Correlation between Diet Pattern and Gingivitis -A Retrospective Study
Type of manuscript : Retrospective study
Running Title : Correlation between diet pattern and gingivitis Padmaharish V
Saveetha Dental College and Hospitals
Saveetha Institute of Medical and Technical Sciences Saveetha University
Chennai, India
Email : [email protected] Jaiganesh Ramamurthy
Professor and Head, Department of Periodontics, Saveetha Dental College and Hospitals,
Saveetha Institute of Medical and Technical Sciences, Saveetha University
Chennai, India
Email : [email protected] Deepa Gurunathan
Professor and head Department of Pedodontics Saveetha Dental College and Hospitals
Saveetha Institute of Medical and Technical Sciences Saveetha University
Chennai, India
Email : [email protected] Corresponding Author
Jaiganesh Ramamurthy Professor and Head Department of Periodontics Saveetha Dental College and Hospitals
Saveetha Institute of Medical and Technical Sciences Saveetha University
162, P.H.Road, Chennai - 600077, Tamil Nadu, India
Email : [email protected] Contact no. : 919840443463 ABSTRACT
Gingivitis is the inflammation of gingiva most commonly caused due to plaque accumulation.
Dental plaque is a complex biofilm accumulation on teeth and oral tissues. Diet seems to have a
profound impact on the gingival and periodontal inflammatory reaction. It is important to create awareness about better nutritional interventions among the general population to prevent further progression of gingival disease. The aim of this study was to assess the correlation between diet pattern and gingivitis. A retrospective study was conducted using the case records of patients visiting a private dental college in Chennai from June 2019 - March 2020. The study population included case records of patients between 18 and 25 years of age with recorded gingival index scores, selected by non-probability purposive sampling. Data was collected and then subjected to statistical analysis. Microsoft Excel 2016 (Microsoft office 10) data spreadsheet was used to collect data and later exported to SPSS IBM (version 20.0). Descriptive statistics and chi square test were employed with a level of significance set at p<0.05. The age group of patients included in the study ranged between 18 and 25 years. 66.67% were males and 33.33% were females.
85.8% of gingivitis patients consumed a non-vegetarian diet and 14.2% were vegetarians. There was no statistically significant correlation between diet pattern and gingivitis (p>0.05), though the prevalence and severity of gingival disease was increased among people with a non- vegetarian diet. There was a significant association between plaque index and gingival index scores (p=0.000), with the severity of gingivitis increasing as the plaque index score increases.
Keywords: Dental plaque; Diet; Gingivitis; Plaque index INTRODUCTION
The health of the oral cavity can have wide‐ reaching effects on overall health[1,2]. Poor oral health may occur concomitantly with a more serious underlying disease process or may predispose an individual to other health conditions[(Varghese et al., 2015),(Avinash, Malaippan and Dooraiswamy, 2017)]. Protecting oral health is therefore critical in maintaining overall health[(Panda et al., 2014)].
Periodontium refers to the supporting structures around the tooth - namely gingiva, cementum, periodontal ligament and alveolar bone[(Mootha et al., 2016),(Ravi et al., 2017)]. Gingivitis is the inflammation of gums most commonly caused due to plaque accumulation[(Khalid, 2017),(Khalid et al., 2016)]. The signs and symptoms include pain, swelling, bleeding on brushing and bleeding on probing etc. If left untreated it can lead to periodontitis and ultimately loss of teeth[(Ramesh et al., 2016),(Kavarthapu and Thamaraiselvan, 2018)].
Dental plaque is a complex biofilm accumulation on teeth and oral tissues[(Ramesh, Ravi and Kaarthikeyan, 2017)]. Environmental and genetic factors are influential in the development of dental plaque biofilms.The role of dental plaque in gingivitis is well established[(Ramesh et al., 2019a)]. Within 8 days of the beginning of plaque accumulation, an early lesion exhibiting many features characteristic of delayed hypersensitivity develops[(Priyanka et al., 2017)]. Individuals react differently regarding their inflammatory response to plaque accumulation, with some individuals showing only a mild expression of gingival inflammation[(Ramamurthy, 2018)].
