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Current Oral Health Reports
https://doi.org/10.1007/s40496-022-00307-y
ORAL DISEASE ANDNUTRITION (F NISHIMURA, SECTION EDITOR)
Healthy Dietary Patterns onClinical Periodontal Parameters: AGRADE
Compliant Systematic Review andMeta‑analysis
GustavoSáenz‑Ravello1· LoretoMatamala1· NidiaCastrodosSantos2· PatriciaCisternas1· JorgeGamonal1·
AlejandraFernandez3,4· NataliaBello‑Escamilla8· MarcelaHernandez3,6· MauricioBaeza1,5,7
Accepted: 31 January 2022
© The Author(s), under exclusive licence to Springer Nature Switzerland AG 2022
Abstract
Purpose of review To evaluate the impact of healthy dietary patterns compared to the Western diet on periodontal indices in
adults, used in the prevention and treatment of periodontal diseases.
Recent findings Four RCTs and seven case–control studies were included on a critical appraisal of the evidence using GRADE,
based on random effects meta-analysis by methodological subgroups for periodontal indices, and a narrative synthesis. There
is a clinically significant reduction on bleeding on probing, Gingival Index and periodontal inflamed surface area, Calculus and
Debris Index and incidence of tooth loss on healthy dietary patterns group, with a very low to moderate certainty of the evidence.
Methodological complementation between included studies allows to consider “real-world data” that RCTs ignore, which have a
significant effect on this association. Although biological plausibility is reported, more studies are required to clarify these results.
Summary healthy dietary patterns could impact on periodontal health–disease status, reducing the global burden of peri-
odontal diseases by improving the results of the standard care actions, such as toothbrushing, interdental cleaning and peri-
odontal therapy. Further research is required to improve the quality of the evidence.
Keywords Healthy diet· Western diet· Periodontal Diseases· Periodontal Indices· Systematic review· Meta-analysis
Introduction
One of the lead causes of tooth loss is periodontal diseases (PD)
that represent a worldwide significant public health problem due
to their high prevalence, biological, economical and social impact,
compromising the quality of life and wellbeing. PD corresponds
to non-communicable diseases (NCD) since they are closely
related, sharing known social determinants and risk factors [1].
Among the risk factors associated with NCD are unhealthy
lifestyles [2, 3], such as the globally widespread Western diet
(WD), which includes highly processed foods rich in saturated
fat, snacks and sugary drinks [4]. These ingredients can generate
obesity, hyperglycemia and concomitantly, systemic inflamma-
tion, accelerating NCD development and progression [5]. In par-
allel, WD contributes to forming a dysbiotic gingival microbiota,
increasing gingival inflammation and the periodontal pocket
depth (PPD) in patients without other systemic conditions [6–11],
and increases the risk of periodontitis in community dwelling
older adults [12].
PROSPERO registration code: CRD42020203508
This article is part of the Topical Collection on Oral Disease and
Nutrition
* Mauricio Baeza
mbaeza.paredes@odontologia.uchile.cl
1 Faculty ofDentistry, University ofChile, Santiago, Chile
2 Dental Research Division, Universidade Guarulho,
Guarulhos, SP, Brazil
3 Laboratory ofPeriodontal Biology, Faculty ofDentistry,
University ofChile, Santiago, Chile
4 Faculty ofDentistry, Universidad Andres Bello, Santiago,
Chile
5 School ofPublic Health, FacultyofMedicine, University
ofChile, 7500011Santiago, Chile
6 Department ofPathology andOral Medicine, Faculty
ofDentistry, University ofChile, Santiago, Chile
7 Centro de Epidemiología y Vigilancia de las Enfermedades
Orales (CEVEO), Facultad de Odontología, Universidad de
Chile, Santiago, Chile
8 Departamento de Enfermería, Facultad de Ciencias de
la Salud y de los Alimentos, Universidad del Bío-Bío,
Concepción, Chile
Current Oral Health Reports
1 3
On the other hand, healthy dietary patterns (HDP) that
includes a high intake of fruit, vegetables, grains, pulses, leg-
umes, nuts and lean meat or meat substitutes such as soy prod-
ucts are rich in low glycemic index dietary fiber, nitrates, vita-
mins A, C, D, E, omega-3 essential minerals and other nutrients,
which, unlike the WD, have antioxidant and anti-inflammatory
properties [13]. HDP includes Mediterranean, vegetarian/vegan
diet, the DASH (Dietary Approaches to Stop Hypertension),
Nordic, Okinawan (similar to the Mediterranean diet) and Port-
folio diet [14]. These have shown significant effects by reducing
NCD-associated mortality, preventing cardiovascular diseases
(CVD), the incidence of cancer, neurodegenerative diseases and
diabetes mellitus [14, 15], and by reducing diagnostic and pro-
inflammatory biomarkers associated with NCD, as well as their
complications [16–20].
The effect of specific nutritional interventions on peri-
odontal health–disease status has been extensively studied,
from invitro to randomized clinical trials (RCT). Vitamin
A, B, C [21], E [22], nitrates [23], flavonoids, polyphenols,
natural antioxidants [24, 25] and aminoacids [26], Omega-3
[27] and minerals such as calcium and magnesium [28] have
been reported to decrease bleeding on probing (BOP), PPD,
clinical attachment loss (CAL), alveolar bone loss (ABL)
and tooth loss, contributing to the prevention and as co-adju-
vant treatment of PD with or without associated NCD. The
vast majority of these nutrients are present in HDP, and the
consumption of meat appears to have a protective impact on
periodontal health in absence of WD [7, 29]. Furthermore,
at least 5 servings per day of fruits and vegetables reduce
PPD, BOP, CAL and ABL, preventing the progression of PD
and future tooth loss [30]. Nevertheless, low certainty of the
evidence is reported [31], in consequence of the interactions
among the nutrients: it must be considered that these nutri-
ents were administered as supplements [32] or isolated food
components [30], ignoring their synergistic metabolic effect.
Despite the potential benefits and the recognized impact
of a HDP in the prevention and control of multiple NCD,
as well as the benefits of the promotion of other healthy
lifestyles in periodontitis patients [33], no systematic
review that assesses the impact of the HDP on periodontal
health–disease status in adults is reported. Therefore, the
aim of our study is to answer the focused question: What
is the impact of the HDP compared to the WD on clinical
periodontal parameters in adults?
Methods
Protocol
This review was designed according to PRISMA 2020 [34]
and AMSTAR 2 guideline [35]. The PROSPERO registra-
tion code is CRD42020203508.
Eligibility Criteria
Types of study. RCT and non-randomized clinical trials were
included using the PICO strategy; PECO for observational
studies including cohort, case–control or cross-sectional
studies. Published or in-press articles that had an English,
Spanish or Portuguese version were included.
Participants (P): Healthy individuals aged between 18
and 60years, enrolled in an intervention with a HDP to treat
PD, or observational studies, with adherence/exposure to
a HDP for at least one year to prevent PD. We excluded
patients that require special needs or immunocompromised,
and patients with food allergies.
Interventions (I)/Exposure (E): We use the terms related
to HDP used to prevent or treat NCD. Dietary question-
naires/indices and its interviewer, or self-reporting, and
biomarkers of nutritional status were extracted. For both
methodologies, we included studies without periodontal
therapy in the last 12months. We excluded studies on I/E
on specific food groups or nutrients.
Comparison (C): A control group correctly matched on
population and dietary habits of a WD, or different diet from
the I/E.
Outcomes (O): Studies that measured periodontal indices
were included.
Primary: PPD, CAL, BOP, Gingival Index (GI) [36],
Gingival Recession (GR), tooth mobility, ABL and others
parameters used to assess periodontal health–disease status,
e.g., periodontal inflamed surface area (PISA) [37].
Secondary: Plaque Index (PI) [38], Calculus Index, Vis-
ible Plaque Index (VPI) [39] or other oral hygiene indi-
ces, and tooth loss/number of teeth with their cause if
available.
Information Sources andSearch Strategy
The search was carried out independently (GS/LM) from
their oldest record up to January 17, 2022 in Cochrane
Library, ClinicalTrials.gov, EBSCOhost (Dentistry & Oral
sciences source), EMBASE, LiLACS, PubMed, SciELO,
Scopus and Web of Science. This search was complemented
by an electronic gray literature in Google Scholar and three
high impact journals in the field of periodontics: Journal of
Clinical Periodontology, Journal of Periodontal Research
and Periodontology 2000. The search in PubMed was
through the MeSH terms; then, this strategy was adopted
in the other electronic resources (Appendix Table5). Rel-
evant studies were identified via title–abstract–keywords
screening, and then, reviewed in full text. Reviewers (GS/
LM/MB) also checked relevant cited articles and discussed
their eligibility.
