Ivoclar's Presentation

2. Progressive Oral Health – Mark James - Ivoclar 27th October 2017
What Guides our Present Dietary Behaviour and how does it Relate to
General and Dental Health Improvement? An Ongoing, Dynamic and
Contrary Learning Journey.

3. • Investigate the recent history and role of nutrition regarding
chronic health conditions linked to oral and general health.
• Gain greater awareness of macronutrients, micronutrients and
dietary behaviours that promote dental and general health.
• Consider future provision of nutritional guidance and treatments
in our daily practice. ( should we?)
Learning Aims of the Day

4. My dental health diet
• Avoid free/added/processed sugars (or
cease). As little sugar as possible
(ALSAP).
• Eat real food – macro/micronutrient
rich, locally sourced ideally. Fibre.
• Omega 3 and 6 oils in good ratios.
• Consider functional foods and drinks.
• Consider Oral probiotics.
• Get enough sunshine

5. Disease and Ill - Health – What Do We Know as a
Percentage - Diet, Tobacco, Alcohol and Physical Activity.

6. Professional Attitudes Towards Providing Dietary advice 1
Cross sectional observational questionaire 987 dental hygs and therapists mailed
questionaires in S W Australia – only 426 responded.
Respondents indicate they believed it was part of their role but also suggests there are
barriers preventing the delivery of dietary advice;
• Time
• Patient compliance
• Patient knowledge
• Clinical counselling skills
• Clinical knowledge of nutrition
• Lack of confidence delivering it
• Authors suggest lack of nutritional workshops and training.
Int J Dent Hyg - Dental and Oral Health Research Review Issue 4 2016

7. Professional Attitudes Towards Providing Dietary advice 2
Attitudes and practices of dentists with respect to nutrition and periodontal health. Kelly & Moynihan, British Dental Journal 205,
E9 (2008)
• 879 questionnaires completed by Dental Hygienists and Dentists.
• 66 % of respondents believe nutrition plays a role in periodontal health.
• Vitamin C ( 70%)
• Fruit and Vegetables (64%)
• Antioxidant vitamins (45%)
• 44% recommended nutritional supplements
• 37% recommended multivitamin and mineral supplements
• 30% recommended Vitamin C
• 82% sourced information from dental journals
• Survey indicated uncertainty about evidence base around nutrition and periodontal health
and a lack of training opportunities.

8. Key Points - Professional Guidance
• Practise within our scope of practice and professional knowledge,
skills and competence or refer.
• Not describe yourself as or imply that you are a health practitioner of
a particular kind unless you are registered and qualified to be a
practitioner of that kind.
• Consider complete health needs of your patient. A holistic approach is
all-inclusive.
• Collaborate with colleagues and other health practitioners.
http://www.dcnz.org.nz/i-practise-in-new-zealand/dental-hygienists/scope-of-practice-for-dental-hygienists/

9. Key Definitions – World Health Organisation
• Nutrition - intake of food, considered in relation to the body’s dietary needs. Good
nutrition – an adequate, well balanced diet combined with regular physical
activity – is a cornerstone of good health.
• Obesity - abnormal or excessive fat accumulation that is a major risk factor for a
number of chronic diseases, including diabetes, cardiovascular diseases and
cancer.
• Diabetes mellitus - a metabolic disorder of multiple aetiology characterized by
chronic hyperglycaemia with disturbances of carbohydrate, fat and protein
metabolism resulting from defects in insulin secretion, insulin action, or both.
• Cardiovascular diseases - a group of disorders of the heart and blood vessels. The
most common reason is a build-up of fatty deposits on the inner walls of the
blood vessels.