Diet seems to have a profound impact on the gingival and periodontal inflammatory reaction[(Li et al., 2010)]. Examining the literature, several dietary recommendations for benefiting the health of periodontal tissues can be found, such as a reduction in carbohydrates, and an additional
Most importantly, the excessive intake of carbohydrates seems to promote dysbiosis and chronic inflammatory diseases[(Ostberg, Halling and Lindblad, 1999)]. The clinical reduction of carbohydrate intake seems to reduce gingival inflammation[(Sakki, Knuuttila and Anttila, 1998),(Furuta et al., 2011)]. In-vitro studies showed that high levels of glucose promote apoptosis and inhibit proliferation of periodontal ligament cells[(Zhang et al., 2010),(Nazir, Arain and Mohsin, no date)].
Furthermore, the intake of vitamins C and D seem to play an important role in gingival and periodontal inflammation[(Boer et al., 2012)]. Several studies showed the positive impact of vitamin D on periodontal tissues both in clinical and in-vitro studies[(Hujoel, 2009)]. Vitamin C has been described as an important vitamin for periodontal health, both in clinical and in-vitro studies for some time[(Velden et al., 2011)]. The absence of vitamin C causes scurvy, which is accompanied by massive periodontal bone loss[(Nishida et al., 2000)].
Last but not least, the role of dietary antioxidants seems to be important for several processes regarding an adequate systemic reaction to oxidative stress. Both clinical and in-vitro studies showed positive effects on periodontal tissues[(Muniz et al., 2015),(Linkosalo and Markkanen, 1985)].
It is important to create awareness about better nutritional interventions among the general population to prevent further progression of gingival disease[(Rahmatulla and Ernest Guile, 1990)]. Our team has rich experience in research and we have collaborated with numerous authors over various topics in the past decade (Subramanyam et al., 2018)(‘Fluoride, fluoridated toothpaste efficacy and its safety in children - review’, 2018; Ezhilarasan, 2018; Felicita, 2018;
Kavarthapu and Thamaraiselvan, 2018; Krishnan et al., 2018; Marimuthu et al., 2018; Nair et al., 2018; Padavala and Sukumaran, 2018; Pandian, Krishnan and Kumar, 2018; Rajeshkumar et al., 2018; Rao and Kumar, 2018; Vijayashree Priyadharsini, Smiline Girija and Paramasivam, 2018; Abhinav et al., 2019; Ke et al., 2019; Mehta et al., 2019; Panchal, Jeevanandan and Subramanian, 2019; Ponnulakshmi et al., 2019; Ramesh et al., 2019b; Sridharan et al., 2019;
Sweta, Abhinav and Ramesh, 2019; Wu et al., 2019; Palati et al., 2020; Paramasivam, Vijayashree Priyadharsini and Raghunandhakumar, 2020). The aim of this study was to assess the correlation between diet pattern and gingivitis.
MATERIALS AND METHODS Study design and setting
This retrospective study examined the records of patients who underwent treatment at a private dental college in Chennai from June 2019 - April 2020. Ethical approval was obtained from the Institutional Ethics Committee of the University (SDC/SIHEC/2020/DIASDATA/0619-0320).
The study population included case records of patients between 18 and 25 years of age who had gingivitis, selected by non-probability purposive sampling. Pediatric patients, patients above 25 years of age, patients with healthy gingiva, medically compromised patients, completely edentulous patients and denture wearers, were excluded from the study.
Data collection
Case records of 3669 patients with recorded gingival index and plaque index scores were reviewed and analysed. Relevant data such as patient age, sex, gingival index score, diet pattern and plaque index score were recorded. Repeated patient records and incomplete records were excluded. The final dataset consisted of 162 patients of Indian origin between the age group of 18 to 25 years with recorded gingival Index and plaque Index scores. Data was verified by an external reviewer.
Statistical analysis
Data was recorded in Microsoft Excel 2016 (Microsoft office 10) and later exported to the Statistical Package for Social Science (SPSS IBM version 20.0) and subjected to statistical analysis. Descriptive statistics and chi square test were employed with a level of significance set at p<0.05.
RESULTS
The data for this retrospective study was based on the patients seeking treatment in a private dental college. Currently there are very few studies investigating the correlation between diet pattern and gingivitis in the South Indian population. The results of the present study show that among the study population, about 6.17% were 18 years, 9.88% were 19 years, 9.26% were 20 years, 4.94% were 21 years, 12.35% were 22 years, 13.58% were 23 years, 23.46% were 24 years and 19.75% were 25 years of age. Majority of the patients were 24 years of age [Figure 1].
About 66.67% were males and 33.33% were females, showing a male predilection for gingivitis [Figure 2].
About 14.2% of gingivitis patients consumed a vegetarian diet and 85.8% were non-vegetarians, which showed that most of the patients consumed a non-vegetarian diet [Figure 3].
