Gingivitis

Gingivitis

1 Introduction

Gingivitis is the most common and mild form of oral/dental disease. According to the Food and Drug Administration, approximately 15 percent of adults between 21 and 50 years old, and 30 percent of adults over 50 have gum disease (FDA 2002). Gingivitis is characterized by inflammation and bleeding of the gums. Because gingivitis is rarely painful in its early stages, it often goes unnoticed until severe irritation or receding gums occur.

The main cause of gingivitis is plaque (or biofilm), a soft, sticky film that forms on the teeth when starches and sugars react with bacteria that is naturally present in the mouth. Plaque buildup occurs between the teeth and gums, in faulty fillings, and near poorly cleaned partial dentures, bridges, and braces. If not removed within 72 hours, plaque will harden into tartar that cannot be removed by brushing or flossing.

The best defense against gingivitis is brushing and flossing after meals, as well as professional cleaning by a dental hygienist every three to four months.

If left untreated, gingivitis may lead to a more serious condition called periodontitis, in which the inner gum and bone pull away from teeth and form pockets. These pockets can collect bacteria and debris, and become infected or abscessed. Bacterial toxins eventually break down the underlying bone and connective tissue that hold teeth in place. The ultimate outcome is tooth loss. For more information, see Life Extension’s Periodontitis and Cavities protocol.

2 Risk Factors For Gingivitis

Several studies suggest that gum disease may be passed from parents to children as well as between couples (Asikainen 1996; Saarela 1993). Based on these findings, the American Academy of Periodontology (AAP) recommends that treatment of gum disease may involve entire families and that if one family member has periodontal disease, all family members should see a dental professional for a periodontal disease screening.

Other conditions that may contribute to gingivitis include:

Medications. Certain prescription and over-the-counter drugs can create a favorable environment for plaque buildup. Cold remedies and tricyclic antidepressant drugs decrease salivation, which allows plaque and tartar to form more easily (Koller 2000). Oral contraceptives can increase microbial flora that contribute to gingivitis (Klinger 1998).
Other drugs—particularly anti-seizure medications such as phenytoin (Dilantin®), calcium channel blockers, anti-hypertension drugs, and medications that suppress the immune system—can sometimes cause an overgrowth of gum tissue (Johnson 2003; Morisaki 2001). This condition, called gingival hyperplasia, can make plaque much more difficult to remove and provide more surface for bacteria to develop.

Infections. Viral and fungal infections can also adversely affect gum health. The herpes virus, for example, can lead to acute herpetic gingivostomatitis, a condition characterized by swollen gums and small, painful sores in the mouth (Kasper 2005). Oral thrush is caused by overgrowth of the yeast known as Candida albicans that is normally found in the mouth. Thrush can produce white lesions on the inner cheeks and tongue that can spread to the gums.

Disease. Certain health conditions that may not be directly associated with the mouth can affect gum health. For example, leukemia patients may develop gingivitis if leukemia cells invade the gum tissue (Kasper 2005). Fanconi anemia is a rare genetic disorder that attacks bone marrow and reduces white blood cell production, leaving the patient predisposed to infections and more susceptible to gum disease (Nowzari 2001).

Hormonal Changes. During periods of hormonal fluctuation (e.g., pregnancy and menopause), women may become more susceptible to gingivitis due to decreased salivation and blood supply to the gums. It is also thought that increased hormone levels cause the gums to respond aggressively to bacteria-producing irritation. However, while it is clear that hormone levels play a role in the progression of periodontal disease, hormones do not specifically cause gingivitis (Mascarenhas 2003). Of particular importance to women is that several recent studies indicate that pregnant women with periodontal disease may be more likely to deliver a pre-term, low-birth-weight infant (Jeffcoat 2003).

Poor Nutrition. A diet lacking in adequate amounts of calcium, vitamin C, and B vitamins can increase the risk of developing periodontal disease (Nishida 2000a,b; Kasper 2005).

Smoking. Tobacco use may be one of the largest preventable risk factors for periodontal disease. According to one study, smoking may be responsible for more than half of adult cases of periodontal disease in the US. The same study also found that smokers are four times more likely to develop advanced periodontal disease than people who have never smoked (Giannopoulou 2003). Smoking diminishes oxygen and nutrient delivery to gum tissue and interferes with the synthesis of cytokines that regulate immunity and inflammation. Smoking also poses a risk of periodontal therapy failure, treatment complications, and increased time to treat the disease (Papantonopoulos 1999).