Current Oral Health Reports
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Selection andData Collection Process
Studies were added to Covidence © (Covidence systematic
review software, Veritas Health Innovation, Melbourne,
Australia) for de-duplication, independent screening and
data extraction (GS/LM). A Cohen’s Kappa test was per-
formed to verify the agreement between reviewers at all
stages of the review. Discrepancies were resolved by con-
sensus or finally by the decision of an arbiter reviewer (MB).
Data Items
For the qualitative synthesis, we designed a personalized
template based on the “Characteristics of included studies”
by Cochrane Collaboration:
• Demographic characteristics: age, sample size, setting
and country where the study was conducted.
• Dietary pattern assessment: Type of diet by self-report-
ing, Food Frequency Questionnaire, 24-h dietary recall
or dietary indices like Mediterranean diet score (MDS),
Alternative Eating Index (AHEI), Healthy Eating Index
(HEI) [40] and others analysis, i.e., biomarkers of nutri-
tional status. If applicable, we extracted who conducted
the dietary interview/evaluation.
• Periodontal assessment: Periodontal indices and exami-
nation protocol.
• Results of the study: Primary and secondary outcomes
related to the HDP.
Study Risk ofBias Assessment
Evaluation of risk of bias for each study was performed by
duplicate individual determination (GS/LM) and arbiter
consensus (MB). Cochrane Collaboration tool RoB 2.0 for
RCT [41] and Newcastle–Ottawa for case–control studies
[42] were used. Funding, protocol registration, conflicts of
interest or other biases were reviewed.
2.6 Summary of evidence.
We use Review Manager 5.4 for the meta-analysis of
RCTs and cross-sectional studies to combine the available
data of clinical periodontal parameters. If the studies were
not qualified to be included in the quantitative synthesis, we
reported a narrative summary.
For the outcomes PPD, BOP, CAL, PISA, GI and PI,
we compared the differences between groups at baseline.
Then, we calculate the mean difference (MD) and its 95%
confidence interval (CI) to summarize the results of stud-
ies that use the same periodontal index. Due to the dietary
variability among the RCTs and case–control studies, as
well as differences in periodontal examination protocol,
we conducted random effects model meta-analysis using
the generic inverse variance method. Heterogeneity was
assessed using the I2 and chi-squared measurement. Pub-
lication bias was investigated for each outcome by visual
inspection of asymmetries in the funnel plot. We per-
formed a subgroup analysis by methodological approach.
Certainty of evidence for each outcome was evaluated
by a panel composed by the authors of this review, using
the GRADE approach [43], that considers risk of bias,
inconsistency of results, indirectness of evidence, impre-
cision and publication bias to ensure the quality of the
evidence raised by this synthesis, initially, categorizing
the results from RCTs as high, and from observational
studies as low certainty of evidence, with the potential of
being upgraded or downgraded. We created a summary
of findings table using GRADEpro GDT web-based soft-
ware to present the results of this review. We interpret the
body of evidence in regard to the diagnostic thresholds for
periodontal indices proposed in the latest classification of
periodontal diseases [44].
Results
Study Selection
A total of 1509 articles were retrieved by searching data-
bases and registers and 643 via other sources. After elimi-
nating duplicates (n = 896), irrelevant studies and reports
not retrieved (n = 1205) after title and abstract identifica-
tion (k = 0.77), 57 papers were reviewed in full text, result-
ing in 10 for inclusion in the qualitative synthesis and 8 for
meta-analysis (k = 0.89) (Fig.1).
Study Characteristics
Four RCTs [45–48] and seven case–control [49–54] stud-
ies were included. These studies presented HDP, including
the vegan [49, 50, 53, 54] and vegetarian diet [51, 52, 54],
omnivore diets like Mediterranean [45] or anti-inflamma-
tory diet [46–48]. The results according to primary and
secondary outcomes are summarized in Table1. The rea-
sons for excluding 47 studies were summarized in Table2.
Risk ofBias inStudies
The RCTs presented low risk of bias in performance,
detection, attrition and reporting; however, there are some
concerns in the allocation concealment on I group (selec-
tion bias) since those might know that they are under a
dietary intervention (Hawthorne’s effect), categorizing
the overall as high risk of bias (Fig.2). For observational
Current Oral Health Reports
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studies, the assessment using the Newcastle–Ottawa
scale reflects a mean overall rating of 5/9 (range 1–6)
for case–control studies. The concerns in this case were
about the case definition and ascertainment of the expo-
sure for case–control, since the dietary evaluation was
carried using self-report and non-standardized question-
naires (k = 0.93) (Fig.3).
Impact ofHDP onPeriodontal Health Status
The summary of findings tables of the collected evidence,
as well as the rationale for GRADEing, is presented in
Tables3 and 4.
Impact onGingival Inflammation
Four RCTs evaluating Mediterranean or Mediterranean-like
diet [45–48] (4–6-week follow-up) on 136 gingivitis patients
show a large reduction in BOP -22.02% [-49.18%,5.13%]
(Fig.4) and a moderate reduction in GI of -0.37 [-0.77, 0.03]
(Fig.5) with moderate certainty of the evidence (Table3).
On the other hand, results from four case–control studies
evaluating vegan/vegetarian [49, 52–54] of 474 patients shows
a moderate reduction of 9.31% [-16.49%, -2.13%] of BOP
(Fig.4) and a small increase of 0.10 [-0.04, 0.23] of GI (Fig.5)
on the exposure group, following this diet from 18months to
40years, with very low certainty of the evidence (Table4).
Impact onFull‑Mouth Periodontal Support Parameters
Four RCTs evaluating Mediterranean diet [45–48] (4–6-
week follow-up) on 136 patients with gingivitis show a
clinically insignificant reduction of 0.10mm [-0.17mm,
-0.03mm] on PPD for the intervention group (Fig.6), with
moderate certainty of the evidence. For CAL, the results
from two RCTs evaluating Mediterranean diet [47, 48] on 69
patients with gingivitis show a trivial reduction of -0.62mm
[-0.67mm, -0.57mm] (Fig.7) with moderate certainty of
the evidence. For PISA, three RCTs [45–47] show a reduc-
tion of -154.78 mm2 [-374.53 mm2, 64.98 mm2] in short-
term adherents of a Mediterranean diet compared to the
control group (Fig.8), with low certainty of the evidence.