10. Heart Disease – New Zealand
Source https://www.heartfoundation.org.nz/statistics

11. What is our Present Knowledge? Periodontitis (PD) and HD
• Periodontal pathogens were isolated
from heart plaques and such bacterial
species (Porphyromonas Gingivalis)
are shown to invade endothelial cells.
Haraszthy et al. 2000, Kuramitsu et al. 2002.
• Further more, oral bacteria can
induce platelet aggregation and
thrombus formation. Herzberg et al. 1994.
• C Reactive Protein (CRP) , a substance
produced in the liver increases
inflammation in the body as a
response to infection and is positively
associated with CVD. Danesh et al. 1998.

12. Correlation between periodontal disease (PD) and atherosclerosis –
Fact or Fiction?
• Consistent association between
periodontal disease and 10 + year risk of
atherosclerosis.
• Periodontal treatment can improve
endothelial function and other makers of
atherosclerosis.
• Lowering LDL prevents or reduces
periodontal disease.
• Causality cannot yet be concluded –
larger longitudinal cohort RCTs required.
Source - Interaction between periodontal disease and atherosclerotic
vascular disease – fact or fiction? Ghazal et al, 2015.

13. Diabetes Type 2 – New Zealand

14. Diabetes Type 2 – The Devil in the Detail
• CDC 2012 – 1 in every 7-8 had DMT2– 12-14% of the population.1
• 38% prediabetic, 36.4% were undiagnosed. 2
• 30% predicted to get diabetes in their lives.1
• 95% of DMT2 associated with overweight and obesity.1
• 80% increase since 1960 - associated rise in sugar consumption especially sucrose and
HFCS.1
• In Auckland NZ estimated 77,000 with diagnosed DMT2 with a further 40,000
undiagnosed.3
1. The Case Against Sugar – Gary Taubes, 2016.
2. Prevalence and trends in diabetes among adults in the United States, 1988 – 2012. Menke et al, 2015.
3. www.diabetesauckland.org.nz

15. What is our Present Knowledge? Periodontitis (PD) and Diabetes Type 2(DMTT)
• PD might exacerbate DMTT complications and increase risk of developing
DMTT. Taylor 2001, Mealey 2006, Lalla& Papapanou 2011, Borgnakke et al. 2013.
• The inflammatory response (cytokines) to PD interferences with glucose
metabolism leading to hyperglycaemia, undermining Macrophage and
Neutrophil function affecting their antibacterial and wound healing activities.
McNamara et al. 1982,Ciantar 2002.
• Further more altering gingival crevicular fluid, collagen metabolism and
subgingival microflora. McNamara et al. 1982,Ciantar 2002.
• DMTT causes a shift in oral microbiome that fosters periodontitis by
enhancing inflammation. E Xiao et al, 2017

16. Obesity – New Zealand
Obesity prevalence New Zealand children 2-14 years old (2006/07 –
2012/13) - Source: Ministry of Health. New Zealand Health Survey
(2006/07, 2011/12, 2012 10/13)

17. Obesity – Report – Centre for Disease Control and
Prevention - October 2017
• 40% of American adults and nearly 20% of
adolescents are obese, the highest rate ever
recorded in the U.S.
• 1 in 5 ages 12-19 and 6-11 and 1 in 10 ages 2 – 5
are obese not just over weight.
• Trend increasing despite many public health
efforts to improve nutrition and physical activity.
• Overall 70.7% of Americans are either overweight
or obese.

18. What is our Present Knowledge? Periodontitis and Obesity in Dental Practice
8 longitudinal and 5 intervention studies were included.
2 studies found direct association between degree of
overweight at baseline and subsequent risk of
developing PD.
3 more found direct association between obesity and PD
amongst adults.
2 found a better response to PD from NSPT was better
amongst lean than obese patients.
Conclusion suggested overweight, obesity, weight gain
and increased waste circumference may be risk factors
for PD or worsening of existing condition.
Association between Periodontal Disease and Overweight and obesity: A Systematic Review. Keller et al, 2011.