Stress and Depression. Stress has been linked to an increased risk of periodontal disease, possibly because it may trigger an increase in behaviors such as smoking and poor oral hygiene. Sustained levels of financial stress and poor coping abilities, which can trigger habits such as poor diet or smoking, double the risk of developing periodontal disease (Genco 1999). Researchers have also found that clinically depressed patients are only half as likely to benefit from periodontal treatment as non-depressed patients (Elter 2002).

3 Gingivitis and Heart Disease

There is a clear association between gum disease and heart disease. A 2004 study found that 91 percent of patients with cardiovascular disease also suffered from moderate to severe periodontal disease (Geerts 2004). While people with gum disease have a 25 percent greater risk of heart disease than those with healthy gums, researchers have only recently begun to uncover possible causes for this link. Researchers now believe that gum disease, which is inflammatory, causes the release of pro-inflammatory chemicals into the bloodstream, which triggers a systemic inflammatory response. Atherosclerosis is also an inflammatory disease, and many of the same factors that increase risk for heart disease also increase risk for gum disease, including C-reactive protein (CRP), fibrinogen, and cholesterol (Wu 2000).

This theory was supported by a recent study involving 5000 participants, which showed that oral inflammatory markers entering the bloodstream encouraged systemic inflammation (Noack 2001). This large study also confirmed that periodontal disease and body mass index are jointly associated with increased levels of CRP in assessing the risk of heart disease.

4 Conventional Treatment

Treatment of gum disease begins with regular brushing and flossing. It is also important to make regular trips to the dentist for cleaning and monitoring. Most dentists recommend yearly full-mouth x-rays to assess the progression of bone loss in the jaws. Life Extension, however, has long been concerned about the radiation exposure that results from undergoing medical x-rays. Even x-rays that emit low levels of radiation damage DNA, which can lead to cancer. While some dental x-rays are necessary, annual x-rays are not advisable.

A full periodontal probe with a tiny, ruler-like instrument is also performed to measure the pockets surrounding the teeth. In healthy gums, the pockets measure less than 3 millimeters (one-eighth of an inch). Pockets measuring 3 to 5 millimeters indicate signs of gingivitis. Pockets measuring more than 5 millimeters signify the development of periodontitis. For more information, see Life Extension’s Periodontitis and Dental Cavities protocol.

A professional cleaning to remove plaque and tartar buildup should be performed at least twice a year. Some people need to have cleanings done more frequently. Non-surgical deep cleaning involves two procedures known as scaling and root planing, which are sometimes performed in sections of the mouth at different times, especially if there is considerable soreness and bleeding from the gums. Scaling removes plaque and tartar above and below the gum line. Root planing smoothes out the tooth root to remove bacteria buildup and encourage the gums to reattach to the teeth.

Mouth Rinses. Mouth rinses are frequently used to help prevent gingivitis. Medicated mouth rinses containing a 0.1% solution of folic acid have effectively reduced gum inflammation and bleeding in double-blind trials (Pack 1984; Vogel 1978b). Prescription antibacterial mouthwashes containing the ingredient chlorhexidine (Peridex®, PerioGard®) are also frequently used to treat gum inflammation.

Decapinol®. Decapinol®, a prescription oral rinse, reduces the adherence of bacterial plaque to oral surfaces. This reduces the formation of new plaque as well as breaks up existing plaque, making it easier to remove with normal brushing. Reducing the presence of plaque also reduces the amount of bacterial toxins released into the gums. The result is a reduction in plaque and gingivitis. Decapinol® is only mildly antibacterial, so it does not upset the oral bacterial flora.

Toothpaste. The natural and synthetic antibacterial agents in many brands of toothpaste can help keep gums healthy. Natural toothpastes contain botanical oils that have antibacterial properties, while commercial formulas offer the benefit of fluoride to help prevent cavities. The brand Colgate Total®—the only FDA-approved toothpaste for fighting gingivitis—contains triclosan, a mild antimicrobial proven to reduce plaque and pocket depths associated with gingivitis (Niederman 2004; Davies 2004).