Among patients consuming a non-vegetarian diet, 41.36% had mild gingivitis, 41.98% had severe gingivitis and 2.47% had severe gingivitis. In patients with a vegetarian diet, 8.02% had mild gingivitis, 5.56% had moderate gingivitis and 0.62% had severe gingivitis. The prevalence and severity of gingivitis was higher in those who consumed a non-vegetarian diet. However, chi square test showed that there was no significant association [Figure 4, Table 1].
Among patients with good plaque index, 33.95% had mild gingivitis and 25.31% had moderate gingivitis. In patients with fair plaque index, 14.2% had mild gingivitis, 19.14% had moderate gingivitis and 1.23% had severe gingivitis. 1.23% of patients with poor plaque index had mild gingivitis, 3.09% had moderate gingivitis and 1.85% had severe gingivitis. Chi square test showed that there was a significant association between plaque index and gingival index, wherein the severity of gingivitis was higher in patients with fair and poor plaque index [Figure 5, Table 1].
DISCUSSION
The effect of diet on systemic diseases like cancer, type 2 diabetes and coronary heart diseases have been studied by various authors but studies correlating diet and oral health are rare .Most authors assessed dental parameters or performed saliva test[(Johansson and Birkhed, 1994),(Johansson and Ravald, 1995),(Laffranchi et al., 2010),(Linkosalo, 1988)].
Only a few studies investigating the influence of diet on periodontal conditions are available[(Linkosalo et al., 1985),(Linkosalo, Markkanen and Syrjänen, 1985)]. The present study evaluated 162 subjects for the correlation between diet and periodontal condition with a comprehensive periodontal examination.
First our data indicate less periodontal problems (i.e) inflammatory signs in vegetarians . This is in accordance with linkosalo et al[(Tonstad et al., 2009)] which revealed a lower bleeding on probing in vegetarians linkasalo et al also used gingival index to assess gingival conditions.
There are several pathways which may lead to inflammation.
Generally vegetarians have low BMI and more physical activity . Hence prevalence of obesity may cause an increased local inflammatory response[(Kuzmanova et al., 2012)]. Additionally vegetarians consume a higher amount of antioxidants which improve immune response[(Jenzsch et al., 2008)].
Considering plaque scores, our data and most of available scientific literature revealed an increased plaque index score among non vegetarians than vegetarians. It's obvious that a lower plaque index score leads to less inflammatory signs.
In contrast to our study Sedgley et al[(Sedgley et al., 1996)] did not find the difference in plaque index or gingival index among vegetarians and non vegetarians. The importance of adequate nutrition for a healthy periodontium was documented by Jenzsch et al. Kober et al[(Männle, 2018)] recommended a dietary change that leads to better periodontal health.
A statistically significant correlation between the occurrence of gingivitis and calorie-adjusted phosphorus intake and between gingivitis and calorie-adjusted sugar intake was observed in a study by Goodson et al. Thus, elevated dietary phosphorus consumption may influence inflammatory disease by altering cytokine levels[(Goodson, Shi and Razzaque, 2019)].
In another study by Sidi et al, it was found that at 3 weeks significantly higher bleeding scores at the two designated levels were found with the high sugar diet but no significant differences were observed with crevicular fluid flow and plaque amount. It was concluded that frequent sugar intakes result in increased gingival inflammation in experimental gingivitis, as measured by gingival bleeding on probing[(Sidi and Ashley, 1984)].
Al-Zahrani et al concluded that poor diet quality was significantly associated with more calculus deposits which predisposes to periodontal disease[(Al-Zahrani, Borawski and Bissada, 2004)].
A randomized control trial on the influence of an anti-inflammatory diet on gingivitis by Woelber et al stated that a diet low in processed carbohydrates and animal proteins, and rich in omega‐ 3 fatty acids, vitamin C, vitamin D, antioxidants, plant nitrates and fibres significantly
reduced gingivitis in a clinically relevant range, while serological inflammatory parameters and the subgingival microbiome seem to be unaffected[(Woelber et al., 2019)].