19. Nutrition for Health
“Don't eat anything your great-grandmother wouldn't
recognize as food.” ― Michael Pollan

20. Fun Food Facts
• ? of the world’s food is generated from only 12 plants and 5
animal species.
• More than ? out of 10 farms in the world are family farms.
• Women make up ?% of the agricultural labour force in
developing countries, and account for about two-thirds of the
world’s 600 million livestock keepers.
• By 2030, global food demand is expect to rise by ?%.
• ?% of a cricket can be eaten, while only ?% of a pig and ?% of
a cow are edible.
75 %
9
43
35
80, 50, 40

21. • Needs to protect against non communicable diseases ( NCD’s) including
Diabetes and Heart Disease.
• A conditional recommendation to limit the intake of free sugars to less
than ?% of total energy intake. A further reduction to ?% is suggested for
additional health benefits.*
• “Free sugars” include mono and disaccharides added by food
manufacturers, in cooking and sugars naturally present in honey, syrups,
fruit juices and concentrates.
WHO Recommendations for a health diet 2015

22. Carbohydrates (do we need carbs?)
1. Monosaccharides – Glucose
2. Disaccharides – Sucrose, Fructose
3. Polysaccharides – complex carbs
4. Fibre
Proteins
1. Amino and essential amino acids
Fats
1. Saturated
2. Unsaturated
3. Polyunsaturated – Essential fatty acids
a-Linolenic acid ALA (Omega 3) and Linolenic acids LA (Omega 6)
Macronutrients

23. Micronutrients - vitamins and minerals

24. Human beings evolved eating a diet with a omega-6:omega-3 ratio of about
1:1. (Paleolithic Ratio)
Modern Western diets exhibit omega-6:omega-3 ratios ranging between 15:1
to 17:1.

25. Nutrition for Dental Health
“Fermentable carbohydrates are the most relevant common dietary risk factors for caries
and periodontal diseases.” Moynihan & Petersen 2004

26. CommonDietaryRiskFactorsforCariesandPeriodontalDiseases
• Fermentable carbohydrates. – Moynihan & Petersen, 2004.*
• For Caries the fermentation process within Biofilm in which acids are
formed.*
• For PD most likely involves glucose and advanced glycation end products
triggering hyper inflammatory state in leucocytes. van der Valden et al.2011.
• Vitamin D deficiency results in enamel hypoplasia/hypomineralisation and
PD. Hujoel, 2013.
• Vitamin B12 deficiency was associated with PD progression and destruction.
Zong et al. 2016.

27. FermentableCarbohydratesandPeriodontalDisease
Reducing sugar intake for 4 – 21 days
lowered gingival scores by approximately
one–third.
Stringent restriction of carbohydrates –
suggested in animal models necessary to
prevent destructive periodontal diseases –
was reported by Gaengler et al, 1986, as
“completely impractical.”
A high sucrose intake is associated with
increased plaque volume as well as gingivitis.
Moynihan & Peterson, 2003
Source - Dietary Carbohydrates and Systemic Diseases. P. Hujeol, 2009

28. Nutrition and Periodontal Disease
• Lower serum magnesium and calcium levels as well as lower antioxidant
micronutrient levels significantly correlate with PD. Van der Valden et al. 2011.
• Vit C depletion can lead to profuse gingival bleeding. Legget et al. 1986, 1989.
• Vit D supplementation combined with
Calcium shown to reduce risk. Krall et al. 2001, Miley et
al 2009.
• Carbohydrate rich diets increases risk of
inflammation and bleeding. Hujoel. 2009, Woelber et al.
2016

29. Fermentable Carbohydrates and Caries
“Caries of teeth is restricted to people and animals who eat liberally of carbohydrate
containing foods. Carnivorous man and animals do not suffer from this disease.” McCullom,
1941
“Low Carbohydrate, high fat diet depressed caries activity to practically nil (commenting
on the Vipeholm Study)” Gustafsson et al, 1954
Low dental caries experience has been reported in groups with habitually low
consumption of dietary sugars, for example, children of dentists. Moynihan & Peterson, 2003
Health recommendations based on Key’s hypothesis asserted that a diet high in
fermentable carbohydrates and low fat reduced systemic chronic diseases, with dental
diseases as a “local dietary side-effect” Konig, 2000