Antibiotic Therapy. Antibiotic therapy used alone or in combination with other treatments may also be recommended to treat gingivitis. Atridox® (doxycycline hyclate), PerioChip® (chlorhexidine gluconate), and Arestin® (minocycline hydrochloride) are antibiotics applied in sustained-release doses directly into the periodontal pocket. A relatively new drug called Periostat® (doxycycline hyclate) was approved by the FDA in 1998 for use in combination with scaling and root planing. Taken orally, Periostat® suppresses the action of collagenase, an enzyme that causes destruction of the teeth and gums (Lee 2004; Lee 2004).

Surgery. If a diligent regimen of proper brushing, flossing, and regular dental cleanings is followed, nearly all cases of gingivitis can be reversed in a short time. However, in advanced gingivitis, or conditions that make treatment difficult, the following surgical treatments can help:

  • Curettage - a procedure in which diseased gum tissue in the infected pocket is scraped away, allowing the infected area to heal.
  • Flap surgery - involves pulling back the gums to remove tartar buildup. The gums are then sewn back in place so that the tissue fits snugly around the tooth, thereby reducing pocket depth.
  • Guided tissue regeneration - stimulates bone and gum tissue growth, and is often performed in combination with flap surgery. In this procedure, a small piece of mesh-like fabric is inserted between the bone and gum tissue. This keeps the gum tissue from growing into the area where the bone should be, allowing the bone and connective tissue to reattach.
  • Soft tissue grafts - reinforce thin gums or replace tissue where the gums have receded. The grafted tissue, usually taken from the roof of the mouth, is sewn in place over the affected area.

Hydrogen peroxide. Hydrogen peroxide, which is included in many toothpastes, is valuable for its ability to reach bacteria hiding among gingival folds and gaps. Hydrogen peroxide is also added to some mouthwashes to reduce gingivitis and whiten teeth (Hasturk 2004). Hydrogen peroxide has been used effectively for years in dentistry.

5 Nutritional Approaches For Healthy Gums

In addition to brushing with a good toothpaste and making regular visits to the dentist, a number of nutrients have been shown to improve gum health.

Coenzyme Q10. Coenzyme Q10 (CoQ10), a vital nutrient needed by every cell in the body to make energy, is beneficial for a variety of diseases and disorders, including periodontal disease. In addition to energy production, CoQ10 plays a vital role as an antioxidant at the cellular level by neutralizing free radicals. As early as the 1970s, researchers found that gum tissue in people with periodontal disease was often deficient in CoQ10 (Nakamura 1974; Hansen 1976). Subsequent studies have shown that CoQ10 doses of 50 to 75 mg daily can halt deterioration of the gums and allow healing to occur, sometimes within days of starting therapy. In one double-blind trial, 50 mg daily of CoQ10 was significantly more effective than placebo in reducing symptoms of gingivitis after three weeks of treatment (Wilkinson 1976).

Stephen T. Sinatra, M.D., clinical cardiologist and author, reports that many of his patients see improvement in their gum health after beginning CoQ10 supplementation for heart disease. According to research by Sinatra, CoQ10's supportive effects on the immune system in general account for its ability to promote healing of diseased gums. Dr. Victor Zeines, a holistic dentist and author, recommends 100 mg of CoQ10 daily in combination with other supplements to help reverse gum disease naturally.

Calcium. A study found that people who do not consume adequate amounts of calcium each day are at significantly higher risk for periodontal disease (Nishida 2000b). According to the American Dietetic Association, three of four people do not fulfill their daily calcium requirement. The study showed that men and women who had low calcium intakes (below the recommended dietary allowance) were almost twice as likely to have periodontal disease, as measured by the loss of attachment of the gums to the teeth.

Vitamin D: According to a recent report from the American Journal of Clinical Nutrition, high blood levels of a vitamin D metabolite are associated with a decreased risk of gingivitis. Researchers at Boston University analyzed data from 6,700 nonsmokers, aged 13-90+, from the National Health and Nutrition Examination Survey. The investigators analyzed blood levels of 25-hydroxyvitamin D and assessed the participants’ gums for the presence of gingivitis. Participants with the highest blood levels of 25-hydroxyvitamin D were the least likely to display signs of gingivitis. The scientists noted that vitamin D may reduce susceptibility to gingivitis by exerting anti-inflammatory effects, and postulated that gingivitis may provide a useful clinical model for further investigation into the anti-inflammatory effects of vitamin D (Dietrich 2005).

