Calcium and oral health
For years we’ve been told that calcium from dairy will keep our teeth healthy. Let’s examine this statement.
Although teeth and bones are quite similar in that they are both composed of calcium, phosphate and water, there are some significant differences with regards to how they function. Teeth begin to form before birth and mostly erupt before the age of 13. Prior to tooth eruption, deficiency of calcium can adversely affect tooth enamel mineralization as well as tooth size, and timing of eruption, resulting in small teeth and developmental defects. Even though teeth are composed of living tissue, similar to bone, they are densely mineralised and avascular. During the course of a person’s life, demineralisation and remineralisation occur mostly in localized areas: on a tooth surface, and deep around the pulp chamber.
After tooth eruption, deficiency of calcium can produce osteoporosis in the alveolar bone of the jaw rather than the teeth themselves and is implicated in periodontal health. However, this calcium deficiency is reversible upon calcium replenishment. It has been suggested that the jaws exhibit osteoporotic changes first before osteoporosis becomes evident in the spine or peripheral sites, but this has since been disputed.
It has also been thought that animal protein leach calcium from the bones, which in more recent studies has been questioned. Radioactive isotope studies have demonstrated that it’s the calcium we consume that gets excreted rather than the calcium from the bones in meat eaters. So, the notions that meat consumption is responsible for leaching calcium from the bones is not entirely correct.
It should be emphasised that calcium is most certainly important for our health. You sometimes hear that vegans do not need as much calcium due to their overall high nutrition intake. This is not supported by scientific evidence, and it is important that vegans put as much thought as non-vegans into their daily calcium intake. Considering numerous studies have demonstrated that calcium can be easily obtained from a whole plant-based diet, there is no need to resort to dairy to ensure the health of our teeth. Packed with bovine oestrogens, antibiotics, lipids, protein, growth factors (IGF-I) and sodium, dairy is hardly a healthy source of calcium. Conversely, plant sources of calcium are packaged with fibre, folate, potassium, and other beneficial nutrients. Although molasses and dry fruits are also high in calcium, consuming these regularly can result in dental caries.
We know that countries with the highest rates of dairy consumption also have the highest rates of osteoporosis, prostate, and breast cancers. We also know now that milk per se has virtually no effect on the teeth, and that nearly every plant-based food there is, from broccoli to soy to watermelon, has calcium. There’s nothing magic about milk that is essential for our teeth. The harmful effects of dairy far outweigh any benefit, and there’s nothing in milk that plants can’t provide without those harmful effects. Nuts, legumes, and green leafy vegetables are all excellent sources of dietary calcium, without the harmful effects of the dairy.
So how much calcium do we need to consume for healthy teeth? The recommended daily intake of calcium varies depending on several factors such as age, gender, or whether you are pregnant or breastfeeding. It can even be influenced by the country. For instance, in some Asian countries the recommended daily intake is only 600mg per day, half the 1200mg recommended in Western countries. The recommended daily amount will provide adequate calcium for healthy teeth.
Caries
Dental caries is the most prevalent and expensive noncommunicable disease worldwide, consuming 5 -10% of healthcare budgets in industrialised countries. 6.9 billion people (92% of world’s population) will at some point suffer from dental carries. Advanced stages of the disease, result in severe pain, hospitalisation, and can be debilitating, resulting in complete loss of dentition, reduced function, nutrition, and deterioration of psychological well being. It’s a disease that is almost exclusively linked to diet and is preventable through good nutrition.
The disease is characterised by demineralisation and permanent damage of tooth enamel and dentine. Certain bacteria in the mouth (streptococcus mutans) metabolise simple sugars and produce acid as a waste product, which in turn demineralises enamel and dentine. Confectionery sugar sources, as well as sugars added to savoury processed foods are a primary cause of caries.
A healthy mouth is in the neutral pH range of around 7.0. Demineralisation starts at or below pH of 5.5. With every sugary meal, pH will drop, but saliva is a natural buffer, which will start clearing acids and remineralising enamel within 20 minutes of sugar consumption. If a person consumes sugar 2-3 times a day, with plenty of sugar-free periods in between, caries will not occur. Thus, it is important to note that it is the frequency of sugar intake, rather than the overall amount, that is implicated in caries. Snacking on even small amounts of sugar, frequently throughout the day, will ensure the development of the disease. Thus, preventative strategies are centred around minimising the frequency of sugar intake:
- Sweets (lollies, chocolates, biscuits, cakes, soft drinks) are to be only consumed occasionally or never. Replacing sweets with sugar free alternatives, which are sweetened with non – sugar sweeteners, such as Stevia is preferable.
