Nutrition and Oral Health

Nutrition for oral health involves more than just avoiding sugar and getting enough calcium. Many different nutrient interactions affect both the hard tissue of teeth and soft tissue of the entire oral environment, and smart meal and snacking patterns and good food choices can go a long way to prevent cavities or enamel erosion, and to maintain healthy soft tissue and tooth-supporting bone to promote periodontal health.

Diet and Dental Decay

Diet plays an important role in prevention of tooth decay, and how foods affect demineralization of teeth is complex and depends on many different factors. From the amount of processing in some foods to the timing of carbohydrate consumption to the remineralization effect from calcium, phosphate, and fluoride in saliva, diet is part of a balancing act to keep teeth healthy. (See "causes of dental disease" to understand to how food interacts in the bacterial process of tooth decay or to understand chemical acid erosion of enamel.) Below are some of the basic nutrition principles affecting cariogenicity (ability to cause tooth decay) of food.

Carbohydrate form sugar and starches - Most people are aware that sugar can cause cavities, but starches can also be cariogenic, and sometimes are more likely to promote decay than sugar. Raw, unprocessed starch is not likely to promote decay, but refined white flour and cooked starch lead to breakdown of starch components that are then more likely to lead to demineralization and tooth decay. Starch tends to get stuck in grooves and between teeth and may be retained on teeth longer than some sugary foods, and the addition of sugar to starches adds more cariogenicity, as the sugar accelerates the decay process of the starch that adheres to the teeth. Acidic, sweet beverages such as apple juice added to a starchy snack such as crackers also accelerate the demineralization process. People may be surprised that a snack of crackers and juice or cookies or cupcakes can be worse for teeth than some candies.

Retention of carbohydrate - How long a carbohydrate stays on the teeth affects its cavity-causing potential. Sticky foods such as dried fruits or caramels or taffy are more cariogenic than fresh fruit or non-sticky candy such as dark chocolate bars. Slow to dissolve hard candy such as lollipops also are more likely to lead to cavities as the sugar from these foods is around the teeth longer. Sugar concentration is a factor, as syrupy foods will dissolve slower and may be more likely to adhere to teeth. Foods that become lodged between the teeth or in grooves are more cariogenic. Examples of these foods include crackers made with processed starch (saltines, fish-shaped crackers) and potato chips. Sweet beverages (sodas, juices, sports drinks) can be particularly bad as they bathe the teeth in sugar.

Amount of carbohydrate versus frequency of intake - Each time a person consumes a fermentable carbohydrate food, there is an acid exposure for 30 - 60 minutes as bacteria in the mouth metabolize the offending food, before other oral action works to balance with remineralization. Carbohydrate foods consumed in one five-minute sitting will result in one exposure, but the same foods spread out over five times during the day will result in five times the exposure. Many parents will think that holiday candy or sweet treats are best doled out to children a piece at a time over several days, when actually the better plan is to get rid of the treat as soon as possible. It is also a good idea to avoid keeping special treats readily available around the house.

Snacking versus mealtime consumption - Carbohydrate foods that can lead to cavities may not be a problem if eaten with meals or paired with other non-carbohydrate foods. For example, protein foods can help counteract the acid production associated with bacterial metabolism of carbohydrate foods by contributing phosphorus to help remineralization, and cheese or milk products provide calcium and casein protein that also help with remineralization. Other foods eaten at mealtime can stimulate saliva to help buffer acids produced, and food consumed at mealtime can physically aid in removal of sticky foods from teeth surfaces.

Order of food eaten in a meal or snack - Surprisingly, the order a food is eaten in a meal can affect the decay-causing potential. Ideally, the last food eaten in a meal should be protective. Milk, hard cheese, protein foods, vegetables, or nuts are good choices, and the practice of providing a sweet dessert at the end of a meal should not be a regular practice. Fruit can be part of a meal, and if the meal is a picnic or party meal, providing a buffet with small amounts of sweet foods presented along with other foods may be a better idea that holding off a desert table for the end. If a dessert is provided, following it with a glass of milk could provide some protection.