On the other hand, results from two case–control [49,
54] studies from 318 patients show a clinically insignificant
reduction of -0.18mm [-0.30mm, -0.07mm] of PPD in
Fig. 1 PRISMA 2020 flow diagram for identification and selection of studies
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Table 1 Characteristics and qualitative synthesis of included studies in this systematic review for the impact of healthy dietary pattern compared to the Western diet on periodontal health status
Reference Setting, country Sample (age distribution,
sex distribution)
Dietary pattern (I/E) and
assessment (performed by)
Periodontal assessment
and examination protocol
Results
Primary outcomes Secondary outcomes Statistical adjustment for
potential confounders
Randomized Controlled Trials
Bartha etal. 2021 [45]†Department of Conserva-
tive Dentistry, University
Hospital Tübingen,
Germany
Generalized gingivitis
patients (BOP > 30%)
I: 18 individuals, aged
32.71 ± 8.87years
M: 10
F: 8
C: 19 individuals, aged
29.21 ± 7.17years
M: 7
F: 12
Mediterranean diet com-
pared to the Western diet
(assessed by MEDAS and
FFQ (with assessment on
the adherence to dietary
recommendations),
conducted by a dietitian
and dentist/specialist in
nutritional medicine)
(6-week follow-up)
PPD
BOP
PISA
GI
PI
Blinded dentist / Full
mouth (6 sites per tooth)
/ ND
―PPD
↓BOP
↓PISA
―GI
―PI Age and sex
Rajaram etal. 2021 [48]†Department of Periodon-
tology at Haldia Institute
of Dental Sciences and
Research, India
Gingivitis patients
(GI > 0.5 and ≤ 3)
I: 27 individuals, aged
35.2 ± 7.2years
M: 13
F: 14
C: 27 individuals, aged
36.1 ± 8.3years
M: 11
F: 16
Oral health optimized diet/
Mediterranean-like diet
compared to the Western
diet (self-reported daily
food diary with assess-
ment on the adherence to
dietary recommendations)
(4-week follow-up)
PPD
CAL
BOP
GI
PI
Blinded dentist / ND
/ UNC 15 probe
(Hufriedy)
―PPD
―CAL
↓BOP
↓GI
―PI -
Woelber etal. 2016 [46] Department of Opera-
tive Dentistry and
Periodontology, Medical
Center—University of
Freiburg, Germany
Gingivitis patients
(GI > 0.5)
I: 10 individuals (1 drop-
out after 2weeks), aged
34.4 ± 14.1years
M: 4
F: 6
C: 5 individuals, aged
34.0 ± 16.5years
M: 2
F: 3
Oral health optimized diet /
Mediterranean-like diet
compared to the Western
diet (self-reported daily
food diary with an assess-
ment on the adherence to
dietary recommendations)
(6-week follow-up)
PPD
CAL
BOP
PISA
GI
PI
Blinded calibrated dentists
/ Full mouth (6 sites) /
Pressure-sensitive
probe (DB764R, Aesculap
AG, Tuttlingen, Ger-
many)
↓PPD
↓CAL
↓BOP
↓GI
↓PISA
↓PI Age, gender, BMI
Woelber etal. 2019 [47] Department of Opera-
tive Dentistry and
Periodontology, Medical
Center—University of
Freiburg, Germany
Gingivitis patients
(GI ≥ 0.5)
I: 15 individuals, aged
27.2 ± 4.7years
M: 6
F: 9
C: 15 individuals; aged
33.7 ± 13.1years
M: 7
F: 8
Anti-inflammatory/Mediterra-
nean-like diet (based on pre-
vious study (45), with higher
vitamin D values, reduction
of animal proteins,
and focused intake of
nitrate‐containing plants)
compared to the Western
diet (self-reported 24-h
dietary recall assess-
ment on the adherence to
dietary recommendations,
and serological levels of
vitamin D, omega‐3‐ and
omega‐6 fatty acids)
(6-week follow-up)
PPD
BOP
PISA
GI
PI
Blinded calibrated dentists
/ Full mouth (6 sites) /
Pressure-sensitive
probe (DB764R, Aesculap
AG, Tuttlingen, Ger-
many)
↓PPD
↓BOP
↓GI
-PISA
―PI -
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Table 1 (continued)
Reference Setting, country Sample (age distribution,
sex distribution)
Dietary pattern (I/E) and
assessment (performed by)
Periodontal assessment
and examination protocol
Results
Primary outcomes Secondary outcomes Statistical adjustment for
potential confounders
Case–control studies
Atarbashi-Moghadan etal.
2020 [49]
Shahid Beheshti Dental
Clinic, Tehran, Iran E: 59 subjects aged
between 18 and 77years
(mean 43.97 ± 14.35)
M: 25
F: 34
C: 59 subjects, aged
between 20 and 77years
(mean 43.90 ± 14.01)
M: 25
F: 34
Raw vegan diet
(total duration of
48.9 ± 66.11months)
(self-reporting)
PPD
GR
CAL
BOP
Furcation involvement
(Glickman)
Tooth mobility (Miller)
Calculus Index
Debris Index
Oral Hygiene Index
Missed Teeth
Periodontist / Full mouth
(4 sites) / Williams peri-
odontal probe
↓PPD
―GR
―CAL
↓BOP
―Furcation involve-
ment
―Tooth mobility
↓Calculus Index
↓Debris Index
↓OHI
-Missed teeth
-
Laffranchi etal. 2010 [50]†Italy E: 15 individuals, aged 24
to 60years
M: 11
F: 4
C: 15 individuals (ND)
Vegan Diet (followed for
at least 18months to
40years) (self-reporting)
GI
PI
Dentist / 6 teeth (4 sites)
/ND
―GI ―PI -
Linkosalo etal. 1985 [52] Finland E: 28 individuals (ND)
C: 28 individuals (ND)
M: 9
F: 19
Lactovegetarians (followed
for at least 2years) (self-
reporting)
All lactovegetarians had
maintained their diet at
least 2years
N° of sites with
PPD ≥ 4mm
GI
Tooth mobility
ABL
N° of teeth
PI
Calculus Index
Dentist / 6 teeth (4 sites)
/ ND
↓ N° of sites with
PPD ≥ 4mm
―GI
―Tooth mobility
―ABL
―PI
―Calculus Index
―N° of teeth
-
Linkosalo etal. 1985 (a)
[51]
Finland E: 9 individuals aged
39.6 ± 10.1years
M: 5
F: 4
C: 9 individuals aged
36.8 ± 12.0years (
M: 5
F: 4
Lactovegetarians (followed
for 10 ± 6years) (self-
reporting)
Two of the nine lactoveg-
etarians were truly
lactovegetarians, eating
no animal products except
milk products, whereas
the other seven were
lacto-ovo-vegetarians
whose diets included
eggs also
Gingival Bleeding Index
ABL
PI
Calculus Index
Dentist / 6 teeth (4 sites)
/ ND
↑Gingival Bleeding Index
↑ABL
↑PI
―Calculus Index
-
Current Oral Health Reports
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Table 1 (continued)
Reference Setting, country Sample (age distribution,
sex distribution)
Dietary pattern (I/E) and
assessment (performed by)
Periodontal assessment
and examination protocol
Results
Primary outcomes Secondary outcomes Statistical adjustment for
potential confounders
Staufenbiel etal. 2013 [54] Hannover Medical School,
Hannover, Germany E: 100 individuals (89
lacto-ovo-vegetarians
and 11 vegans) aged
41.5 ± 14.1years
M: 29
F: 71
C: 100 individuals, aged
41.7 ± 15.3years
M: 29
F: 71
Lacto-ovo-vegetarian,
Vegan diet (followed for
15.1 ± 9.1years) (self-
reporting)
PPD
GR
CAL
BOP
N° of teeth with furcation
involvement
N° of mobile teeth
Hygiene Index
Missed Teeth
Calibrated investigators
/ Full mouth (6 sites) /
WHO periodontal probe)
↓PPD
―Gingival Recession
―CAL
↓BOP
―N° of teeth with
furcation involvement
↓N° of mobile teeth
↑Hygiene Index
↓Missed Teeth
-
Zotti etal. 2014 [53]†Italy E: 50 individuals aged
between 24 to 60years
M: 28
F: 22
C: 50 individuals (ND)
Vegan diet (followed from
18months to 20years)
(Not standardized dietary
questionnaire)
GI
PI
Dentist / 6 teeth (4 sites) / ND
―GI ―PI -
I: Intervention, E: Exposition, C: Control, M: Male, F: Female; FFQ: Food Frequency Questionnaire, MEDAS: Mediterranean Diet Adherence Screener, ABL: alveolar bone loss, BOP: bleed-
ing on probing, CAL: clinical attachment loss, GI: Gingival Index, GR: Gingival Recession, PI: Plaque Index, PPD: periodontal pocket depth, BMI: Body Mass Index, ND: Not declared, †:
Records identified in gray literature and relevant citations
Current Oral Health Reports
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adherents to a vegan/vegetarian diet compared to the control
(Fig.6). For CAL, the results from two control [49, 54] stud-
ies of 318 adherents to a vegan/vegetarian diet that showed
trivial reduction in this parameter (-0.15mm [-0.42mm,
0.11mm]) (Fig.7), with very low certainty of the evidence.
The quantitative synthesis of two case–control studies for
vegan/vegetarian diet [49, 54] shows trivial to no effects on
GR (Fig.9a), N° of teeth with furcation defects (Fig.9b)
and N° of mobile teeth compared to the control (Fig.9c).
In the case of ABL, there are inconclusive results across the
studies that evaluate also the vegan/vegetarian diet [51, 52],
with very low certainty of the evidence (Table4).
Impact onSecondary Outcomes
For PI, evidence from four RCTs evaluating the Mediter-
ranean diet [45–48] on 136 patients with gingivitis (-0.02
[-0.08, 0.04]) (Fig.10) shows almost no differences between
groups, with moderate to very low certainty of the evidence
respectively (Table3).
Two case–control studies of 156 adherents to a vegan/
vegetarian diet show the same anterior trend on PI [52, 53]
(0.04 [-0.08, 0.15]) (Fig.10), with very low certainty of the
evidence. Two case–control study evaluating vegan/vegetar-
ian diet [49, 54] (n = 474) shows a small reduction on Cal-
culus (-0.28, p < 0.01) and Debris Index (-0.15, p < 0.05),
and a considerable better Hygiene Index (50.62 ± 18.16%)
in adherents to a vegan/vegetarian diet compared to the con-
trol (35.7 ± 18.62%) (p < 0.001), with very low certainty of
the evidence. In addition, one case–control (n = 200) [54]
showed considerably lower number of missed teeth in veg-
etarians (1.53 ± 3.30) compared to the control (2.28 ± 3.67)
(p < 0.05), with very low certainty of the evidence. Never-
theless, some studies show no differences on plaque accu-
mulation indices between groups [51, 52]. For this narrative
synthesis, low certainty of the evidence is reported (Table4).