30. Nutrition and Caries
• Lack of Vitamin D, K and Calcium phosphates has a negative impact on
minerality, quality and size of teeth and may also affect risk in later life.
• Concentration and bioavailability of carbohydrates ( and starches ) within
foods and composition as well as adhesiveness of the diet, are additional
influencing factors.
• There is moderate evidence that a diet with less than
10% of free sugars ( 50 g/day ) is associated with low
caries experience. (WHO recommendations)
• More significant relationship between sugar intake and
caries when free sugar intake is less than 5%.
• The EFB group supports the challenging goal of
eliminating sugars from modern diets.
Source - Interaction of lifestyle, behaviour or systemic diseases with dental caries and periodontal diseases. Chapple et al, 2017

31. Omega3essentialfattyacidsandPeriodontitis–AStudy
• Cross sectional study using data from 9,182 adults 1999-2004.
• 1042 fitted periodontal criteria – indicated + association of PD with CRP.
• Dietary DHA (omega 3 ) associated with a low prevalence of PD.
• No statistical benefits of higher than normal amounts detected.
• Limitations of study can only prove association but demonstrated the
protective – anti inflammatory effects of n-3 and n-6.
Source - Omega 3 acids and periodontitis in U.S. adults. J Am Diet Assoc. Asghar et al, 2010

32. Essential Micro-Nutritional in Dental Health
• Vitamin A. – importance unclear but potential
antioxidant benefits.
• B- vitamins 1, 2, 3, 5, 6, 7, 9, 12. – Supplementation
may accelerate post – surgical healing.
• Vitamin E. – Impaired gingival wound healing and a
key extracellular antioxidant.
• Vitamin K. - Deficiency may lead to gingival bleeding.
Unknown supplementation effects.
Source Journal of Clinical Periodontology– Micro nutritional approaches
to periodontal therapy. Van der Valden et al, 2011.

33. Vitamin C and D
•Vitamin C - Ascorbic Acid
• Powerful Anti-Oxidant Radical Scavenger accumulates in PMNL*, MN*,
platelets and Endothelial cells helping to react to inflammatory stimuli.
Boxer et al 1979, Evans et al 82.
• RDA – Men 90 mg daily – Women 75 mg daily – some think these values
are still too low. Levin et al (2001a).
•Vitamin D2 (dietary vitamin) and D3 (sunshine vitamin)
• D3 synthesised through skin from Sun UV light and absorbed from diet. Van
der Velden et al, 2010.* ( with help from Cholesterol )
• Stimulates absorption of calcium and osteoblasts to produce collagen.*

34. Vitamin D3 Guidelines - Sensible Sun Exposure
• Over Exposure increases the risk of skin cancer so avoid
burning.
• Between September and April Sun protection
recommended especially between 10am and 4pm. Between
May and August with sun protection.
• Different people need different degrees of sun exposure.*
( skin colour, age, activity, where you live, meds and health )
• Check UVI via www.niwa.co.nz all your round advice
throughout NZ and www.sunsmart.org.nz for times of day
with UVI over 3.
www.health.govt.nz/your-health/healthy-living/food-and-physical-activity/healthy-eating/vitamin-d

35. Dietary Minerals and Trace Elements
• Calcium – tooth formation – supplementation in
non-surgical periodontal treatments.*
• Magnesium – supplementation may improve non-
surgical periodontal treatments.*
• Iron – possible antioxidant benefits to
periodontium.*
• Zinc – possible antioxidant effects and reduces
severity of diabetes induced periodontitis.*
• Fluoride – supplementation and topical application
to tooth structure.*
Source Journal of Clinical Periodontology– Micro nutritional approaches to
periodontal therapy. Van der Valden et al, 2011.
Calcium - milk eggs nuts seds
Magnesium - Cocoa spinach
tomatoes
Iron - red meat tuna spinach
Zinc - grains spinach
Fluoride - cocoa F- water tea