Folic Acid. Studies have demonstrated that folic acid is very effective in preserving gum tissue and reducing the risk of gingivitis and periodontitis (Stein 1973). Although the benefits of oral folic acid in protecting against heart disease and birth defects are well documented, new evidence suggests that using folic acid topically (as a mouthwash) can also strengthen one's oral defenses. Studies have demonstrated folic acid's ability to improve gingivitis symptoms, reduce gum tissue's inflammatory response, and make gum tissue more resilient to irritants such as bacteria and plaque (Thomson 1982; Pack 1984).

Folic acid has been clinically tested in mouthwash solutions to assess its benefit in treating gingivitis. One study showed significant improvement after four weeks of using a folic acid mouthwash. In this double-blind, placebo-controlled study of 60 patients, dietary folic acid intake did not correlate with treatment results, suggesting the importance of applying folic acid topically to the gums (Pack 1984).

A double-blind study of 30 pregnant women evaluated the effects of folic acid mouthwash and folic acid tablets versus placebo. After 28 days, folate serum levels increased significantly in both groups receiving folic acid, but only the group receiving folic acid mouthwash showed a highly significant improvement in a gingival index (Thomson 1982).

Another study evaluated 30 patients with normal blood folate levels in a clinical setting. One group rinsed their mouths daily with a folate solution, and the other used a placebo mouth rinse. After 60 days, the group receiving the folic acid rinse showed significant improvement in gingival health compared to the placebo group (Vogel 1978a).

A double-blind study of 30 patients compared supplementation with 4000 mcg of ingested folic acid to placebo. After one month, plaque and gingival indices showed that folic acid supplementation appeared to increase the resistance of the gingiva to local irritants, leading to a reduction in inflammation (Vogel 1976).

Green Tea. Green tea extract is rich in a class of antioxidants called catechins. Two in particular, epigallocatechin gallate (EGCG) and epicatechin gallate (ECG), combat oral plaque and bacteria (Horiba 1991; Otake 1991; Rasheed 1998). These green tea polyphenols work as anti-plaque agents by suppressing glucosyl transferase, which oral bacteria use to feed on sugar. Other research has demonstrated that green tea extract can kill oral bacteria and inhibit collagenase activity. Collagenase, a natural enzyme that becomes overactive in the presence of bacterial overgrowth, can destroy healthy collagen in gum tissue.

Green tea extract applied topically inhibits Streptococcus mutans bacteria, which have been implicated in the development of dental caries (the decay and breakdown of teeth and their bone support). Scientists suggested that certain extracts from green tea might be especially helpful in preventing tooth decay by preventing the development of bacterial plaque (Hattori 1990). In a Chinese study, green tea extract was used to rinse and brush the teeth. The study demonstrated that S. mutans could be inhibited completely after contact with green tea extract for five minutes. There was no drug resistance after repeat cultures (You 1993). The scientists concluded that green tea extract is effective in preventing dental caries (You 1993). Other studies have shown that the plaque index and gingival index decreased significantly after green tea extract was used (Tsuchiya 1997).

More recent studies confirm the benefits of green tea in fighting gum disease, especially when combined with conventional treatments. In a pilot study, hydroxypropylcellulose strips containing green tea catechins as a slow-release local delivery system were applied once a week for eight weeks to the pockets in periodontal patients. The green tea catechins inhibited the bacteria P. gingivalis and Prevotella spp., and a reduction in pocket depth was observed (Hirasawa 2002).

Hyperimmune egg. Agricultural scientists discovered long ago that they could immunize hens against germs that threaten humans. This immunity was then passed on by the hen to her egg (Dias da Silva 2010; Dean 2000; Cama 1991). Scientists have now been able to customize eggs to provide different types of immunity. At least 24 different organisms have been used to immunize a single hen, which then lays eggs that offer passive immunity to all of the organisms (Dean 2000).

Hyperimmune egg extract has been shown to reduce the volume of dental plaque, which in turn cuts down on the total load of inflammation in the mouth (Hatta 1997). Animals supplemented with hyperimmune egg against the leading bacterial cause of dental caries developed significantly lower dental caries scores than did control animals (Otake 1991; Mitoma 2002). Oral hyperimmune egg rinses have also been used successfully in humans to reduce disease-causing bacteria; the extracts remain active and present in the mouth at least overnight, offering long-standing protection (Carlander 2002; Wang 2003; Zhou 2003).