- Choosing wholefoods, which do not contain added sugars will significantly minimise the frequency of sugar intake. Look at the list of ingredients when shopping and exclude products with added sugar. For instance, Vita Brits don’t contain added sugar, but Wheat-Bix do. Plant milks, sauces, condiments, and even canned chickpeas can contain added sugar.
- Natural sugars, which are found in maple syrup, agave nectar, molasses, honey, coconut sugar, dry fruit, juices, and smoothies are also damaging. It is also possible for fresh fruit to cause caries, if consumed frequently throughout the day. One should not limit the quantity of healthful fresh fruit consumption, but rather aim to eat it 3-4 times a day at the most, at mealtimes, rather than to snack on it.
Some studies suggest that there might be a slightly elevated incidence of caries and dental erosion in vegans, but overall, the incidence is similar to that of the general population.
Sweeteners
If sugar is so harmful, what about non-sugar sweeteners such as Splenda (sucralose), Sweet one (Acesulfame K), NutraSweet and Equal (aspartame)? There seems to be a link between these and inflammatory bowel disease (IBD). In China, Canada, and the US, studies have demonstrated a direct correlation between the introduction of sucralose to the market and a massive jump in IBD incidence.
Xylitol and Erythritol on the other hand appear to be safe but training our palates to move away from the sweet taste is a better solution. Considering the evidence, do we really want to sweeten our taste buds?
Stevia is a very sweet plant and when processed, produces a substance 100 to 300 times sweeter than sugar. There are some new studies, which show that excessive amount of Stevia can also alter the microbiome in the guts of rats, which as it turns out are similar enough to our own. But it seems to be safe to consume small amounts of Stevia without any harmful effects. Green, unprocessed ground up Stevia leaf is a great alternative for sweating your food.
Fruitarian diet
Strong evidence exists supporting a well-balanced, health promoting diet consisting of a combination of grains, legumes, fruits, and vegetables. Evidence supporting a purely raw diet is not as prevalent. Oral health is an excellent indicator of the shortcomings of a raw diet. If such a combination is consumed, natural sugar from fruit, bound with fibre, can only practically be consumed several times a day, which in of itself isn’t an issue. However, raw vegans and fruitarians are displacing grains and legumes with foods that have a high sugar content, therefore increasing the frequency of sugar consumption, thus they are more likely to develop erosion and caries. Moreover, because of the low-calorie content of these diets, fruitarians are more likely to be snacking on sugary foods throughout the day, increasing the frequency of sugar consumption even further.
As nutritious as fruits are, historically, they were always seasonal, and our predecessors only ate them when nature provided. High quantities of simple-sugar foods were not freely available throughout the year, so they were consumed in moderation (and in their whole form) as a part of a well-balanced diet, and not as a whole source of nutrition and calories.
Of further consideration are dietary acids, lemon water, vinegar dressings, sucking on lemons, oranges etc, ruthlessly dissolve enamel. Once again, raw vegans and fruitarians are particularly prone to subjecting their teeth to an acidic environment over extended periods of time given the acidity in fruits and juices. Not a problem if consumed in moderation but moderation is an impossibility with a fruitarian diet.
Complex carbohydrates are a different matter. They are not implicated in caries. The only exception here is white bread with its pre-refined carbohydrates, which, with the assistance of salivary amylase, start breaking down to simple sugars in the mouth. 100% rye bread or wholemeal for instance is less damaging than white bread.
Fluoride
Fluoride has earned itself a bad reputation in the health-conscious circles, vigorously opposed by anti-fluoridationists. Most of the anti-fluoridation arguments have been debunked over 60 years ago. According to the World Health Organization (WHO), water fluoridation is one of 10 great public health achievements of the 20th century.