36. Nutrition - General and Oral Health

37. "Correlation is not causation"
means that just because two
things correlate does
not necessarily mean that one
causes the other.
... Correlations between two
things can be caused by a third
factor that affects both of
them.
A cause - effect relationship is
a relationship in which one
event (the cause) makes
another event happen
(the effect). Tsunamis happen
when tectonic plates shift.
Correlation, Confusion and Confounders

38. Confusion and Contradiction
84
99
15

39. 1992 2005
2011
1977 – 2002 The
Lipophobia Years

41. Which Hypothesis? AKA Ancel Keys verses John Yudkin
Ancel Benjamin Keys was an
American physiologist and
biologist who studied the
influence of diet on health.
John Yudkin FRSC was a
British physiologist and
nutritionist, founding Professor
of the Department of Nutrition
at Queen Elizabeth College,
London.

42. • Keys’ hypothesis
• High Dietary intake of fermentable carbohydrates is nutritious, has no metabolic
adverse effects and causes only dental chronic diseases which are viewed as a dietary
side effect and a local infection.
• The evidence for Sucrose as the “Greatest killer in Western Societies is “utter nonsense”
and would never pass an acceptable term paper in an undergraduate course in home
economic. Keys 1975.
• Yudkin’s hypothesis
• High dietary intake of fermentable carbohydrates is an evolutionary abnormality with
first causes dental chronic diseases, a marker for an unhealthy diet and alarm bells for
future systemic diseases.
• My research on coronary heart disease has convinced me beyond doubt that sugar
plays a considerable part in this terrifying epidemic. Yudkin 1972.

43. Keys concluded “Whether or not cholesterol etc., are involved, it must be concluded that
dietary fat somehow is associated with cardiac diseases mortality, at least in middle age

44. • 1958 – 64 - grant of $200,000 -12,763 mostly rural middle – older aged men 40 -59 years.
• Observational, longitudinal, epidemiological and unrandomised, 16 cohorts, 7 countries, 10
year follow - ups.
• CHD risk in individual and population directly and independently related to total serum
cholesterol. More observed in Northern Europe and USA.
• Demonstrated the slower lifestyle changing habits of Mediterranean populations with less
activity and less traditional dietary habits than other countries.

45. • The findings of the Cretan cohort were of major
importance so a follow up was undertaken in 1991.
• Cretan males 10 x less to have CHD compared to
East Finland males
• Looked at total survivors from 13 villages – 245
men survived of original 686.
• Significant increase in Serum Cholesterol + BMI and
BP. Still lower after 38 years than USA and other
groups.
• Increase in saturated fat – decrease in unsaturated
fat over past 30 years.
• Cretan cohort also had highest life expectancy, low
cancer and dementia

46. • In Corfu men ate less fat than than Crete
but heart disease rates were higher.
• Selection bias regarding Cretan farmers
being chosen not being representative of
the island.
• 60% of Cretan men ate low amounts of
meat for 180 days a year on
recommendation of Orthodox Christian
Church. More sea food, fish and snails eaten
in those times of fasting.
• It appeared that it wasn’t the amount of fat
eaten but the type of fat.
• Investigators did’nt evaluate sugar intake –
they’d have found that Crete and Corfu ate
3 – 4 x less than Japan and UK.

47. Cholesterol• Cholesterol is an organic fat (lipid) molecule
essential for all animal life. Needed to make
certain important hormones.
• 80% of cholesterol is made in the body.
• When dietary consumption decreases, the
body will create more to compensate.
• In the presence of sunlight, the body converts
cholesterol to Vitamin D.
• The body sends cholesterol from the liver to
places of inflammation and tissue damage.
• It is necessary for the absorption of fats and
fat-soluble vitamins (A,D, E and K).

