Table 1: Knowledge Regarding Nutrition and Diet Counselling Associated with Periodontal Diseases.

Association of Nutrition and Diet Counselling Associated with Periodontal Health and Disease among Dental Students

Table 2- shows the Association of Nutrition and Diet Counselling Associated with Periodontal Health and Disease among Dental Students. In relation to periodontal health 77.2% dental students believed that high fiber diet has a self-cleansing effect resulting in less plaque accumulation and strengthen the periodontium. 92.7% dental students believed that diet counselling at the early stages of life can help in the prevention of gingivitis/periodontitis. in relation to prevention of periodontal disease, 79% dental students responded positively that tooth brushing is advisable after the consumption of food which reduces the plaque accumulation in the oral cavity. Majority of dental students (94.5%) believed that nutrition and diet counselling is an important subject to be covered during their educational curriculum.

Table 2: Association of nutrition and diet counselling with periodontal diseases

Discussion:

The relationship between nutrition, infectious disease, and the immune system is synergistic. Infection may promote malnutrition, malnutrition elicits dysfunction in the immune system, and impaired immunity intensifies infection. Deficiency of nutrition may affect the microflora of dental plaque, salivary secretion, and the pH levels of the oral cavity. It also impacts systemic diseases, obesity, and inflammatory markers all of which have been shown to be associated with periodontal disease. Adequate and appropriate nutrient intake is needed for growth, development, and maintenance of the oral tissues and for the prevention of dental caries, gingivitis, and periodontitis. Research in the literature suggested that nutrition have a role in the onset and progression of periodontal disease. It may affect the entire immune system of the host which make more susceptible to number of systemic diseases and oral diseases. Recently the prime importance of oral health has received the recognition as research to be more established in the direction of oral and systemic health. The oral cavity can be the gateway for assessment by dental professionals to determine nutritional deficiencies. Therefore, it is significant for dental professionals to understand these impacts for an excellent care to their patients.

Many nutritional deficiencies can first be seen in the oral cavity. For example, deficiency of vitamin c may result in bleeding gums, delayed wound healing and Defective collagen formation whereas deficiency of vitamin B12 may result in halitosis, hemorrhagic gingivitis, detachment of periodontal ligament fibres and bone loss. The serum level of vitamin C and dietary intake of vitamin c have shown a weak but statistically significant relationship to periodontal disease.[12,13] Also. an inverse association has been found between calcium intake and dairy products and prevalence of periodontitis.[14] The increased level of magnesium to calcium ratio has been linked with less attachment loss.[15] And the supplementation of vitamin B complex led to significantly improved clinical attachment level. A very scant data is available in the literature with nutritional advice by general dentists and association with periodontal diseases. This survey was conducted among dental students to assess the knowledge and association of nutrition and diet counselling associated with periodontal diseases.

The majority of dental students believed that nutrition plays a role in periodontal health. Most of the studies that have been conducted on nutrition and diet are observational studies which may assess a relationship between certain aspects of diet and periodontal disease, including an inverse association with intake of vitamin C, calcium, and wholegrains.[13,14,15,16] However, there is a well-established link between consumption of a healthier diet and prevention of many chronic diseases associated with periodontitis. However, there is a very scant data in terms of dietary interventional randomised controlled clinical trials which may demonstrate whether nutrition has a therapeutic and preventive effect in the management of gingival and periodontal disease. More clinical trials are needed to clarify and strengthen the evidence of nutritional diet and periodontal disease.

In the present survey, most of the dental students (80.9%) responded positively that high blood sugar level can increase the risk of infection in the oral cavity. There is a direct casual relationship between diabetes and periodontitis in which the advanced glycosylation end products may triggers the inflammatory response to phenotypic cells such as fibroblast, endothelial cells and macrophages. Endothelial cells may become hyperpermeable and hyper expressive for adhesion molecules and increased cellular permeability. The increased accumulation of AGEs and their interaction with RAGE in diabetic gingiva resulting in hyper production of proinflammatory cytokines, vascular dysfunction, and loss of effective tissue integrity and barrier function.[17,18] Smoking and oral hygiene are undoubtedly major risk factors for periodontal disease with a strong evidence base. There is a decrease in pro- inflammatory cytokines and chemokines and various regulators of NK cells and T-cells resulting in immunosuppressant effect on the host immune response which may enhance the susceptibility of periodontitis. In the present survey, dental students (84%) strongly believed that smoking may cause gingivitis and periodontitis.

In the present survey majority of dental students (89%) agreed that dental plaque and calculus are the initiating factor for gingivitis and periodontitis. plaque and calculus both are the initiating primary etiological factors which plays a more direct role in periodontal inflammation and destruction. There is a positive correlation of plaque and calculus and prevalence of gingivitis and periodontitis. Plaque is the primary initiating factor for gingival inflammation resulting in pocket formation and provides a habitat niche for bacterial accumulation along with increased flow of gingival fluid may provide the minerals that convert plaque in the sub-gingival calculus.

Cross-sectional data in the literature evidenced that a “high-quality” diet is considered as an oral health-promoting factor only when there is a control of weight and an adequate exercise. In the present survey 77.2% dental students agreed that high finer diet have self- cleansing effect causes low plaque accumulation and strengthens the periodontium. A pro- inflammatory diet and poor consumption of micronutrient have been linked to an increased risk of periodontal disease. Similarly, adherence to an anti-inflammatory dietary pattern especially “high micronutrient and fibre” has shown a linked with lower risk of periodontal destruction and tooth loss.[8,9] Twin studies have shown that genetic factor may affect the clinical measure of gingivitis, probing depth, attachment loss and interproximal bone height. In the present survey only one half of dental students (54%) agreed that periodontitis have genetic predisposition. However, 30% dental students did have any knowledge regarding the genetic factors associated with periodontitis. genes associated with periodontal disease are associated with immunological alteration in neutrophil abnormality, Monocytic hyper- responsiveness to LPS and Alterations in the monocytes/macrophage. Genetic studies in the literature showed that gene polymorphisms are associated with stable inter-individual differences in IL-1 and TNF production. Interleukin-4 (IL-4) is a potent down-regulator of macrophage function. A higher occurrence of IL-4 gene polymorphism has been demonstrated in a group of Aggressive periodontitis patients than controls.[21]

The findings of the survey highlighted that majority of dental students are knowledgeable in the subject of nutrition and diet counselling. Although, 94.5% dental students felt that nutrition and diet counselling as a subject in their educational course or curriculum (BDS/MDS) is important with more emphasis on the prevention of oral diseases. The subject of dental nutrition must be taught on the basis of clinical implications, systematic and methodical training or in the form of a continuing education programs. The present survey has certain limitations such as the number of dental students included in this survey was very less. Also, dental practitioners and specialized dentists should be included with more emphasis on the clinical implication of dental diseases and their association with dietary factors for designing the questionnaire to assess the knowledge, and attitude of diet and nutrition. Longitudinal studies should be conducted to evaluate the effectiveness of nutrition counselling in terms of prevention of oral diseases.

Conclusion:

There is concern amongst dental students that the literature may not be strong enough to support a therapeutic role of diet and nutrition in periodontal diseases. Well-designed clinical trials of diet and nutrition intervention are needed to establish the potential role of nutrition in the prevention and treatment of periodontal disease. This survey has also highlighted that majority of dental students have the knowledge of diet counselling and nutrition and needs a greater number of longitudinal and cross-sectional studies which may help to define the casual relationship potential intervention strategies and future recommendations. Future research is also required to further elucidate the role of micronutrients in the prevention and treatment of periodontal disease