There were not studies that assess the impact of HDP on
patient-reported outcome measures or any additional cost-
effectiveness analysis.
Publication Bias
The limited number of studies included in the meta-analysis
did not allow a correct visual or statistical evaluation of the
funnel plot to determine a possible publication bias among
the included studies.
Discussion
HDP could improve the results to reduce the global burden
of PD. We suggest the use of HDP intervention for PD at
primary and secondary prevention levels.
Table 2 Characteristics of the excluded studies
P: Patient, I / E: Intervention / Exposition, C: Comparator, O: Out-
comes, NA: Not available, †: Records identified in gray literature and
relevant citations
Reference Excluded by wrong:
P I / E C O
Abbas etal. 2019 [55]○ ● ○ ○
Alhassani etal. 2021 [56]○ ○ ○ ●
Alhassani etal. 2021 (a) [57]†○ ○ ○ ●
Alsyefi & Alasqah 2021 [58]†○ ○ ● ●
Altun etal. 2021 [59]○ ○ ○ ●
Al-Zahrani etal. 2004 [6]○ ○ ○ ●
Al-Zahrani etal. 2005 [60]○ ● ○ ●
Bawadi etal. 2011 [8]○ ○ ○ ●
Caine 1976 [61]NA
Chalikias etal. 2011 [62]● ● ○ ○
Costa etal. 2021 [63]○ ● ○ ●
Eberhard etal. 2021 [64]○ ● ○ ●
Grobler & Brignaut 1989 [65]NA
Holmes & Collier 1966 [66]● ○ ○ ○
Hosoda etal. 2021 [67]○ ● ○ ●
Hung etal. 2005 [68]○ ● ○ ●
Iwasaki etal. 2021 [69]○ ○ ○ ●
Jaghasi etal. 2012 [70]● ○ ○ ○
Jauhiainen etal. 2016 [71]○ ○ ○ ●
Jauhiainen etal. 2020 [9]○ ○ ○ ●
Kalyanpur etal. 2019 [72]†○ ○ ○ ●
Karjalainen etal. 1997 [73]● ● ○ ○
Kaye etal. 2015 [74]● ○ ● ○
Khocht etal. 2021 [75]○ ○ ○ ●
Kondo etal. 2014 [76]● ○ ● ○
Kono etal. 2021 [77]○ ○ ○ ●
Kotsakis etal. 2018 [78]○ ○ ○ ●
Kumar & Shetty 2018 [79]†NA
Kwok etal. 2004 [80]● ○ ○ ●
Li etal. 2021 [81]○ ○ ○ ●
Linkosalo etal. 1988 [82]NA
Machado etal. 2021 [83]○ ○ ○ ●
Mazur etal. 2020 [84]†○ ○ ○ ●
Nielsen etal. 2016 [85]○ ● ○ ●
Pulikkotil etal. 2020 [10]†○ ○ ○ ●
Rahmatulla 1990 [86]†● ○ ○ ●
Reyes-Izquierdo etal. 2021 [87]○ ○ ○ ●
Richardson 1958 [88]○ ○ ○ ●
Salazar etal. 2018 [11]○ ○ ○ ●
Sedgley etal. 1996 [89]○ ○ ● ●
Sherfudhin 1996 [90]†○ ○ ○ ●
Stein etal. 2021 [91]○ ○ ○ ●
Tennert etal. 2020 [92]○ ○ ○ ●
Väänänen 1994 [93]○ ○ ○ ●
Woelber etal. 2021 [94]○ ○ ● ○
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Yoshihara etal. 2009 [96]● ○ ○ ●
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Gingival Inflammation
According to the latest classification of periodontal and
peri-implant diseases, BOP is an early and accurate sign
of gingival inflammation and has been correlated with the
severity of the gingival inflammatory condition at the site
level. This review shows an overall reduction of 18.51% in
BOP that favors HDP, which may contribute to reaching
values below the 10% threshold defined as a cut-off point
for gingivitis [97]. Although this BOP meta-analysis shows
a significant impact in favor of the study group, these results
should be interpreted with caution due to the small num-
ber of articles included in this meta-analysis and the high
heterogeneity between them, probably due the difference at
initial periodontal health status, in addition to the inherent
differences on the dietary patterns among the participants
enrolled in observational and experimental studies. Inline,
a HDP showed a trend towards a lower GI; however, there
are unclearly conclusions, probably due to the difficulty in
achieving a standardized and reliable clinical assessment,
resulting in different styles and levels of certainty in clinical
performance [98, 99].
Fig. 2 Risk of bias of the RCTs
included in this review, evalu-
ated with the RoB 2.0 tool from
Cochrane Collaboration
Current Oral Health Reports
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Periodontitis andFull‑Mouth Periodontal Support
Parameters
Although the effect of a healthier diet has been less explored
in relation to clinical parameters more associated with peri-
odontal support, our results at the full mouth level suggest a
potential positive effect of a HDP on PPD and CAL. In line
with these results, a clinical study observed that patients with
greater intakes of fruits and vegetables, b-carotene, vitamin C,
tocopherol and Omega-3 fatty acids had a lower percentage of
sites with PPD > 3mm after SRP, indicating that they experi-
enced a greater degree of periodontal healing compared with
patients with lower intakes [100]. Other related parameters such
as furcation defects, tooth mobility or the number of missing
teeth also seem to be influenced by the dietary pattern. There-
fore, more observational and intervention studies with longer
follow-up periods are necessary to clarify the association.
Potential Mechanisms Between Diet
andPeriodontal Health
PI did not have significant differences between both groups,
which would rule out its potential participation as an explan-
atory mechanism in the reduction of gingival inflammation
(BOP) and periodontal parameters (PPD and CAL), as a
consequence of a HDP. These results support findings from
studies of changes in diet patterns, which have observed the
effect of a HDP on periodontal parameters independently of
plaque levels [7]. However, it is noteworthy that there are
studies in which dietary quality (DQ) was positively corre-
lated with oral hygiene [49, 54, 71] and negatively correlated
with the presence of calculus [6, 49, 55]. Oral hygiene can
be positively influenced by the educational level of the par-
ticipants, and it has been described that those subjects have
a higher educational level [49, 54]. This implies that a more
exhaustive statistical analysis, e.g., meta-regression, sensi-
tivity analysis or, if it is possible, an individual patient data
meta-analysis for complex interventions like diet [101] is
required, to controlling the possible impact of sociocultural
variables and its interaction on diet and periodontal diseases
independently. Nevertheless, it can be hypothesized that
the clinical outcomes were caused by an altered microbial
composition and/or metabolism of the subgingival biofilm
independent of the amount of plaque [102, 103] or by an
altered immune response in periodontal tissues. Concerning
the latter, the association between endothelial inflammation
and diet has already been demonstrated for CVD [104]. Simi-
larly, diet could induce vascular inflammation in periodontal
tissues, that favors the proliferation of periodontal pathogens
that amplify local and systemic inflammation [105]. This
hypothesis supports the connection between periodontal dis-
ease and other chronic inflammatory diseases (e.g., diabetes
or coronary heart disease), where diet can play a key role in its
development [106]. Indeed, a high-fat diet increased molecu-
lar remodeling, matrix proteins degradation causing reduced
gingival blood flow, that may lead to alveolar bone loss [107].