48. The LDL Conundrum – Separating fa(c)t from fiction?
LDL a powerful marker for the development of an
atherosclerotic event. Enters endothelial blood vessel
wall in high levels, forms plaque and can oxidise
triggering inflammation. Preventive Cardiology of Victoria.
Called “Bad Cholesterol” – actually a protein “boat”
transporting serum fat. Important in brain health –
higher levels associated with less risk of adverse brain
changes in recent Neurology Journal.
www.drperlmutter.com.
LDL occurs in small dense and large buoyant bundles.
Shifting small dense to large buoyant LDL can switch by
exercise, weight loss and reduction of saturated fat.
Preventive Cardiology of Victoria.

49. My lipid/Cholesterol Profiles

50. Diet Heart Studies
• Framingham Heart Study
• 1948 - A long-term, ongoing cardiovascular longitudinal, observational, cohort
study with 5,209 adult subjects . Observational correlation between high
cholesterol and heart disease up until the age of 50 and not after.
• Minnesota Coronary Experiment
• 1968 - 1973, a well-planned and executed, ethical (?) RCT study 9,000+ subjects.
The study demonstrated eating a diet rich in saturated fats did not lead to more
heart disease than those who ate a diet rich in polyunsaturated fat from
vegetable oil. These findings went unpublished until 1989. One of the principal
investigators said because "we were just so disappointed in the way they turned
out.”

51. • 1991 – 2006 women aged 50 – 79 RCT purpose of identifying the effects of a
low-fat diet and randomly assigned to the dietary intervention group (40%; n
= 19541) or the control group (60%; n = 29294).
• Participants in the intervention group underwent a regimen of training, group
meetings, and consultations which encouraged low-fat eating habits, targeted
to 20% of daily caloric intake, along with increased consumption of fruits,
vegetables, and grains. Those assigned to the control group were not asked to
adopt any specific dietary changes.
• The mean follow-up for the DM intervention was 8.1 years. The results
indicated that, despite some reduction in CVD risk factors there was no
significant reduction in the risk of CHD, stroke, or CVD.
Diet Heart Studies - Women’s Health Initiative – Diet Modification

52. What I found, incredibly, was not only that it
was a mistake to restrict fat but also that our
fear of the saturated fats in animal foods—
butter, eggs, and meat—has never been based
in solid science. ” Nina Teicholz, The Big Fat Surprise: Why
Meat, Butter, and Cheese Belong in a Healthy Diet
“The simplest way to look at all these associations, between
obesity, heart disease, type 2 diabetes, metabolic syndrome,
cancer, and Alzheimer's (not to mention the other the
conditions that also associate with obesity and diabetes, such
as gout, asthma, and fatty liver disease), is that what makes
us fat - the quality and quantity of carbohydrates we
consume - also makes us sick.”Gary Taubes, Why We Get Fat: And What to Do
About It
Are we now in the age of “Carbophobia”?

53. Saturated Facts
• Crucial provider of essential fats vital for immune function ( Linoleic and Alpha –
Linoleic Acids ).
• Essential for absorption of fat soluble vitamins A, D, E and K.
• All unprocessed fats have varying degrees of saturated, unsaturated and
polyunsaturated types.*
• Doesn’t raise blood sugars and fatty foods like extra virgin olive oil and nuts
have proven to prevent heart attacks and strokes.
• Dietary fat is satiating – feeling fuller for longer compared to refined
carbohydrates.

54. Lyon Heart Study 1999 – benefits of anti inflammatory foods
• RCT of more than 600 first heart attack survivors.
• 1 standard American Heart Association Diet (low fat). 34% fat, of which 12%
saturated fat, 11 % unsaturated with less fibre and omega 3’s.
• 2 Mediterranean Diet rich in olive a rapeseed oils. Diet averaged 30% of fat, of
which 8% being saturated, 13% unsaturated with more fibre and omega 3’s.
• Results showed a 70% risk reduction in cardiovascular complications after 4 years
relative to AHA diet. For every 30 people adopting Med Diet 1 life was saved, better
statistically than taking Statins ( 1 in 83 ).
• Reduction in further heart attacks went to 1 in 18 and a lower onset rate of cancer
after 4 years too.