While interpreting the present data one should keep in mind that generally a vegetarian diet represents a healthy lifestyle . Vegetarians are physically more active and have lower BMI. In the present study the vegetarians and non vegetarians were matched with gingival index and plaque index. However physical activity and BMI were not evaluated. Both have an influence on periodontal tissues[(Bawadi et al., 2011)] and could be considered as a co-founder if correlation between diet and periodontal condition is investigated further. Our institution is passionate about high quality evidence based research and has excelled in various fields ( (Pc, Marimuthu and Devadoss, 2018; Ramesh et al., 2018; Vijayashree Priyadharsini, Smiline Girija and Paramasivam, 2018;
Ezhilarasan, Apoorva and Ashok Vardhan, 2019; Ramadurai et al., 2019; Sridharan et al., 2019;
Vijayashree Priyadharsini, 2019; Chandrasekar et al., 2020; Mathew et al., 2020; R et al., 2020; Samuel, 2021)
The results of this study have to be interpreted with the geographic limitation of the study population and the sample size selected. Hence, it cannot be generalized to other populations of geographic and cultural variation.
CONCLUSION
Within the limits of the study there was no significant association between diet pattern and gingivitis, though the prevalence and severity of gingival disease was increased among people with a non-vegetarian diet. There was a significant association between plaque index and gingival index scores, with the severity of gingivitis increasing as the plaque index score increases. Thus a vegetarian diet and patients with lower plaque index had a positive effect on periodontal condition respectively.
ACKNOWLEDGEMENTS
We would like to thank the administration of Saveetha University, Chennai for granting us the clearance to conduct this study and for funding this research. Also we thank the Chancellor and Director of academics, Dean saveetha dental college for encouraging us to the research work
AUTHORS CONTRIBUTION
All the authors contributed equally to the study conception and design, data collection, analysis and interpretation and drafted the work. All authors critically reviewed the manuscript and approved the final version.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
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GRAPHS AND TABLES
Figure 1 : Age distribution of patients included in this study.
Figure 2 : Gender distribution.
Figure 3 : Diet pattern among patients.
Figure 4 : Association between diet pattern and gingivitis.
Figure 5 : Association between plaque index and gingival index scores.
Table 1 : The severity of gingivitis among patients with various diet patterns and plaque index scores.
Figure 1 : Bar graph representing the age distribution of patients included in this study. X axis represents the age and Y axis represents the percentage of patients included in this study. The age group of patients included in the study ranged between 18 and 25 years.
Majority of the patients were 24(orange) years of age.
Figure 2 : Bar graph representing the gender distribution. X axis represents the gender and Y axis represents the percentage of patients included in this study. Majority of the patients who had gingivitis were males (blue) compared to females (pink).
Figure 3 : Bar graph representing the diet pattern among patients. X axis represents the diet pattern and Y axis represents the patients included in this study. Majority of the patients in this study who had gingivitis were non-vegetarian (red) compared to vegetarians (green).
Figure 4 : Bar graph representing the association between diet pattern and gingivitis. X axis represents the diet pattern and Y axis represents the number of patients included in this study. The prevalence and severity of gingivitis was higher in those who consumed a non-vegetarian diet. Chi square test showed that there was no significant association between diet pattern and gingivitis. Pearson Chi square value = 0.813; p-value = 0.666 (p>0.05, statistically not significant).
Figure 5 : Bar graph representing the association between plaque index and gingival index scores. X axis represents the plaque index scores and Y axis represents the number of patients included in this study. The severity of gingivitis was higher in patients with fair and poor plaque index. Chi square test showed that there was a significant association between plaque index and gingival index. Pearson Chi square value = 31.426; p-value = 0.000 (p<0.05, statistically significant).
Gingival Index Chi square test
Diet pattern : Non-vegetarian
Vegetarian
0.1 - 1.0 (mild gingivitis)
1.1 - 2.0 (moderate gingivitis)
2.1 - 3.0 (severe gingivitis)
Pearson Chi square value = 0.813; p- value = 0.666 (p>0.05,
*statistically insignificant).
41.36%
8.02%
41.98%
5.56%
2.47%
0.62%
Plaque index : 0.1 - 1.0 (good)
1.1 - 2.0 (fair)
2.1 - 3.0 (poor)
33.95%
14.2%
1.23%
25.31%
19.14%
3.09%
0%
1.23%
1.85%
Pearson Chi square value = 31.426; p- value = 0.000 (p<0.05,
*statistically significant).
Table 1 represents the severity of gingivitis among patients with various diet patterns and plaque index scores. Severe gingivitis was more common in patients with a non-vegetarian diet and poor plaque index. Chi square test showed that there was a significant association between plaque index and gingivitis (p<0.05). Though there was a higher prevalence of gingivitis among patients who consumed a non-vegetarian diet, there was no significant association (p>0.05).