Clinical Implications andFuture Directions
Multiple studies have found that a HDP reduces the risk
for NCD complications. Such a diet is likely to be low in
saturated fats, which may improve blood lip profile and
Fig. 3 Risk of bias of the observational studies included in this review, evaluated with the Newcastle–Ottawa tool
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Table 3 Mediterranean diet compared to a WD for clinical periodontal parameters and periodontal health–disease status in adults with gingiviti
a We have some concerns about the allocation concealment of the studies, high heterogeneity and no overlapping of CI (inconsistency) that is logical according to the sampling distribution
and size; we have some concerns about indirect evidence regard to the intervention (differences in the consumption of animal protein and higher levels of plants nitrates), but we decided not to
downgrade because of this; Imprecision: optimal power of the RCTs according to the sample size, but less than 300 participants; includes null effect and appreciable reduction of BOP, bigger
than the 10% proposed in the new classification, and a significant reduction of GI in regard to the diagnostic criteria for gingivitis defined by the authors with low number of studies; we cannot
assess the publication bias, but we are likely to have no serious concerns about this: we decided to downgrade 1 level *Although we have some concerns about the reliability of GI, we decided
not to downgrade for imprecision, since this index was assessed using a similar protocol among the studies **Imprecision: we have no serious concerns, since there is a clinically insignificant
reduction on this parameter that includes null effect ***Imprecision: we have serious concerns, since it includes null effect and a moderate reduction of PISA
Outcomes N° of studies N° of par-
ticipants
Overall effect with a healthy dietary
pattern (95% CI)
Certainty of the evidence Interpretation from the available
evidence
Gingival Inflammation BOP [%] 4 RCTs (4–6-week follow-up) I: 70
C: 66
MD -22.02% [-49.18%, 5.13%],
I2 = 99%, p < 0.05
⊕ ⊕ ⊕ ◯
MODERATE aShort-term adherence to a Mediter-
ranean diet likely results in large
reduction of the gingival inflamma-
tion in patients with gingivitis. We
are moderately confident in the effect
estimate: The true effect is likely to be
close to the estimate of the effect, but
there is a possibility that it is substan-
tially different
GI 4 RCTs (4–6-week follow-up) I: 70
C: 66
MD -0.37 [-0.77, 0.03],
I2 = 97%, p > 0.05
⊕ ⊕ ⊕ ◯
MODERATE a*
Full-mouth periodontal support
parameters PPD [mm] 4 RCTs (4–6-week follow-up) I: 70
C: 66
MD -0.10mm [-0.17mm, -0.03mm],
I2 = 52%, p > 0.05
⊕ ⊕ ⊕ ◯
MODERATE a**
Short-term adherence to a Mediterra-
nean diet likely results in a clinically
insignificant reduction of PPD and
CAL in patients with gingivitis. We
are moderately confident in the effect
estimate: The true effect is likely to be
close to the estimate of the effect, but
there is a possibility that it is substan-
tially different
CAL [mm] 2 RCTs (4–6-week follow-up) I: 37
C: 32
MD -0.62mm [-0.67mm, -0.57mm],
I2 = 0%, p > 0.05
⊕ ⊕ ⊕ ◯
MODERATE a**
PISA [mm2]3 RCTs (6-week follow-up) I: 43
C: 39
MD -154.78 mm2 [-374.53 mm2, 64.98
mm2]
I2 = 85%, p < 0.05
⊕ ⊕ ◯◯
LOW a***
Short-term adherence to a Mediterra-
nean diet likely results in a moderate
reduction of PISA in patients with
gingivitis. Our confidence in the effect
estimate is limited: The true effect
may be substantially different from the
estimate of the effect
Secondary Outcomes PI 4 RCTs (4–6-week follow-up) I: 70
C: 66
MD -0.02 [-0.08, 0.04],
I2 = 38%, p > 0.05
⊕ ⊕ ⊕ ◯
MODERATE aShort-term adherence to a Mediterra-
nean diet likely results in no reduction
of PI on patients with gingivitis. We
are moderately confident in the effect
estimate: The true effect is likely to be
close to the estimate of the effect, but
there is a possibility that it is substan-
tially different
Patient-reported outcome measures There were no studies reporting this outcome
Cost-effectiveness There were no studies reporting this outcome
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Table 4 Vegan/vegetarian diet compared to a WD for clinical periodontal parameters and periodontal health–disease status in adults
Outcomes N° of studies N° of participants Overall effect with a healthy
dietary pattern (95% CI)
Certainty of the evidence Interpretation from the avail-
able evidence
Gingival Inflammation BOP [%] 2 Case–control E: 159
C: 159
MD -9.31% [-16.49%,
-2.13%],
I2 = 35%, p > 0.05
⊕ ◯◯◯
VERY LOW bMedium- to long-term adher-
ence to a vegan/vegetarian
diet likely result in a moderate
reduction in the gingival
inflammation in adults
We have very little confidence
in the effect estimate: The true
effect is likely to be sub-
stantially different from the
estimate of effect
GI 2 Case–control E: 78
C: 78
MD 0.10 [-0.04, 0.23],
I2 = 0%, p > 0.05
⊕ ◯◯◯
VERY LOW d
Full-mouth periodontal sup-
port parameters PPD [mm] 2 Case–control E: 159
C: 159
MD -0.18mm [-0.30mm,
-0.07mm], I2 = 0%, p > 0.05
⊕ ◯◯◯
VERY LOW b*
Medium- to long-term adher-
ence to a vegan/vegetarian
diet likely result in a clinically
insignificant effect on clinical
parameters used to measure
the periodontal destruction at
full-mouth level in adults
We have very little confidence
in the effect estimate: The true
effect is likely to be sub-
stantially different from the
estimate of effect
GR [mm] 2 Case–control E: 159
C: 159
MD -0.05mm [-0.27mm,
0.17mm], I2 = 0%, p > 0.05
⊕ ◯◯◯
VERY LOW b*
CAL [mm] 2 Case–control E: 159
C: 159
MD -0.15mm [-0.42mm,
0.11mm], I2 = 49%, p > 0.05
⊕ ◯◯◯
VERY LOW b
N° of teeth with furcation
defects 2 Case–control E: 159
C: 159
MD 0.27 [0.05, 0.49],
I2 = 0%, p > 0.05
⊕ ◯◯◯
VERY LOW b*
N° of mobile teeth 2 Case–control E: 159
C: 159
MD -0.26 [-0.48, -0.04],
I2 = 0%, p > 0.05
⊕ ◯◯◯
VERY LOW b*
ABL [mm] 2 Case–control E: 37
C: 37
1 Case–control found no
differences between both
groups [52], while the
other found higher ABL on
healthy dietary pattern [51]
(p > 0.05)
⊕ ◯◯◯
VERY LOW c
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Table 4 (continued)
Outcomes N° of studies N° of participants Overall effect with a healthy
dietary pattern (95% CI)
Certainty of the evidence Interpretation from the avail-
able evidence
Secondary Outcomes PI 2 Case–control E: 78
C: 78
MD 0.04 [-0.08, 0.15],
I2 = 0%, p > 0.05
⊕ ◯◯◯
VERY LOW d*
Medium- to long-term adher-
ence to a vegan/vegetarian
diet likely result in no differ-
ence of PI in adults. We have
very little confidence in the
effect estimate: The true effect
is likely to be substantially
different from the estimate of
effect
Other oral hygiene indices 2 Case–control E: 159
C: 159
Adherence to a vegan/veg-
etarian diet show a small to
moderate difference in the
Calculus and Debris Index
and better OHI in adults
from Germany [54] and Iran
[49] (p < 0.05)
⊕ ◯◯◯
VERY LOW bMedium- to long-term adher-
ence to a vegan/vegetarian
diet likely result in a small to
moderate reduction of plaque
accumulation in adults. We
have very little confidence in
the effect estimate: The true
effect is likely to be sub-
stantially different from the
estimate of effect
Patient-reported outcome measures There were no studies reporting this outcome
Cost-effectiveness There were no studies reporting this outcome
b We have serious concerns about the case definition and ascertainment of the exposure (self-reporting); we have some concerns about moderate heterogeneity regard to differences in popula-
tion; however, there is the same direction and overlapping of CI in the MA, we decided not to downgrade because of this; we have serious concerns about the indirect evidence regard to the
higher education level in the exposure group and the diversity on examination protocols; however, since the outcome BOP is dichotomous, there is optimal power of the studies, in addition to
that not includes the null effect in the estimates, we decided not to downgrade because imprecision; we cannot assess the publication bias but we are likely to have no serious concerns about
this, there is no large effect or dose–response rate, as well as any additional confounders to consider for upgrade: we decided to downgrade 1 level *Imprecision: we have no serios concerns
about this parameter since it has a clinically insignificant reduction on this parameter that includes null effect, we decided not to downgrade because of this
c We have very serious concerns about the representativeness of the exposed group and methodological design and power of the studies. In addition, we have very serious concerns about the
inconsistency, indirectness evidence and imprecision of the results since it has an important effect on this outcome with high variability of result between the studies and low number of studies.
We decided to downgrade 1 level
d We have very serious concerns about the case definition and ascertainment of the exposure (self-reporting) and assessment of the outcome; we have no serious concerns about inconsistency,
since there is low heterogeneity, same direction and overlapping of CI; we have serious concerns about indirect evidence regard to the examination protocols, since the low reliability of GI and
the fact that this index was assessed by different examinators in different centuries; we have serious concerns about the sample size and distribution, additionally, there is an appreciable effect
favoring the control group, inconsistent with the actual evidence; we cannot assess the publication bias but we are likely to have no serious concerns about this, there is no large effect or dose–
response rate, as well as a potential confounders to consider for upgrade, as well as low number of studies: we decided to downgrade 1 level *Inconsistency and Imprecision: there are no differ-
ences between the groups, since PI that is a reliable measure to assess the plaque accumulation, but there is a low sample size
Current Oral Health Reports
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decrease systemic inflammation, due to the antioxidant
effects of polyphenols [108, 109]. The gut microbiome
represents another pathway in which a HDP may influence
NCD. Modifications in the diet have been shown to rap-
idly alter the structure of the gut microbiota [110–112].