Unprocessed foods - In general, less processed foods are better choices for teeth. For example, fresh fruit contains water and fiber that are both protective. Water provides a mechanism to dilute acid and fiber offers a mechanical means to help remove food particles. Processed fruit cups packed in juice or syrup, squeezable fruit in a tube, or fruit beverages don’t have the same protective benefits of whole fruits. Whole-grain foods are better choices than starchy foods made with processed refined flour, chips, or other processed snack food, as they do not break down as easily in the oral environment. Increased chewing required for unprocessed food also increases saliva production to provide a balance to demineralization action.

Importance of saliva - As mentioned above, saliva plays an important part in providing balance to prevent cavities. Saliva production helps to dilute acid and provides buffering action to bring the oral environment back to a neutral level rather than acidic. Saliva can also act to deliver calcium, phosphorus, and fluoride to the teeth to remineralize enamel. Foods that require chewing increase saliva production, as does sugarless gum. Xylitol sweetened gum, in particular, has special cavity-fighting properties that aid in preventing decay-promoting bacteria from forming plaque.

Protective factors from foods and beverages - There are several foods that provide protective factors for teeth. Hard cheeses and milk provide calcium, phosphorous, and casein protein, and other protein foods provide phosphorus to help remineralize teeth. Water dilutes acid and washes away food particles, and if fluoridated, contributes fluoride to strengthen enamel. Unsweetened black tea, hot or iced, contains some fluoride to aid in remineralization and provides an alternative to acidic or sweet beverages. High-fiber vegetables such as celery or carrots encourage chewing and stimulate saliva. Cocoa and dark chocolate contain chemicals that can fight cavity development through effects on decay-causing bacteria, and unsweetened cocoa nibs can be protective. While the sugar in chocolate candy subtracts from the benefits of cocoa, plain dark chocolate with low sugar content does not promote decay as much as other candy.

Diet and Enamel Erosion

Whereas dental decay is caused by a bacterial process in which fermentable carbohydrate foods are metabolized by bacteria to form acids that demineralize enamel, acid erosion from food is a chemical process whereby acidic foods etch enamel to demineralize tooth surface. Erosion occurs when the effects of acidic exposure from foods and beverages throughout the day foods overcome the balance of remineralization that occurs with normal saliva process supersaturating with calcium, phosphate, and fluoride. Enamel erosion is on the rise as there are so many foods and beverages available now that contribute to the problem, and habits of continual sipping of beverages or frequent snacking throughout the day has become a habit for many. The following tips will help minimize erosion.

Use a straw - If an acidic beverage is consumed, it is important to avoid contact with teeth as much as possible. A straw will minimize contact.

Check for bad habits with beverages - Avoid swishing an acidic beverage in the mouth since that action bathes the teeth in a solution contributing to erosion. Also avoid frequent consumption of acidic beverages. A habit of having a soda around for constant sipping throughout the day is going to accelerate the etching effects of the erosive process.

Drink water or rinse after consuming an acidic food or beverage - Having water available to rinse after consumption of an acidic beverage or food will help dilute the acid and rinse it off tooth surfaces. Ideally, substituting water for sipping other beverages is a good habit to develop.

Don’t brush immediately after acidic exposure - When teeth are exposed to acid, the enamel is softened for a period of time, and vigorous brushing can remove the soft enamel. Wait about an hour after an acid exposure before brushing, and make sure to know the proper way to brush. (A check with the dentist or hygienist can help with learning proper technique.)

Stimulate saliva with food that requires chewing or sugar-free gum - One of the most important actions to prevent erosion as well as dental decay is to promote saliva production to remineralize teeth surfaces. Foods that require chewing or use of sugar-free gum can promote saliva production, and if medications are causing dry mouth, use of a product such as Biotene© rinse can help. Also, make sure to give the mouth a rest from constant exposure to either decay or erosion-producing foods or beverages. To achieve a healthy balance, teeth need periods of no food or beverage consumption when the remineralization process can occur.