Pomegranate. Researchers are finding important applications for pomegranate in the field of dental health. Clinical studies have shown that this popular antioxidant attacks the causes of tooth decay at the biochemical level with remarkable vigor (Vasconcelos 2006; Sastravaha 2005; Menezes 2006; Sastravaha 2003; Taguri 2004). Pomegranate literally attacks bacteria where they live. Research shows that by interfering with production of the chemicals the bacteria use as “glue”, pomegranate extract suppresses bacteria’s ability to adhere to the surface of the tooth (Vasconcelos 2006) (Li 2005).

A study conducted in 2007 examined the effects of a mouthwash containing pomegranate extract on the risk of gingivitis (DiSilvestro 2007). Investigators noted that pomegranate’s active components, including polyphenolic flavonoids (e.g., punicalagins and ellagic acid), are believed to prevent gingivitis through a number of mechanisms including reduction of oxidative stress in the oral cavity, direct antioxidant activity (Seeram 2005; Chidambara 2002; Battino 1999), anti-inflammatory effects, antibacterial activity (Madianos 2005; Aggarwal 2004), and direct removal of plaque from the teeth (Menezes 2006). Saliva samples were evaluated for a variety of indicators related to gingivitis and periodontitis. Subjects rinsing with pomegranate solution experienced a reduction in saliva total protein content (DiSilvestro 2007), which is normally higher among people with gingivitis (Narhi 1994) and may correlate with plaque-forming bacterial content (Rudney 1993).

Xylitol. Pure xylitol is a white crystalline substance that resembles and tastes like sugar. It is found naturally in fruits such as plums, strawberries, and raspberries. Xylitol is used commercially to sweeten sugarless gum and candies.
Xylitol has been shown to inhibit the formation of plaque. In a double-blind and controlled study, Swedish researchers had 128 children chew gum containing either xylitol or the sweeteners sorbitol and maltitol, three times daily for four weeks. While both were effective against the buildup of dental plaque, only the xylitol-sweetened gum eliminated microbes found in saliva, particularly a strain of bacteria implicated in tooth decay (Holgerson 2007). Xylitol could thus be an essential ingredient in a targeted strategy to avert dental disease.

A double-blind, placebo-controlled study of 2,630 children compared a standard fluoride toothpaste with one containing 10% xylitol. Over a three-year period, children given the xylitol-enriched toothpaste developed notably fewer cavities than those using the fluoride-only toothpaste (Sintes 1995).

Probiotics. Probiotics have been defined as “living microorganisms which upon ingestion in certain numbers exert health benefits beyond inherent general nutrition” (Gorbach 2002). Scientists have been interested in the makeup of the microbes that live in the mouth (the “oral flora”) for decades, seeking to identify factors that promote the growth of healthy organisms and reduce the growth of those implicated in disease and inflammation (Li 1999; Marsh 1991; Marsh 1994; Marsh 2006).

Probiotics not only improve oral health but can help change the stubborn composition of dental biofilm and plaque (Marsh 2006; Kornman 2008). Reducing the total amount of plaque through teeth brushing is always a desirable goal; however, its complete elimination is not possible. Therefore, changing the actual composition of plaque from an inflammatory cytokine-rich environment to a more benign environment (dominated by neutral or even helpful organisms) can contribute to overall systemic health (Kamma 2009; Compend 2008; Pasquantonio 2008).

In laboratory studies, the probiotic S. salivarius helped inhibit the formation of the sticky biofilm that can contribute to oral disease (Tamura 2009). Building on these results, an animal study showed that the S. salivarius probiotic helped displace biofilm from the teeth, displacing cavity-causing bacteria and inhibiting tooth decay (Tanzer 1985). Another in vitro experiment demonstrated how effectively a second oral probiotic protects oral health (Ganeden 2009). In this experiment, a form of Bacillus coagulans (known as GanedenBC30™) was shown to competitively inhibit the cariogenic (cavity-inducing) bacterium Streptococcus mutans, which contributes to significant tooth decay.