55. The Mediterranean diet and CVD, diabetes, and obesity
Diabetes Type 2
2 med diet (one with nuts 30gs
per day and the other with
olive oil ) interventions v low
fat control diet in an RCT.
4 year follow up.
When 2 med diet groups were
compared to the low fat
control diabetes incidence was
reduced by 52%.
Obesity
Cross sectional assessment of
7,447 participants with type 2
diabetes of CVD risk.
Dieticians assessed dietary habits
via a 14 item questionnaire.
High consumption of nuts and low
consumption of SSB’s presented
strongest inverse association with
abdominal obesity
CVD
2 med diet (one with nuts 30gs per
day and the other with olive oil )
interventions v low fat control diet
in an RCT.
7,447participants from 2003 to
2009 randomly assigned to three
study groups.
Study indicated an absolute risk
reduction of 30% amongst high risk
people of suffering a cardiovascular
death, a myocardial infarction or a
stroke.
The PREDIMED trail – Spain and Portugal – Parallel, multicentre, randomised trial 2003 -2011

56. PURE – Prospective Urban Rural Epidemiology Study August
2017. A Prospective, Cohort Study, The Lancet
• Looked at the relationship between macronutrients, CVD and mortality.
• 5 continents, 18 countries, 135,335 individuals aged between 35 – 70 – 7 year follow up.
• Primary outcomes – total mortality and CVD events.
• Secondary outcomes – MI, stroke and non CVD mortality.
• Organised into groups representative of nutritional intake (carbs, fat, protein) as a percentage
of energy provided by nutrients and their association to the above.
Design

57. PURE – Prospective Urban Rural Epidemiology Study August
2017. A Prospective, Cohort Study, The Lancet
• Follow up – 5796 deaths and 4784 major CVD events.
• Higher carbohydrate intake associated with an increased risk of total mortality.
• Intake of fat (all types) was associated with lower risk of total mortality.
• Total fat, saturated and unsaturated not significantly associated with risk of MI
and CVD mortality.
Findings

58. Functional Foods – Pre and Probiotics
Functional foods deliver additional or enhanced benefits over and above their basic
nutritional value.
Some functional foods are generated around a particular functional ingredient, for
example foods containing probiotics, prebiotics, or plant stanols and sterols.
Probiotics are defined as live microorganisms – mostly bacteria – which when taken in
adequate amounts confer a health benefit.
Prebiotics promote the growth of particular bacteria in the large intestine that are
beneficial to intestinal health and also inhibit the growth of bacteria that are
potentially harmful to intestinal health.
Source - https://www.nutrition.org.uk/nutritionscience/foodfacts/functional-foods.html

59. Fermented foods
• Sources of live active beneficial microbes
• Improves food taste, texture and digestibility
• Increases concentrations of vitamins and bioactive compounds in foods
Fermented foods that retain cultures
Yoghurt, sauerkraut, olives and some cheeses
Kefir, Kombucha and Kimchi
Fermented foods consumed without living cultures
Beer, Wine, Salami and Chorizo
Sourdough Bread and Chocolate
www. isappscience.org/probiotics

60. Oral Probiotics – A young science going back billions of years
In oral disease environmental and bacterial
changes shift toward pathological changes
promoting infection and host response.
Common strains used in oral probiotics are
Streptococcus salivarius (M18 – K12) and
Lactobacillus reuteri Prodentis. Bhatia & Sidhu.
2014
They retard and inhibit bacterial recolonization of
pockets and reduce total aerobic bacterial count
and metabolism. Bhatia & Sidhu. 2014
Probiotics can also produce antioxidants. Bhatia &
Sidhu. 2014