These studies show a link between animal-based diets with
increased dietary fats, bile acids and microbial dysbiosis
leading to systemic inflammation. Herein, we observed that
a HDP reduces gingival inflammation, as well as promoted
greater BOP reduction than WD. In this direction, some
evidence shows heterogeneous conclusions [56, 57, 69, 71].
Indeed, an observational study concludes that the Mediter-
ranean diet has no impact on insulin resistance in patients
with periodontitis [113], contrary to other study that shows
an improvement on periodontal health in diabetic patients
with periodontitis [114]. In addition, a case series study
on Okinawan diet shows an improvement in bleeding on
probing and HbA1c in diabetic patients after two weeks
[115]; Similarly, a RCT on obese [116] shows a reduction
in PD, BOP and CAL, improving the effect of the conven-
tional periodontal therapy in obese in comparison with the
control group, a direct consequence of the weight loss and,
at the same time, the reduction on systemic inflammation
after twelve weeks. In like manner, Jauhiainen etal. [117]
demonstrated an improvement in periodontal health status
in daily smokers with good oral hygiene. Nevertheless, evi-
dence that assesses the effect of a HDP in comparison with
the standard periodontal treatment in patients with peri-
odontitis with or without other NCD or risk factors, control-
ling for other covariates, is not reported.
Fig. 4 Random effects meta-analysis for healthy dietary pattern (Intervention/Exposition) vs Western diet (Control) for BOP [%] at baseline. CI:
Confidence interval, IV: inverse variance, SD: standard deviation
Fig. 5 Random effects meta-analysis for healthy dietary pattern (Intervention/Exposition) vs Western diet (Control) for GI at baseline. CI: Confi-
dence interval, IV: inverse variance, SD: standard deviation
Current Oral Health Reports
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Strengthens andLimitations
Conventionally, gingival bleeding is the primary outcome
for clinical studies that evaluate gingivitis, while mean
CAL has been used to assess patients with periodontitis.
Thus, the practitioner should consider the inherent differ-
ences in regard to these variables for the interpretation of
our findings. Furthermore, few studies reported the number/
Fig. 6 Random effects meta-analysis for healthy dietary pattern (Intervention/Exposition) vs Western diet (Control) for PPD at baseline. CI:
Confidence interval, IV: inverse variance, SD: standard deviation
Fig. 7 Random effects meta-analysis for healthy dietary pattern (Intervention/Exposition) vs Western diet (Control) for CAL at baseline. CI:
Confidence interval, IV: inverse variance, SD: standard deviation
Fig. 8 Random effects meta-analysis for healthy dietary pattern (Intervention/Exposition) vs Western diet (Control) for PISA at baseline. CI:
Confidence interval, IV: inverse variance, SD: standard deviation
Current Oral Health Reports
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percentage of periodontal pockets, which hampers the inter-
pretation of clinical studies to clinical practice. It is still dif-
ficult to determine if a HDP intervention would be clinically
relevant for the treatment of periodontitis. Recently, a clini-
cal endpoint for periodontal trials (≤ 4 sites with PD ≥ 5mm)
has been proposed [118], that is effective in determining dis-
ease remission/control after active periodontal treatment and
encouraged researchers in the field to report this endpoint in
future periodontal trials, allowing direct comparisons across
studies and extrapolation to clinical practice.
Although the trend among the excluded studies is that a
HDP reduces the prevalence and incidence of periodontitis
[8–11, 59, 81, 83, 95] and gingival inflammation [59, 71, 84,
87], as well as the prevalence of plaque accumulation [6, 59]
and tooth loss [8, 78], after several statistical adjustments,
there was evidence of high heterogeneity in the definition
of periodontitis that difficult the quantitative synthesis for
the impact of HDP on periodontal diagnosis; 2 studies [55,
58] used the latest classification of periodontal and peri-
implant diseases and conditions [44], while the others used
Fig. 9 Random effects meta-analysis for healthy dietary pattern (Intervention/Exposition) vs Western diet (Control) for GR (A), N° of teeth with
furcation defects (B) and N° of mobile teeth (C) at baseline. CI: Confidence interval, IV: inverse variance, SD: standard deviation
Fig. 10 Random effects meta-analysis for healthy dietary pattern (Intervention/Exposition) vs Western diet (Control) for PI at baseline. CI: Con-
fidence interval, IV: inverse variance, SD: standard deviation
Current Oral Health Reports
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parameters such as self-report [56, 57, 87], the 1999 Clas-
sification system for periodontal diseases and conditions [44,
69], the CDC-AAP [119, 120] diagnostic criteria and sever-
ity for periodontitis [10, 11, 59, 81, 83], or were defined by
the authors themselves [8, 9, 52, 71, 77]. Thus, the use of the
latest classification of periodontal and peri-implant diseases
and conditions is highly recommended for future studies.
Similarly, the dietary evaluation was varied among the
included studies, which made it difficult for them to be quan-
titatively synthesized in a meta-analysis. The dietary assess-
ment has come under much criticism of late, to the extent that
it has been questioned whether self-reported dietary assess-
ment methods are valuable to consider. DQ indices such as
the HEI, AHEI or DASH score have proven to be reliable tools
in the study of the impact of dietary interventions in other
NCD [40]. Under-reporting of energy intake, limitations and
changes to input due to memory and the burden of recording,
and social desirability bias all significantly impact the accuracy
of the dietary information collected. Biomarkers can be used to
improve the under-reporting of energy intakes that have been
recognized as a problem in dietary research [121].
In addition, although no significant differences were
observed between retrospective studies and randomized
clinical trials, both have different characteristics and non-
uniform follow-up times. In this case, we adopt a meth-
odological diverse approach, first, in relation to the fact
that the study designs answered the same question, under
the premise that the “real world” observations comple-
ment the RCT setting [122]. It has been demonstrated that
the methodological diversity has no implication per se on
the meta-analysis results on healthcare outcomes, as other
aspects play a role in the effect estimates [123], i.e., from
biases or covariates, that were statistically controlled in
observational studies. Additionally, there is a limitation in
the search of the studies, due to the fact that we performed
the electronic search in three languages. It is relevant to
clarify that the external validity of the meta-analysis relies
on data primarily from high income countries in Europe
and Iran. We suggest more investigation from other coun-
tries and a retrieval protocol for the evidence using other
languages that could gather more information and improve
the results of this review.
Therefore, more standardized studies are required, with
an adequate sample size, follow-up and setting, using the
new periodontal classification or standard clinical peri-
odontal parameters, and dietary quality indices that can
be complemented with more reliable nutritional indices or
biomarkers, that allow to assess the heterogeneity and pub-
lication bias that improves the certainty in the evidence.
Conclusions
HDP could impact on periodontal health–disease status,
reducing the global burden of PD by improving the results
of the standard care actions, such as toothbrushing, interden-
tal cleaning and periodontal therapy. Although biological
plausibility is reported, more standardized and comparable
studies with high methodological quality are necessary to
establish with greater clarity, and certainty of the evidence,
the effect of HDP on periodontal health–disease status.