What foods and beverages contribute to erosion? - Carbonated beverages promote erosion, and citric acid as an ingredient in a beverage is particularly bad, so beverages containing that acid can be damaging. However, the acid of the beverage and the pH are not the only factors affecting erosive qualities, and some beverages have protective factors that can reduce erosion. Calcium in an acidic beverage reduces erosive effects, and some other factors also appear to help. Colas and root beer are less erosive than clear soft drinks. Sports drinks are concentrated sources of acid and are one of the worst culprits; substitution of milk or chocolate milk may be a good idea for replenishing after a workout. Eating lemons or limes contribute to erosion and this habit should be avoided.

Diet and Periodontal Disease

While there are specific tips to prevent decay or erosion, overall good nutrition habits are important in relation to periodontal disease. Periodontal conditions are not caused by nutrient deficiencies, but maintaining a healthy diet to support development and maintenance of the hard, calcified structures of teeth and bone supporting teeth and the soft oral tissue - gums, tongue, roof of mouth - will be protective. Inflammation plays a role in development of periodontal disease, and collagen production is important in promoting both hard and soft tissue health, so a diet that is high in nutrients related to these factors is essential for oral health. Below are outlined some nutrients that are particularly important for periodontal health, along with descriptions of why they are important and what foods are good sources.

Nutrients Important for Hard and Soft Tissue of the Oral Environment

While specific nutrients are described below, it should be noted that good nutrition is not a matter of working to consume foods to obtain individual vitamins or minerals but is instead an overall effect of balance of all required nutrients consumed in recommended amounts from a healthy diet. Even when there is an association of a particular nutrient with improved oral health or reduction in oral disease conditions, the general research findings show that consumption of recommended amounts through a healthy diet offer the best benefit, with little evidence that higher levels of supplemental use confers any additional benefit. The inclusion of the vitamins, minerals, and fatty acids described below reflect their function in bone or soft tissue heath, and also reflect the fact that many people consume less than the recommended amount in their diets of several of these nutrients. A balanced diet with high intake of fruits and vegetables, whole grains, dairy products or other calcium-rich foods, and protein sources including beans and nuts as well as animal protein sources can help ensure that optimal intake of important nutrients is obtained.

Calcium - This mineral is important for development of strong bones and teeth. Calcium combines with phosphorus in the body to form calcium phosphate, which is deposited in crystals around a protein framework in bones. For children, calcium is obviously a significant factor in tooth development, but calcium continues to be important for adults, and as described previously, it is a necessary component in saliva to remineralize tooth on a continual basis. Calcium is also necessary for maintaining dense bone in the jaw to provide resistance to the destruction caused by periodontal disease. Recommended intake of calcium is 700 mg for children ages 1 - 3, and 1000 mg for children to age nine and adults ages 19 - 50. 1300 mg is recommended for ages 9-18, and 1200 mg is the recommended intake for women over 50 and all adults over 70.

Calcium is found primarily in dairy products - milk, cheese, and yogurt. (Low fat dairy products are recommended.) It can also be obtained in moderate amounts from tofu, green vegetables such as broccoli or kale, and in almonds, beans, soy or other vegan milk choices or calcium-fortified juices. Spinach contains high amounts of calcium but its absorption is inhibited from oxalates present in this food.

Although calcium can be obtained from supplements, only limited amounts of calcium can be absorbed at one time, so it is advisable to split up the supplements into two or more dosages per day, with no more than 500 mg administered at one time. High intake of calcium (over 2000mg) has been associated with kidney stones and with vascular calcification. It should be noted that one study found that high use of calcium supplements (>805 mg/day, without additional vitamin D supplementation) in adults age 40 or older was associated with increased occurrence of myocardial infarction (heart attack). Similar intake of calcium from dietary sources did not show this association.

