in the corners of the mouth).30

Children and Teenagers

Dental problems in early childhood may not only predict future dental problems but can also interfere with growth and cognitive development by affecting nutrition, which in turn affects concentration and school participation.7 Early childhood caries, the most severe form of dental caries in primary teeth, is the most common oral health condition of American children (Figure 2). Early childhood caries results when newly erupted primary teeth are exposed to excessive cariogenic foods and beverages over time.7,8,36 The prevention of early childhood caries requires avoidance of nighttime, or prolonged daytime, bottle usage; limiting sugar-containing beverages; keeping teeth clean; and ensuring that children have adequate exposure to fluoride.7 For children and adolescents, sweetened, high-calorie beverage usage has increased drastically in recent years37 as has the incidence of obesity. Although a direct association has not been shown between childhood obesity and dental caries, both conditions share some common etiologic factors. For example, food choices, such as excessive intake of sodas, juice or juice drinks, and sweets, increase both calories and caries risk. Sedentary activities can also lead to increased between-meal snacking, a risk factor for both obesity and dental caries.6,38-42 Teenagers drink twice as much soda as milk43 and therefore are deriving about 40% of their carbohydrate calories from soft drinks.44 As a result, the dental benefits of fluoride are in danger of being overwhelmed by caries-promoting sugars and acids.36,37,45 Teenagers may be unaware that the sugar-free beverages they consume, if they are acidic, can also cause tooth enamel demineralization.33

Figure 2.Early childhood caries. With permission of the Australian Dental Association,

Eating disorders have significant medical, dental, and nutritional complications. They most commonly affect 14- to 28-year-old women, but have been seen in males and females of all ages. Eating disorders, particularly bulimia, can present significant risks to oral health. Many of the first clinical signs of eating disorders appear in the oral cavity. Dental patients may complain that tooth enamel appears to be flaking off, and teeth and gingiva may be sensitive or painful. There may also be swollen glands, evidence of xerostomia, and even mucosal trauma (from objects used to induce vomiting). Constant vomiting results in acid that can demineralize tooth enamel. Xerostomia results in the loss of the protective effects of saliva. Because of the complex nature of eating disorders, patient management needs to be multidisciplinary and include medical, psychiatric, dental, and nutrition professionals if treatment is to be successful.46,47

Adults and Elders

As people age, periodontal disease may result in recession of the gingival tissues around the teeth. The newly exposed tooth surface (cementum) is less mineralized than enamel and thus more susceptible to acid demineralization. Caries in these areas is termed root caries, as it occurs around the roots of the teeth (Figure 3).46

Figure 3. Adult root caries. With permission of the Australian Dental Association,

The risk of developing root caries is increased with the use of medications, because many of the drugs commonly used by adults and elders-antidepressants, antihypertensives, anti-Parkinson disease agents, diuretics, sedatives, antidiarrheals, and bronchodilators, to name a few-can cause xerostomia.48 When saliva production is diminished, the cariogenic risk of diet increases, as foods are cleansed more slowly from the mouth, and enamel is less readily remineralized.19

Many of the changes associated with aging-decreased wound healing, bone mass, and immunity; and increased incidence of diabetes, cancer, and reliance on medications-may also affect the oral cavity.13,49,50

Several studies show associations between loss of alveolar bone and long bone.10,19,50 Poor skeletal bone status has been associated with increased oral bone loss, periodontal disease, and tooth loss in postmenopausal women.51 Also, inadequate calcium and vitamin D intake has been associated with increased alveolar bone loss, increased risk of periodontal disease, and increased risk of tooth loss as well as with long bone osteoporosis.28,48,52,53 It has been suggested that tooth loss may be an early warning sign for long bone osteoporosis.54

Other Chronic Health Conditions

Nutrition and oral health issues are also of concern in a variety of chronic health conditions such as diabetes, osteoporosis, and immune-compromising conditions. There is a strong correlation between periodontal disease, poor glycemic control, and oral infections.19,55 Diabetes is a risk factor for developing severe periodontal disease. Conversely, severe periodontal disease increases diabetes mellitus severity and complicates metabolic control. Thus, control of chronic periodontal infection is essential for achieving long-term control of diabetes mellitus.