Table 5 Electronic search strategy algorithms
Electronic
database
Algorithm Filters
PubMED
/MEDLINE
("Periodontal Index"[Mesh] OR "Periodontal Diseases"[Mesh] OR "Gingival Diseases"[Mesh] OR "Gingivitis"[Mesh]
OR "Periodontitis"[Mesh] OR "Chronic Periodontitis"[Mesh] OR "Periodontal Pocket"[Mesh] OR "Dental Plaque
Index"[Mesh] OR "Tooth Mobility"[Mesh] OR "Furcation Defects"[Mesh] OR "Gingival Recession"[Mesh] OR "Alve-
olar Bone Loss"[Mesh] OR "Periodontal probing depth" OR "Clinical attachment loss" OR "Clinical attachment level"
OR "Periodontal condition" OR "Periodontal pocketing" OR "Clinical periodontal parameters" OR "Periodontal param-
eters" OR "Tooth Loss"[Mesh]) AND (("Diet, Vegan"[Mesh] OR "Diet, Vegetarian"[Mesh] OR "Dietary Approaches
To Stop Hypertension"[Mesh] OR "Diet, Mediterranean"[Mesh] OR "Diet, Healthy"[Mesh] OR "Optimized diet" OR
"Okinawan diet" OR "Anti-inflammatory diet" OR "Nordic diet" OR "Baltic sea diet" OR "Recommended Finnish
diet" OR “Portfolio diet”) OR ("Diet, Western"[Mesh] OR "Diet, Paleolithic"[Mesh] OR "Diet, High-Fat"[Mesh]
OR "Diet, Ketogenic"[Mesh] OR "Diet, Gluten-Free"[Mesh] OR "Diet, Cariogenic"[Mesh] OR "Diet, High-Protein
Low-Carbohydrate"[Mesh] OR "Diet, High-Protein"[Mesh] OR "Diet, Carbohydrate Loading"[Mesh] OR "Dietary car-
bohydrates" OR "Diet, Atherogenic"[Mesh] OR "Artificial diet" OR "High glycemic index diet" OR "Casein free diet"
OR "Fiber free diet" OR "Gluten free diet" OR "High calorie diet" OR "High salt diet" OR "Lipid diet" OR "Low iodine
diet" OR "Obesogenic diet" OR "Unhealthy diet" OR "Poor diet"))
ENGLISH, PORTUGUESE,
SPANISH, HUMANS
All dates
Appendix
Current Oral Health Reports
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Table 5 (continued)
Electronic
database
Algorithm Filters
Cochrane Library ("plant-based diet" OR “healthy diet”) AND ("periodontal" OR "gingival" OR "periodontitis" OR “gingivitis”) AND
("human")
("vegan diet" OR "vegetarian diet") AND ("periodontal" OR "gingival" OR "periodontitis" OR "gingivitis") AND
("human")
("mediterranean diet" OR "Nordic diet") AND ("periodontal" OR "gingival" OR "periodontitis" OR "gingivitis") AND
("human")
("dash diet" OR "okinawan diet" OR "baltic sea diet") AND ("periodontal" OR "gingival" OR "periodontitis" OR "gingi-
vitis") AND ("human")
("western diet" OR "poor diet" OR "unhealthy diet") AND ("periodontal" OR "gingival" OR "periodontitis" OR "gingivi-
tis") AND ("human")
-
ClinicalTrials.gov periodontitis OR gingivitis OR periodontal OR gingival | healthy diet OR diet OR dietary
EMBASE "human"/exp AND ("vegan diet"/exp OR "diet, vegan" OR "vegan diet" OR "veganism" OR "vegetarian diet"/exp OR
"diet, vegetarian" OR "plant-based diet" OR "vegetarian diet" OR "vegetarian eating patterns" OR "vegetarianism" OR
"dash diet"/exp OR "dash diet" OR "dash-style diet" OR "dietary approaches to stop hypertension (dash) " OR "dietary
approach to stop hypertension" OR "dietary approach to stop hypertension (dash) style diet" OR "dietary approach to
stop hypertension diet" OR "dietary approaches to stop hypertension" OR "dietary approaches to stop hypertension diet"
OR "dietary approaches to stop hypertension style diet" OR "nordic diet"/exp OR "nordic diet" OR "baltic sea diet" OR
"mediterranean diet"/exp OR "meddiet" OR "mediterranean diet" OR "diet, mediterranean" OR "okinawan diet"/exp OR
"healthy diet"/exp OR "diet, healthy" OR "health-enhancing diet" OR "health-promoting diet" OR "healthful diet" OR
"healthy diet" OR "optimized diet" OR "anti-inflammatory diet" OR "recommended finnish diet" OR "western diet"/exp
OR "western diet" OR "diet, western" OR "paleolithic diet"/exp OR "caveman diet" OR "diet, paleolithic" OR "hunter
gatherer diet" OR "paleo diet" OR "paleolithic diet" OR "stone age diet" OR "lipid diet"/exp OR "diet, high fat" OR
"diet, high-fat" OR "diet, lipid" OR "fat diet" OR "fat meal" OR "fat-rich diet" OR "fat-rich meal" OR "fatty diet" OR
"high fat diet" OR "lipid diet" OR "lipid meal" OR "lipid-rich diet" OR "lipid-rich meal" OR "meal, fat" OR "ketogenic
diet"/exp OR "diet, ketogenic" OR "keto diet" OR "ketogenic diet" OR "ketogenous diet" OR "ketotic diet" OR "gluten
free diet"/exp OR "diet, gluten free" OR "diet, gluten-free" OR "gluten free diet" OR "cariogenic diet"/exp OR "cari-
ogenic diet" OR "diet, cariogenic" OR "high-protein low-carbohydrate diet"/exp OR "hp-lc diet" OR "hplc diet" OR
"diet, high-protein low-carbohydrate" OR "high-protein low-carb diet" OR "high-protein low-carbohydrate (hplc) diet"
OR "high-protein low-carbohydrate diet" OR "protein diet"/exp OR "diet, high protein" OR "diet, high-protein" OR
"high protein diet" OR "protein diet" OR "protein meal" OR "protein-enriched diet" OR "protein-rich diet" OR "carbo-
hydrate loading diet"/exp OR "carbohydrate loading" OR "carbohydrate loading diet" OR "diet, carbohydrate loading"
OR "carbohydrate intake"/exp OR "atherogenic diet"/exp OR "atherogenetic diet" OR "atherogenic diet" OR "diet,
atherogenic" OR "artificial diet"/exp OR "artificial diet" OR "diet, artificial" OR "diet, synthetic" OR "synthetic diet"
OR "high glycemic index diet"/exp OR "high gi diet" OR "high glycemic index diet" OR "high glycemic index treat-
ment" OR "casein free diet"/exp OR "casein free diet" OR "caseinfree diet" OR "fiber free diet"/exp OR "fiber free diet"
OR "fibre free diet" OR "no fiber diet" OR "no fibers diet" OR "no fibre diet" OR "no roughage diet" OR "roughage free
diet" OR "gluten free casein free diet"/exp OR "gfcf diet" OR "casein and gluten free diet" OR "casein/gluten free diet"
OR "gluten and casein free diet" OR "gluten free and casein free diet" OR "gluten free casein free diet" OR "gluten free/
casein free diet" OR "gluten/casein free diet" OR "high calorie diet"/exp OR "high caloric diet" OR "high calorie diet"
OR "high calory diet" OR "high energy diet" OR "hypercaloric diet" OR "high salt diet"/exp OR "high salt diet" OR
"salt-rich diet" OR "low iodine diet"/exp OR "iodine limited diet" OR "iodine poor diet" OR "iodine restricted diet" OR
"limited iodine diet" OR "low iodine diet" OR "low level iodine diet" OR "restricted iodine diet" OR "obesogenic diet"/
exp OR "obesity-inducing diet" OR "obesogenic diet" OR "unhealthy diet"/exp OR "non-healthy diet" OR "unhealthy
diet" OR "poor diet") AND ("periodontal index"/exp OR "gingiva disease"/exp OR "exfoliation, tooth" OR "gingiva
disease" OR "gingiva recession" OR "gingival diseases" OR "gingival recession" OR "inflammation, tooth crown" OR
"pericoronitis" OR "tooth crown inflammation" OR "tooth exfoliation" OR "gingivitis"/exp OR "acute gingivitis" OR
"chronic gingivitis" OR "crevicular fluid" OR "fluid, gingiva crevice" OR "gingiva crevice fluid" OR "gingiva inflam-
mation" OR "gingiva pocket" OR "gingival crevicular fluid" OR "gingival inflammation" OR "gingival pocket" OR
"gingivitis" OR "gingivitis syndrome" OR "periodontitis"/exp OR "paradontitis" OR "parodontitis" OR "peridontitis"
OR "periodontitis" OR "chronic periodontitis"/exp OR "adult periodontitis" OR "chronic periodontitis" OR "peri-
odontitis chronica" OR "periodontal pocket"/exp OR "periodontal pocket" OR "plaque index"/exp OR "silness and loe
plaque index" OR "silness-loe plaque index" OR "dental plaque index" OR "plaque index" OR "tooth plaque index" OR
"periodontal disease"/exp OR "dental loss" OR "dental migration" OR "dental mobility" OR "edentulism" OR "furca-
tion defects" OR "mesial movement of teeth" OR "paradontal disease" OR "paradontopathy" OR "paraodontopathy" OR