Vitamin D works along with calcium in maintaining healthy bones and teeth, and is a nutrition factor of concern for development of healthy teeth and in maintenance of health jaw bone in relation to periodontal disease. While the recommended amount for this vitamin ranges from 600 IU in children over age four and in adults to age 70 to 800 mg in age 71+, it has been found that some people consuming recommended amounts can still show low blood levels of this vitamin. Vitamin D can be obtained from sunlight, but is blocked by sunscreen use. In the winter months the sun is not strong enough in the mid-Atlantic area to provide enough vitamin D, so supplementation may be necessary for part of the year, especially for people who do not consume vitamin D fortified milk. Older adults in particular may have difficulty with absorption of vitamin D. If people have concerns or if there is a high-risk for osteoporosis (e.g.- small frame, female, postmenopausal, family history of the disease) they should check with their doctor to see if blood testing is warranted to make sure they do not have deficiencies.

Vitamin C - This vitamin, also known as ascorbic acid, is known to aid in healing and tissue repair, and plays a role in forming and maintaining collagen. The breakdown of collagen by bacteria is a major factor in the development of periodontal disease, so it follows that adequate vitamin C is necessary for a healthy oral condition. It should be noted, however, that while vitamin C is involved in the maintenance of tissue health, periodontal disease should not be considered to be a vitamin deficiency disease. Best sources of vitamin C include citrus fruits, red, green, or other-colored bell peppers, tomatoes, leafy green vegetables, cabbage, cantaloupe, strawberries.

Magnesium - This mineral is important for a wide variety of metabolic processes and is important for bone formation and maintenance. Good sources of magnesium include whole grains, beans, almonds and almond butter, spinach, sunflower seeds, peanuts and peanut butter.

Potassium - This mineral aids in retention of calcium and it is important to balance potassium and sodium in the diet. A high potassium/low sodium diet can improve absorption of calcium., while a high sodium/low potassium diet can decrease calcium absorption. Potassium is also important for heart function, muscular contraction, and many other metabolic processes. White potatoes and sweet potatoes are among the best sources of potassium, which is good to know for people who love potato products. (Even French fries and potato chips contribute potassium, just be careful not to overindulge.) Spinach, broccoli, tomatoes (including tomato sauce and juice - but read nutrition labels to find a brand with lower sodium content), winter squash such as pumpkin, acorn, or butternut squash, carrots, beets, oranges, cantaloupe, and bananas are good sources. Fruits and vegetables in general help increase total daily potassium intake, and increasing intake to seven to ten servings will help ensure that recommended amounts of potassium are consumed.

Vitamin K - In addition to its role in blood clotting, vitamin K is important for formation of a bone matrix protein, osteocalcin, and some studies have shown that it is associated with lower risk of bone fractures in older adults. Vitamin K is found primarily in leafy green vegetables such as spinach, kale, broccoli, Swiss chard, lettuce.

Vitamin E - This vitamin is an anti-oxidant, and offers protection to prevent cell damage by free radicals. It also helps immune function and has anti-inflammatory properties. Since periodontal disease, like so many other medical conditions, is associated with inflammation, it is suggested that this nutrient as part of a healthy diet can be beneficial for oral health. It is prudent to consume the recommended amount from dietary sources for overall good health. There is no indication that supplemental use in higher doses than obtained through a healthy diet offer additional benefits. Almonds or almond butter and sunflower seeds are the best sources of this vitamin, and spinach, bell peppers, hazelnuts, broccoli, peanuts, and olive oil are also good sources.

Omega 3 fatty acids - This nutrient is found primarily in fatty fish such as salmon, and in walnuts and flax seeds. It has anti-inflammatory properties, and consumption of recommended dietary amounts is associated with lower levels of periodontitis. No additional benefits have been associated with higher supplemental use.