61. Oral Probiotic M18 Streptococcus salivarius 2.4 cfu/dose
• AIM – to determine colonization of oral cavity, plaque reduction and SMS levels with
M18.
• METHOD - 83 children randomised into test and control groups. The group were required
to suck two lozenges a day, one after brushing the other after brushing at night for 3
months. Children were reviewed at 1, 2 and 7 months.
• RESULTS – 11 participants dropped out – 4 cases of adverse reactions, 3 in the M18 group
one in the control. 80% compliance.
1. M18 was safe. (GRAS)
2. Efficacious in plaque reduction – 87.5% lower in comparison in treatment group to 44%
in placebo.
Influence of the probiotic Streptococcus Salivarius strain M18 on induces of dental health in children: a randomized double –
blind, placebo-controlled trial. Burton et al, 2013. New Zealand

62. Clinical influence of probiotics as adjunctive therapy of SRP when
compared with SRP alone or in combination with placebo in the treatment
of CP. Journal Clinical Periodontology
• Only 4 eligible publications of systematic review and 3 for Meta – analysis.
• L. reuteri bacterial species.
• M-A showed significant short term CAL gain and BOP reduction for SRP +
probiotic Tx.
• Limitations as small sample of studies – findings support use of L. reuteri in Tx
of CP beneficial short term, especially in deep pockets.
Probiotics and Non - Surgical Periodontal Treatment – A Systematic Review and Meta Analysis – 2016 Martin – Cabezas et al.

63. What might a dental health diet look like?

64. Nutritional Guidance for a Dental Health Diet
• Carbohydrate reduction/restriction/cessation in those with active caries and/or gingival
bleeding. Starch reduction in particular for root caries.
• Micronutrient assessment where there is disease activity.
• Requirement for Vitamin’s C, D and K, B6 and B12 and minerals such as magnesium, calcium
and phosphate.
• Refer to dietician or GP when necessary. (?)
• Promote weight loss in at risk obese clients and glycaemic control in TTDM. (?)
• CONSIDER FUNCTIONAL FOODS and PROBIOTICS
Source - Interaction of lifestyle, behaviour or systemic diseases with dental caries and periodontal diseases. Chapple et al, 2017Source - Interaction of lifestyle, behaviour or systemic diseases with dental caries and periodontal diseases. Chapple et al, 2017

65. My dental health diet
• Avoid free/added/processed sugars (or cease).
As little sugar as possible (ALSAP).
• Eat whole food – macro/micronutrient rich,
locally sourced ideally. Fibre.
• Omega 3 and 6 oils in good ratios.
• Consider functional foods and drinks.
• Oral probiotics.
• Get enough sunshine/ consider
supplementation of Vitamin D if required – 25
– OH Vitamin D blood test check.

66. In addition to the dental health diet
• Refer PD clients with hypertension,
overweight or obese, or smoking to
doctor if not seen in over a year.
• Modifiable lifestyle risk factors should be
addressed in our clinical setting –
smoking cessation, diet and exercise – or
refer.
• Make diabetic PD patients aware of need
for gylcaemic control and higher risks to
CVD and kidney disease.
Periodontitis and systemic disease, Winning & Linden, BDJ Team,
2015.

67. Reflection and Future Research
Don’t fear cholesterol ( unless super high or LDL ApoB) – inflammation is more
important
Understand blood and inflammatory metrics and hormones better ( Leptin )
Sugar and addiction
Metabolic - Insulin Resistance Syndrome and Adiposity function
Simple life style behaviour changes ( walking fast and resistance training )

68. The Low/Slow Carb High/Healthy Fat Movement

71. My Friend and Colleague Dave
David qualified as a dental hygienist in 1987.
He joined Clarence House in 1994 and is particularly
interested in treating patients with advanced
periodontal disease (gum disease) as well as all
aspects of preventive care.
In January 2015, David qualified as a dental therapist.
David is married with two children. He has a keen
interest in motorcycling, road cycling and watching
rugby - he reluctantly retired from refereeing in 2007.

72. “Eat meat and vegetables,
nuts and seeds, some fruit,
little starch and no sugar.”
Greg Glassman– CEO
CrossFit