Lactoferrin. Lactoferrin, a naturally occurring antimicrobial agent, is found in saliva and gingival fluid, breast milk, tears, and other bodily fluids.

This protein is a well-known immune system booster involved in the body’s responses to infection, trauma, and injury (Kruzel 2007).
Lactoferrin may bind to and slow the growth of periodontitis-associated bacteria (Kalfas 1991). In an animal study, locally applied lactoferrin powder appeared to support the healing of oral lesions (Addie 2003).

Vitamin C. People deficient in vitamin C may be at risk of developing gingivitis (Vaananen 1993). In one study, a group of subjects with periodontal disease who normally consumed only 25 to 30 mg of vitamin C daily were supplemented with an additional 70 mg. They experienced marked improvement in gum tissue after only six weeks (Aurer-Kozelj 1982). Although it is established that smoking contributes to gum disease, tobacco users may especially benefit from vitamin C supplementation, as smoking depletes the body of vitamin C (Nishida 2000a).

Herbal Protection. Tea tree oil, used as an oral rinse, has been proven to kill bacteria (Kulik 2000). In fact, research has shown that a tea tree oil concentration of 0.6 percent inhibited 14 of 15 oral types of bacteria. In one study, 49 subjects aged 18 to 60 with severe, chronic gingivitis were divided into groups, one of which was given a gel containing tea tree oil to apply with a toothbrush twice daily. The tea tree oil group had improved gingival index and papillary bleeding index scores attributed to the herb’s anti-inflammatory properties (Soukoulis 2004).

Camu-camu, a shrub from the Amazon rainforest, is revered for its rich supply of vitamin C, which aids in circulation, fortifying blood vessel walls, and regenerating tissue. Moreover, camu-camu has astringent, antioxidant, and anti-inflammatory properties (Visentainer 1997; Justi 2000).

Both gotu kola and vitamin E help to heal wounds, promote connective tissue growth, and fight free radicals. Goldenseal is a medicinal plant that boosts immune function (Rehman 1999).

Chamomile and red thyme oil are mild antimicrobials (Aggag 1972). Finally, herbs such as parsley, spearmint, menthol, and eucalyptus are stimulating to the gums, as well as refreshing and cooling for the mouth in general (Sato 1998).

Reducing Gum-Related Inflammation

Fish oil and borage oil. Because of the association between gum disease and systemic inflammation, researchers have begun looking at anti-inflammatory nutrients in the context of gum disease. In one study, 30 adults with gum disease were given a variety of polyunsaturated fatty acids, including omega-3 fatty acids from fish oil (up to 3000 mg daily) and omega-6 fatty acids from borage oil (up to 3000 mg daily). At the end of the study, clinically significant improvements were measured in both gingival inflammation and the depth of gum pockets (Rosenstein 2003). Another preliminary human study found that omega-3 fatty acids tended to reduce inflammation, but called for more thorough research (Campan 1997). However, in light of the established connection between omega-3 and omega-6 fatty acids and inflammation, as well as fatty acids’ lack of side effects, it is reasonable for people with gum disease to consider using these supplements. Other anti-inflammatory supplements include ginger and curcumin, though neither of these has been studied in the context of inflammatory gum disease.

Disclaimer and Safety Information

This information (and any accompanying material) is not intended to replace the attention or advice of a physician or other qualified health care professional. Anyone who wishes to embark on any dietary, drug, exercise, or other lifestyle change intended to prevent or treat a specific disease or condition should first consult with and seek clearance from a physician or other qualified health care professional. Pregnant women in particular should seek the advice of a physician before using any protocol listed on this website. The protocols described on this website are for adults only, unless otherwise specified. Product labels may contain important safety information and the most recent product information provided by the product manufacturers should be carefully reviewed prior to use to verify the dose, administration, and contraindications. National, state, and local laws may vary regarding the use and application of many of the therapies discussed. The reader assumes the risk of any injuries. The authors and publishers, their affiliates and assigns are not liable for any injury and/or damage to persons arising from this protocol and expressly disclaim responsibility for any adverse effects resulting from the use of the information contained herein.

The protocols raise many issues that are subject to change as new data emerge. None of our suggested protocol regimens can guarantee health benefits. Life Extension has not performed independent verification of the data contained in the referenced materials, and expressly disclaims responsibility for any error in the literature.

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