So how does Fluoride aid in caries prevention? Remineralisation of enamel takes place when calcium and phosphate from saliva re-enter demineralised enamel, to form a natural Hydroxyapatite [Ca₁₀(PO₄)₆(OH)₂] compound. When saliva has fluoride (Flurosilic acid from water or Stannuos fluoride from toothpaste), enamel and dentine are able to take in Fluoride ions (F-) and replace groups (OH–) in the formation of a new fluorapatite [Ca5(PO4)3F]. Fluorapatite forms rather than hydroxyapatite in the remineralisation process, which is stronger and more resistant to caries.
This is a very useful and well researched process, but perhaps too much emphasis is placed on fluoride in prevention of caries, and less on good nutrition. Knowing the principles of dental caries occurrence, fluoride is merely a band-aid. A well balanced, whole food plant-based diet, that is low and infrequent in simple carbohydrates, is the ultimate prevention strategy.
Periodontal disease
Periodontitis is a form of advanced inflammatory disease affecting surrounding soft (gums) and hard tissues(bone) of the teeth. It is responsible for being the most common cause of tooth loss. Inflammation is one of the underlying factors in periodontal disease. Saturated fat is known for being associated with inflammation. A study found that “High dietary saturated fat intake was significantly associated with a greater number of periodontal disease events”. The same diet of animal fat and protein, that leads to high cholesterol may also contribute to periodontitis.
Inflammatory cytokines, mediate tissue destruction in periodontal disease. A vegetarian diet seems to reduce these cytokines. A plant-based diet may improve the balance between damaging free radicals and protective antioxidants which is our defence system.
According to the American heart journal, a male with periodontitis is 70% more likely to develop coronary heart disease. Bacteria in the mouth responsible for periodontitis is the same bacteria as found in the heart. When pathogenic bacteria is reduced in the mouth through good care and treatment of periodontal disease, it is also reduced in the heart.
Researchers examined case studies of patients aged over forty years who suffered from coronary heart disease (CHD) in order to ask this very question. (J Gen Intern Med, Humphrey.) They figured that smoking, diabetes, diet, and socio-economic status were all factors that could increase one’s risk to periodontal and coronary heart diseases. So they adjusted they parameters, and still found a link independent of these factors. Periodontitis and CHD aren’t just related through lifestyle choices, they’re also linked even without these factors.
The researchers found that patients who only had the periodontal disease treated by a dentist, without making any lifestyle changes or undergoing treatment for coronary heart disease, also had improved heart function when the periodontal disease improved. The bacteria in the mouth responsible for the chronic gingival inflammation was the same bacteria associated with chronic inflammation in the heart, and when it was reduced in the mouth, it was also reduced in the heart.
Oral Microbiota
Oral microbiota has been a hot topic in recent years. Not only does the composition of oral biome affects oral diseases, it also affects general health. Increasing evidence links oral microbiome with diabetes, obesity, and cancer. About 700 kinds of microorganisms, comprising of bacteria, fungi and viruses, constitute the human oral biome, and it comprises the most complex microbial communities in the human body [1]. Bacterial colonies primarily comprise of the Firmicutes, Bacillus, Proteobacteria, and Actinomycetes [2]. Interestingly, diet and environment exert minimal effect on the composition of oral biome. Healthy people from different parts of the world share similar compositions of oral microbiota.
Interactions with gastrointestinal system
In many experiments, oral bacteria have been identified in the gut of patients with various systemic diseases [3]. Recent studies have demonstrated that oral bacteria can colonise and persist in the gut, leading to chronic intestinal inflammation [4].
Three possible ways have been described in which microbiota can travel from the oral cavity to distant organs of the digestive system:
- Invasion of the intestinal tract through the esophageus [5], [6], [7], [8].
- Through the bloodstream. Periodontal disease in the mouth opens an easy pathway for oral bacteria to enter the circulation, thus acting on the whole body [9].
- Metabolites of oral microbiota can also enter circulation through the periodontium, resulting in low grade systemic inflammation. Although this pathway is not well researched, it has been supported by studies on microbiota imbalance leading to systemic disease [10], [11], [12].
P. gingivalis is of particular interest, as it can be transferred from the mouth to the gut in many diseases (colon cancer, IBD and diabetes). It impairs innate host defences, and at the same time promotes inflammatory responses in phagocytic cells [13], [14].