Patients with type 2 diabetes have twice the risk of developing periodontal disease as people who do not have diabetes.19 A similar phenomenon occurs in type 1 diabetes. Signs of periodontal disease can emerge in children with type 1 diabetes as young as age 6 years.56 In addition, persistent oral infections increase blood glucose levels, which catalyze further infections, and can result in declining oral health over the long term.19,56,57

Periodontal disease may also be associated with increased risk of cardiovascular disease and stroke. There is mounting evidence that oral health tends to reflect vascular health, although the evidence does not prove that periodontal disease is a direct cause of cardiovascular disease.58,59 The American Academy of Periodontology has reported that people with periodontal disease are almost twice as likely to have coronary artery disease as those without periodontal disease.60

One study of 1056 patients, reported that people with high levels of periodontal bacteria also had thicker internal linings of their carotid arteries-a major risk factor for stroke.61 In another study, high levels of bacteria were related to a high incidence of heart disease in study participants.62 Yet analyses of NHANES (National Health and Nutrition Examination Survey) data have failed to show similar relationships.63-65

Patients with autoimmune diseases commonly have mastication difficulties, gingivitis, oral lesions, and candidiasis (fungal infections), as well as high rates of dental caries.14 In Sjogren's syndrome or pernicious anemia, the associated xerostomia often increases caries rates. Malnutrition and weight loss are often unfortunate sequelae of HIV/AIDS or cancer therapy. In these cases, oral pain along with anorexia can be significant contributing factors to oral problems.66 Whether from a fungal infection, virus, oral lesion, or periodontitis, oral discomfort has the same result: decreased interest in food and an increased risk of malnutrition.14

Emerging Research on Nutrition and Oral Health Relationships

Nutrition and oral health relationships are complex, and many past studies have suffered from methodological problems. Nevertheless, current research is further exploring relationships between nutrition and oral health that may ultimately result in clinical benefits. For example, nutrients that influence gene expression and inflammation such as vitamin D and omega-3 fatty acids may have potential oral health effects.23,67 Dietary and supplemental sources of omega-3 fatty acids have been shown to reduce chronic and acute inflammation. As such, they may prove to be a useful adjunct in the treatment of periodontal disease by helping assuage some of the inflammation-related degenerative effects of periodontal disease.67 In rats, omega-3 fatty acids reduce resorption of alveolar bone as well.23

Research on the effects of omega-3 fatty acids in patients with the autoimmune disease, Sjogren syndrome, showed that treatment with a flax seed- and fish oil-based omega-3 fatty acid supplement was effective in increasing salivary secretion and improving the characteristic dry mouth and dry eyes in these patients.68

Relationships between calcium, vitamin D, and oral bone loss are also undergoing active investigation. Calcium and vitamin D deficiencies not only affect oral bone, but also result in increased oral tissue inflammation, a major symptom of periodontal disease.53,69,70 Conversely, supplementation with vitamin D and calcium may help retard alveolar bone loss70and reduce gingival inflammation. Sixty-eight of 70 randomized clinical trials studying the effects of calcium and vitamin D in the treatment of alveolar bone deterioration reported positive benefits from supplementation.28,29,70 Unfortunately, to date there have not been well-designed vitamin D-calcium-periodontitis clinical trials to demonstrate the value of calcium and vitamin D as adjuncts to standard treatments for preventing and treating periodontal disease.57

The evidence for an association between obesity and periodontal disease is growing as well.57,71 Obese individuals are more likely to have periodontitis and a higher proportion of certain bacteria in their dental plaque than are nonobese individuals.57,72 Obesity may cause decreased blood flow to periodontal tissues and affect host immune responses due to the thickening of the innermost membrane of periodontal blood vessels.73 Adipose tissue secretes tumor necrosis factor, which mediates injury to periodontal tissues through increased matrix-degrading enzyme and osteoclast (bone resorbing) activity as well as increased insulin resistance.73,74 In obese patients with diabetes, these effects are even more pronounced and severe.56,73

