Lifestyle factors such as smoking, stress, depression, and alcohol consumption, have been shown to be increased risk factors for periodontitis, as well as systemic diseases. Use of tobacco products are also important risk factor in the etiology of periodontitis. As a result of this information, the American Academy of Periodontics has established a separate category for smoking – associated periodontal disease.  The associations between the deleterious effects of tobacco on periodontitis and systemic diseases may involve its effects on neutrophil function and morphology; its ability to elevate serum C-reactive protein (CRP), cholesterol, and lipoproteins; and increase insulin-resistance.

Emotional stress often increases the severity of gingivitis. One study of 52 medical students found that out of 26 students who had just completed a major exam, six had severe gingival bleeding, which the authors attributed to stress. Stress, depression and periodontitis are common conditions in older adults. Grossi reported an association between stress and periodontal disease, and Persson and co-workers found an association between depression and tooth loss and chronic pain. Smoking, stress, and lack of physical activity have all been reported to be common denominators for periodontal disease, heart attack, and diabetes mellitus. However, physical activity, in the form of walking, has been shown to be beneficial to periodontal health.

Sound nutrition may delay or deter oral and systemic disease initiation and progression. Topical and systemic nutritional supplementation are beneficial adjuncts to gingivitis and periodontitis therapy and can modify oral – systemic disease associations. Whole foodstuffs and combined nutritional therapeutics can have an enhancing effect.

Important: Make no changes or additions to ongoing therapy until you have consulted your physician and dentist.


Long-term medication therapy is common, allowing increasing numbers of people to control chronic illnesses and achieve improved quality of life. However, use of medications is rarely without side effect of risk, making prevention and management of medication complications more challenging. As individuals with chronic illness age, it is more common to encounter multiple medications directed at multiple organ systems, compounding the challenge of managing the adverse effects of, and interactions among, multiple medications. Drug-nutrient interactions and nutritional deficiencies are a potential primary problem with many medications which can affect primarily the oral environment and have secondary nutritional and diet consequences.

Drug-induced nutritional deficiencies may develop through various mechanisms, occurring through different physiologic pathways. Drugs can interfere with synthesis of nutrients and alter the ability to transport, store, and metabolize nutrients. Nutrient depletion can result either by preventing nutrient absorption, enhancing nutrient elimination, or both. Drugs, even in therapeutic doses, can interfere with nutrient utilizatio, especially when the intake of nutrients is less than the demand or when nutrient stores are depleted. Vitamin and mineral deficienies can result from poor nutrient absorption caused by binding of nutrients to drugs, increased excretion, or impaired utilization. The inhibition of gastrointestinal (GI) absorption of vitamins by cholestryramine; the enhancement of potassium, magnesium, and zinc depletion by thiazide diuretics; and the acceleration of vitamin D metabolism and calcium depletion by anticonvulsants such as phenytoin and phenobarbital are well-documentd examples.

Drugs can produce damage to the exocrine pancreas, causing decreased production or release of pancreatic enzymes, which leads to decreased digestion of fat, protein, and starch. Some drugs decrease the absorption of macronutrients incluing sugars, fats, amino acids, vitamins, and minerals, causing nutritional deficiencies depending on the relative absorptive capacity of the small intestine. Drugs can additionally have a direct depressant or stimulating effect on appetite and food intake.

  • Drugs & Food Intake

Drugs can affect appetite along the GI function, resulting in alterations in food intake. Drugs affecting appetitie may have either a central or peripheral effect. Some drugs such as antidepressants and prednisone may increase appetite and cause weight gain, whereas others such as chemotherapeutic agents contribute to weight loss by causing anorexia, nausea, and vomiting. Many drugs have oral side oral side effects such as xerostomia or stomatitis that can affect food intake. A wide variety of drugs can cause changes in taste or smell alterations. Potassium iodide is secreted into the saliva, producing a constant unpleasant taste that inhibits food intake that is difficult to eradicate. Chlorpromazine and metronidazole cause a persistent metallic taste that inhibits food intake. Penicillamine causes zinc depletion, leading to loss of taste and loss of desire for food. Digitalis, especiallyin patients with decreased renal function, can cause marked nausea and vomiting. Biquanides, used as hypoglycemic agents, cause impaired appetite and decreased food intake. Chemotherapy drugs, especially cisplatin, actinomycin D, adriamycin, decarbazine, streptozocin, nitroureas, nitrogen mustard, and cyclophosphamide, and folic acid analogs. induce vomiting, anorexia, and subsequent weight loss. In patients who may have marginal intake of required nutrients, drugs causing anorexia can result in nutritional deficiencies. Persistent vomiting can be very detrimental to tooth enamel. The GI juices are very acidic and can remove the enamel from the teeth.

  • Drugs That Affect Oral Health and Nutritional Intake

Many prescription and over-the-counter medications have the potential to cause adverse oral conditions. Drug-induced oral lesions or dirorders occur frequently, especially among the elderly who take multiple medications to treat chronic diseases. Synergistic effects between medications can increase the incidence of such adverse events, either directly as an adverse effect of the drug or indirectly as the result of drug0induced vitamin deficienices. These effects can present as part of a general systemic effect, a specific oral adverse effect to the systemic use of a drug, or a local effect secondary to direct contact with the oral mucosa. The presence of these adverse drug effects can impair appetite and food intake and adversely affect the nutritional status of the patient.