Diet
Although diet’s influence on oral microbiota is not well researched, some patterns are emerging. Through DNA sequencing of salivary DNA, evidence has shown that the abundance of pathogens (Neisseria and Haemophilus) species are different in individuals with different dietary patterns. Oral pathogens found in hunter-gatherers shows that eating too much meat carries a higher risk for oral disease. In vegetarians the oral microbiota’s composition is significantly different, including oral pathogens such as Neisseria and Haemophilus and respiratory tract microbes (Campylobacter and Porphyromonas) [15]. Westerners fall somewhere in between. More research is needed to draw conclusions on how significant different diets are in promoting a healthy oral microbiome.
Green tea
An interesting ally for the mouth’s microbiome is green tea. A few studies have been conducted on the effectiveness of green tea in fighting streptococcus bacteria. Streptococcus mutans is a species that is implicated in dental carries, and green tea has actually been found to be more effective in killing Strep. mutans than chlorhexidine, an antibacterial mouthwash. Another study found that attempts to control oral bacteria with antibiotics have failed due to bacteria developing antibiotic resistance. Yet another study demonstrated that rinsing with green tea solution without sugar for a short time strongly inhibit salivary and plaque Strep. mutans. If 20 minutes before swishing sugar water, you swish with green tea, you wipe out enough bacteria, that sugar water hardly has any effect. Even more fascinating is that green tea can change oral microbiota namely abundance of(Streptococcus and Staphylococcus), and lower carcinogenesis and thus prevent oral cancer [16].
Oral cancer
Recent research indicates that microorganisms exist on the surface of oral cancers in significantly different compositions to that of healthy mucosa. Prednisone and S. mutans are increased in individuals with oral squamous cell carcinoma [17], and thus might be valuable in future diagnosis for oral squamous cell carcinoma.
Another study showed evidence of the beneficial effects of fruits and vegetables on oral and pharyngeal cancer risk consistently observed in patients regularly eating raw and green leafy vegetables, tomatoes, and citrus fruit. Several case control studies also found consistent inverse associations of cancer and dietary carrot intake.
Diabetes
Researchers have found significant differences in oral microbiota between healthy individuals and patients with type 2 diabetes. Counts of pathogenic organisms such as TM7, Aggregatibacter, Neisseria, Mycobacterium, and Eikenella, Selenomonas, Actinomyces, Capnocytophaga, Fusobacterium, Veillon, and Streptococcus are highly increased in individuals with type 2 diabetes. Illumina2 generation sequencing technology studies revealed that oral microbiota is an important factor in the development of diabetes, and in turn its effects on alveolar (supporting teeth) bone health [18], [19].
Obesity
Little is known about the underlying mechanisms of changes to oral microbiota between ‘normal’ weight and obese individuals. However, it has become evident in recent studies that the bacterial diversity and abundance of oral microbiota in the periodontally healthy obese people were significantly reduced. Obese people exhibited fewer counts of Haemophilus, Corynebacterium, carbonophillic phage, and Staphylococcus, and increased abundance of Plasmodium, S. genus, and S.mutans [20].
Liver diseases
Both gut microbiota and the imbalance of oral microbiota are closely related to liver disease. The oral biome of individuals with liver cancer is increased than in healthy people, and the composition is significantly different. Clostridium, Oribacterium, Ciliate, Actinomycetes, and Campylobacter are more abundant, and Haemophilus, Streptococcus, and Pseudomonas are reduced in people with liver disease. Furthermore, Clostridium and Oribacterium is a biomarker, which can assist in the diagnosis of liver cancer. Similarly, patients with liver cirrhosis exhibit an imbalance of oral microbiota, with an abundance of pathogens, such as Weirong, Streptococcus, and Pasteurella genus, Haemophilus, Lactobacillus, and Clostridium. A proposed theory is that oral microbes invade the gut microbiota of patients with cirrhosis, change the gut’s bacterial composition, increase intestinal mucosal permeability and insulin resistance, and cause gut bacteria to migrate to the liver, causing an increase in triglyceride levels in the liver [21], [22].