Many food components also appear to have unique oral effects. For example, cranberries contain flavonoids (eg, quercetin and myricetin), phenolic acids (benzoic acid), anthocyanins, condensed tannins, and other phytochemicals can inhibit plaque formation, affect cariogenic bacteria, and prevent acid formation.75 Some components of cocoa can impede bacterial adherence to teeth (thus providing an anticaries benefit).76 A recent study found that phytochemicals in raisins [eg, oleanolic acid, oleanolic aldehyde, 5-(hydroxymethyl)-2-furfural] inhibited the growth and adherence of some species of oral bacteria that cause caries and periodontal disease.77

However, it is important to keep in mind that preliminary research is often used by industry as a tool for product endorsement, which can lead to confusion among consumers and health advocates alike. For example, based on the cocoa research, candy companies have advertised that sugar-laden chocolate is actually beneficial to teeth-a claim that is unwarranted.78 The raisin industry also touted sugar-laden raisins as "good for teeth."79 This distortion of research does a disservice to the public, despite the hope that this preliminary research may have some benefits in the future. More research on food components as modifiers of the carbohydrate effects of foods may result in more accurate, appropriately targeted messages for future consumers.

Interest in dental enamel remineralization has increased with the increase in dental erosion evidenced in all age groups-especially teenagers.80,81 Calcium and phosphorus in foods, as well as fluoride, can help remineralize eroded dental enamel and are thought to be the reason that cheeses are not dentally harmful despite their lactose content. These minerals may hold promise as erosion-preventive food additives in the future.

Whereas chewing gum was traditionally considered harmful to teeth, today, in line with increased research, recommendations have changed. Gum chewing stimulates the saliva that cleanses the mouth, removes caries-promoting food debris, and remineralizes teeth. The salivary-stimulating effects of sugar-sweetened chewing gum may override any cariogenic risk from the sugar when the gum is chewed infrequently. Artificial sweeteners are not cariogenic, so artificially sweetened gum confers even greater benefit.82 Xylitol-containing gum is not only noncariogenic, but also has specific antibacterial activity that helps prevent caries.83 Indeed, there also is good evidence that when mothers of infants and young children chew xylitol-sweetened gum, this habit will block transmission of mutans streptococci from mother to child.84

Research on the oral effects of black and green tea has also been intriguing. Catechins and theaflavins are polyphenolic compounds derived from tea. They have shown diverse and potent health effects, especially in the oral cavity.85 In animal studies, they inhibit oral carcinoma cells.86 Black tea can also contribute to reduced caries risk in animals by inhibiting bacterial adhesion to enamel and by inactivating starch reduction even in the presence of a cariogenic diet.87 Thus, tea consumption may prove to be effective in reducing the cariogenic potential of starch-containing foods.88 Green tea also aids the buffering action of saliva.89 Although animal and in vitro studies have documented benefits and possible mechanisms of tea's effects on oral tumor reduction, conclusive evidence of human effects is lacking.75

How Can Nondental Professionals Help?

Diseases of the oral cavity are serous, yet preventable. Like most other health conditions, the emphasis should be on prevention rather than treatment.4 Nutrition professionals and other health care professionals can help promote good oral health through good nutrition. Table 4 summarizes the important dental/nutrition messages for various age groups. All of these simple principles can be provided in conjunction with other nutrition or other health guidance. For example, a recent study showed that nutrition counseling resulted in significantly increased fruit and vegetable consumption by edentulous people who received new dentures.13,17Table 5 debunks common myths related to oral health and may help health care providers recommend appropriate oral health information to the public. Table 6 provides some reliable Internet resources for further information. We hope that all health-related educators will consider nutrition and oral health as an important component of their practices.

Table 4. Dietary Suggestions for Oral Problems

Table 5. Dental Health and Nutrition-Myth Versus Reality

Table 6. Selected Dental Internet Resources

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