(Dry Mouth) Xerostomia

Xerostomia is the perception of dry mouth and may or may not be associated with acual decreased salivation. Xerostomia is probably the most frequent, undesirable effect of drugs. Comonly used classes of medications such as anticholinergics, centralling acting antihypertensives, antihistamines, antipsychotics, narcotis analgesics, hypnotics, muscle relaxants, anticonvulsants, antieoplastics, antidepressants, and iuretics can cause a decrease of normal salivary secretion. Drug-induced xerostomia can cause alterations in taste and difficulty chewing and swallowing, leading to decreased food intake, subclinical malnutrition, and reduced resistance to disease and stress, especially among the elderly. Lack of lubrication can cause mucosal irritation, inflammation, and ulceration, and make it difficult for the patient to wear removable dental prostheses.

Xerostomia increases the development of candidal infections, often leading to complaints of pain, burning and altered taste. Decreases in salivary flow leads to decreased enzymatic debridement of plaque, decreased buffering and neutralization of acid formed in the tooth decay process, and increased accumulation of food debris, resulting in increased caries and periodontal diseases.

Changes in Taste Sensations

Many drugs induce abnormalities of taste and smell. The alteration may be decreased sensitivity in taste perception (hypogeusia), a total loss in the ability to taste (ageusia). Or an unpleasant or altered taste sensation (dysgeusia). Although ageusia is rare, drugs can give rise to dysgeusia or hypogeusia by interfering in the chemical composition and amount of saliva, by directly affecting taste-receptor function or signal transduction (either stimulating or desensiting), or by adversely affecting the renewal process of taste buds . The effect of drugs on taste may also be mediated by their actions on trace metals such as copper, zinc, and nickel. Reduction in salivary flow may concentrate electrolytes in the saliva, resulting in a salty or metallic taste. Alterations in taste can cause anorexia, food aversion, and weight loss.

Classifications of medications that can alter taste or smell include antihistamines, anticonvulsants, antidepressants, antihistamines, antihypertensives, anti-inflammatories, antimicrobials, antineoplastics, asthma medication, bronchodilators, lipid-lowering drugs, muscle relaxants, and vasodilators. Griseeofulvin, metronidazole (Flagyl), capoten (Captopril), pencillamine, and metformin (Glucophage) are frequently associated with altered taste. Up to 40% of patients treated with angiotensin-converting enzyme (ACE) inhibitors may have dysgeusia, although this effect in self-limiting and reversible within a few months, even with continued therapy. Therapies such as HAART, protease inhibitors, clarithomycin, and lansoprazole (Prevacid) therapy for Helicobacter pylori infection, terbinafine, pentamidine, and isotretinoin (Accutane) may cause some degree of loss of taste or altered taste. Taste disturbances tend to be self-limiting and often reversible in 2-3 months following discontinuation of the medication. It may be feasible to contact your physician to see whether there are substitute medications that can be used that have less effect on either salivary flow or taste. Possible approaches to relief from dygeusia include increased use of flavoring agents during food preparation, substituting alternative protein sources if the patient is unable to tolerate meat, and use of artificial saliva as needed. Optimal oral hygiene is essential. Use of a “swish and spit” with iced lemon water can temporarily decrease dysgeusia and increase patient comfort and satisfaction with subsequent meals. Patients should be reassured that, in most cases, taste will return to baseline. If the patient has persistent taste disturbances, a referral to an oral medicine specialist would be appropriate.


Stomatitis (inflammation of the mucosal lining of the mouth) from medications can be caused by both local effects and systemically mediated responses. Pain from mucosal lesions can be severe and can interfere with eating. Some cases of drug-induced stomatitis have no clinical presentation other than erythema, whereas other cases can be categorized as allergic stomatitis, lichenoid drug eruptions, lupus erythmatous like eruptions, pemphigus like drug reactions, and erythema multiforme. Ulceration of the oral mucosa is a common side effect of a wide variety of antineoplastic agents, including methotrexate, 5-fluorouracil, doxorubicin, daunorubicin, bleomycin, and melphalen through inhibition of epithelial cell mitosis. Allergic reactions can occur either locally from contact with the medication or from systemic administrations, including antibiotics (tetracycline, penicillin, sulfonamides, nitrofurantoin, isoniazid, para-amino salicylic acid, streptomycin, ketoconazole, grisefulvin), oral hypoglycemics (sulfonylureas), antihypertensives (β-adrenergic blocking agents (indomethacin, azulfidine, phenylbutazone, naproxen), and heavy metals (especially gold compounds). Secondary oral effects may be seen with drug-induced vitamin deficiencies, including the B-complex vitamins, iron, vitamin C, and vitamin A. Thiamine deficiency (often the result of chronic alcoholism) may lead to painful mucosa and small vesicles on the buccal mucosa.