Colon cancer
As with many other conditions, the specific mechanism is yet to be identified, but previous studies have closely linked both gut and oral microbiotas with colorectal cancer. F. nucleatum from the oral cavity circulate to other parts of the body and has been isolated from colorectal cancer tissue [2], [24].
Studies have found that if F. nucleatum is transferred from the mother’s mouth to foetal tissue, it can cause foetal death. Flynn et al. found that the biofilm component of the colonic mucosa of patients with colorectal cancer is consistent with it’s periodontal biofilm component.
Pancreatic cancer
Pancreatic cancer is the fourth most common cancer to cause mortality. Again, imbalance of oral microbiota is linked with the development of pancreatic cancer. A comparative study of 371 pancreatic cancer patients with healthy individuals demonstrated, that individuals with pancreatic cancer exhibited a high detection rate of P. gingivalis and Actinobacillus actinomycete in the oral cavity [25].
H. pylori, which is known to cause gastric ulcers, might also be linked with an elevated risk of pancreatic cancer (i.e. 38%). Reduced acid production and elevated levels of nitrosamines, which are associated with gastric ulcers, can elevate pancreatic cancer risk [26].
Rheumatoid Arthritis
Periodontitis is often observed in patients with rheumatoid arthritis. An increased number of studies indicate that periodontitis can activate rheumatoid arthritis by producing enzymes which initiate an autoimmune response.
Rheumatoid arthritis is associated with elevated levels of species such as Lactobacillus salivarius, Atopobium, Leptotrichia, Prevotella, and Cryptobacterium curtum but reduced levels of Corynebacterium and Streptococcus. Even patients who have rheumatoid arthritis but no periodontitis exhibit elevated levels of periodontitis-associated bacteria, such as Prevotella [27].
Septicaemia
Septicaemia is characterised by microorganisms travelling from one organ to another via bloodstream, causing infection and inflammation. The chairman of the department of dental medicine at the University of Pennsylvania conducted a clinical study on patients with septicaemia, and found that over half of the patients who developed septicaemia while in the care of doctors at the University of Pennsylvania hospital, developed it from bacteria that originated in the mouth. Dental care subsequently became a part of routine treatment for cancer patients and patients with coronary heart disease.
Tooth Erosion
Although enamel demineralisation takes place at a pH of 5, it is the type of acid that determines the nature of this process. Citric acid from fruit not only takes minerals out of enamel but also binds calcium preventing it from being deposited back into enamel (remineralising). And therefore, is more erosive than Carbonic acid from carbonated water for instance. Carbonic acid is mild and clears quicker than citric acid. Also, saliva buffering is important as well as frequency and duration of acid exposure. Mixing acids together, as is the case with sports drinks (citric acid and carbonic acid) is the most damaging, as acids work in unison to attack enamel.
Oil pulling
There are many ancient practices from times when we lacked evidence. The ritual of Oil pulling seemingly originates from India. It was thought that the mechanism by which oil pulling (with coconut, sunflower or sesame) through vigorously swishing it around the mouth for 15 minutes to create a soapy emulsion, would supposedly draw harmful bacteria out of the mouth with the expulsion of this concoction. It is also claimed to aid other systemic conditions such as meningitis, heart and kidney disorders, hormonal disorders, cancer and even AIDS. It all sounds like a plausible possibility. Why not? If other liquids such as chlorhexidine have been demonstrated to reduce gingivitis? However, when this practice was researched, little evidence emerged to suggest that is actually true. In fact, little research has been conducted on oil pulling at all. The studies which are available have either used a small sample size of participants or have not used a control group to compare the difference between those who practiced oil pulling and those who didn’t. The studies which were adequately set up did not demonstrate any benefits of oil pulling, other than one study suggesting that in comparison to chlorhexidine, swishing oil around the mouth for 10 minutes daily demonstrated similar effects to chlorhexidine after two weeks. In a scientific world, few conclusions can be drawn based on such inadequate evidence. To date, there is no evidence that oil pulling can prevent cavities, detoxify the body, strengthen teeth, treat cancer, or reduce headaches, despite such claims made online. Until we have more empirical evidence, it is still recommended to stick with traditional methods of chemo-mechanical (brushing correctly with toothpaste) debridement and having a healthy diet. At this stage it does not appear that oil pulling is a useful, evidence-based adjunct to brushing and a good diet.
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