"parodentopathy" OR "parodontal disease" OR "parodontium disease" OR "parodontive tissue disease" OR "peridontal
disease" OR "peridontal tissue disease" OR "peridontium disease" OR "periodontal atrophy" OR "periodontal attach-
ment loss" OR "periodontal cyst" OR "periodontal disease" OR "periodontal diseases" OR "periodontal infection" OR
"periodontium disease" OR "periodontopathy" OR "tooth loss" OR "tooth migration" OR "tooth mobility" OR "tooth
movement" OR "alveolar bone loss"/exp OR "alveolar bone loss" OR "alveolar resorption" OR "mandible alveolar bone
loss" OR "periodontal bone loss" OR "periodontal probing depth"/exp OR "clinical attachment level"/exp OR "clinical
attachment loss"/exp OR "periodontal condition" OR "periodontal pocketing" OR "alveolar bone level" OR "bleeding
on probing"/exp OR "gingiva bleeding"/exp OR "clinical periodontal parameters") AND ([article]/lim OR [article in
press]/lim OR [review]/lim) AND ([english]/lim OR [spanish]/lim)
ARTICLE, ARTICLE IN
PRESS, REVIEW, ENG-
LISH, SPANISH
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Table 5 (continued)
Electronic
database
Algorithm Filters
Scopus (TITLE-ABS-KEY ( "Plant-based diet” OR "Vegan diet" OR "vegetarian diet" OR "dash diet" OR "mediterranean diet"
OR "okinawan diet" OR "healthy diet" OR "anti-inflammatory diet" OR "nordic diet" OR "baltic sea diet" OR "recom-
mended finnish diet" OR vegan OR vegetarian OR veganism OR vegetarianism) OR TITLE-ABS-KEY ( "western diet"
OR "artificial diet" OR "carbohydrate loading diet" OR "cariogenic diet" OR "casein free diet" OR "atkins diet" OR
"carbohydrate diet" OR "fiber free diet" OR "gluten free diet" OR "high calorie diet" OR "high glycemic index diet" OR
"high salt diet" OR "lipid diet" OR "low iodine diet" OR "Obesogenic diet" OR "unhealthy diet" OR "poor diet")) AND
(TITLE-ABS-KEY ( "periodontal disease" OR "gingiva disease" OR "Alveolar bone loss" OR "Alveolar bone level" OR
"pocket depth" OR "gingival index" OR "plaque index" OR "Periodontal pocket depth" OR "clinical attachment level"
OR "clinical attachment loss" OR "Periodontal index" OR "periodontal parameters" OR "gingivitis" OR "Periodontitis"
OR "periodontal condition" OR "bleeding on probing" OR “Clinical periodontal parameters”)) AND (TITLE-ABS-
KEY(HUMAN)) AND (SUBJAREA(DENT))
All dates
EBSCOhost
(Dentistry &
Oral Sciences
Source)
(“Plant-based diet” OR "Vegan diet" OR "vegetarian diet" OR "dash diet" OR "mediterranean diet" OR "okinawan diet"
OR "healthy diet" OR "anti-inflammatory diet" OR "nordic diet" OR "baltic sea diet" OR "recommended finnish diet"
OR vegan OR vegetarian OR veganism OR vegetarianism) OR ( "western diet" OR "artificial diet" OR "carbohydrate
loading diet" OR "cariogenic diet" OR "casein free diet" OR "atkins diet" OR "carbohydrate diet" OR "fiber free diet"
OR "gluten free diet" OR "high calorie diet" OR "high glycemic index diet" OR "high salt diet" OR "lipid diet" OR
"low iodine diet" OR "Obesogenic diet" OR "unhealthy diet" OR "poor diet") AND ("periodontal disease" OR "gingiva
disease" OR "Alveolar bone loss" OR "Alveolar bone level" OR "pocket depth" OR "gingival index" OR "plaque index"
OR "Periodontal pocket depth" OR "clinical attachment level" OR "clinical attachment loss" OR "Periodontal index"
OR "periodontal parameters" OR "gingivitis" OR "Periodontitis" OR "periodontal condition" OR "bleeding on probing"
OR “Clinical periodontal parameters”)
All dates
Web of Science #1: (TS = ("periodontal disease*" OR "gingiva disease*" OR "Alveolar bone loss" OR "Alveolar bone level" OR "pocket
depth" OR "gingival index" OR "plaque index" OR "Periodontal pocket depth" OR "clinical attachment level" OR
"clinical attachment loss" OR "Periodontal index" OR "Periodontal indice*" OR "periodontal parameters" OR "gingivi-
tis" OR "Periodontitis" OR "periodontal condition*" OR "bleeding on probing" OR "Clinical periodontal parameter*"
OR "CPITN" OR "tooth loss"))
#2: (TS = ("western diet" OR "artificial diet" OR "carbohydrate loading diet" OR "cariogenic diet" OR "casein free diet"
OR "atkins diet" OR "carbohydrate diet" OR "fiber free diet" OR "gluten free diet" OR "high calorie diet" OR "high
glycemic index diet" OR "high salt diet" OR "lipid diet" OR "low iodine diet" OR "Obesogenic diet" OR "unhealthy
diet" OR "poor diet"))
#3: (TS = ("plant-based diet*" OR "Vegan diet*" OR vegan* OR "Vegetarian diet*" OR vegetarian* OR "DASH diet" OR
"mediterranean diet" OR "okinawan diet" OR "healthy diet" OR "anti-inflammatory diet" OR "nordic diet" OR "baltic
sea diet" OR "recommended finnish diet" OR "portfolio diet"))
(#2 OR #3) AND #1
Language:(English OR
Spanish)
Types of documents:(Article
OR Abstract of Published
Item)
All dates
SciELO ("plant-based diet" OR “Healthy diet”) AND ("periodontal" OR "gingival" OR "periodontitis" OR “gingivitis”) AND
("human")
("vegan diet" OR "vegetarian diet") AND ("periodontal" OR "gingival" OR "periodontitis" OR "gingivitis") AND
("human")
("mediterranean diet" OR "Nordic diet") AND ("periodontal" OR "gingival" OR "periodontitis" OR "gingivitis") AND
("human")
("dash diet" OR "okinawan diet" OR "baltic sea diet") AND ("periodontal" OR "gingival" OR "periodontitis" OR "gingi-
vitis") AND ("human")
("western diet" OR "poor diet" OR "unhealthy diet") AND ("periodontal" OR "gingival" OR "periodontitis" OR "gingivi-
tis") AND ("human")
-
LiLACS ("plant-based diet" OR “Healthy diet”) AND ("periodontal" OR "gingival" OR "periodontitis" OR “gingivitis”) AND
("human")
("vegan diet" OR "vegetarian diet") AND ("periodontal" OR "gingival" OR "periodontitis" OR "gingivitis") AND
("human")
("mediterranean diet" OR "Nordic diet") AND ("periodontal" OR "gingival" OR "periodontitis" OR "gingivitis") AND
("human")
("dash diet" OR "okinawan diet" OR "baltic sea diet") AND ("periodontal" OR "gingival" OR "periodontitis" OR "gingi-
vitis") AND ("human")
("western diet" OR "poor diet" OR "unhealthy diet") AND ("periodontal" OR "gingival" OR "periodontitis" OR "gingivi-
tis") AND ("human")
-
Google Scholar
(Search Engine)
("plant-based diet" OR “Healthy diet”) AND ("periodontal" OR "gingival" OR "periodontitis" OR “gingivitis”) AND
("human")
("vegan diet" OR "vegetarian diet") AND ("periodontal" OR "gingival" OR "periodontitis" OR "gingivitis") AND
("human")
("mediterranean diet" OR "Nordic diet") AND ("periodontal" OR "gingival" OR "periodontitis" OR "gingivitis") AND
("human")
("dash diet" OR "okinawan diet" OR "baltic sea diet") AND ("periodontal" OR "gingival" OR "periodontitis" OR "gingi-
vitis") AND ("human")
("western diet" OR "poor diet" OR "unhealthy diet") AND ("periodontal" OR "gingival" OR "periodontitis" OR "gingivi-
tis") AND ("human")
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Authors Contributions CRediT: Gustavo Sáenz-Ravello was involved
in conceptualization, methodology, formal analysis, writing—original
draft, Loreto Matamala helped in methodology, formal analysis,
writing—original draft, Nidia Castro dos Santos, Patricia Cisternas,
Jorge Gamonal, Natalia Bello, Alejandra Fernandez, Natalia
Bello-Escamilla and Marcela Hernandez were involved in writing—
review & editing, Mauricio Baeza contributed to conceptualization,
methodology, formal analysis, writing—original draft, supervision,
funding acquisition.
Funding This study was supported by National Commission for Scien-
tific and Technological Research, National Ph.D. Scholarship Program
[2018—21180023], Santiago, Chile. The receiver of this funding is the
corresponding author Dr. Mauricio Baeza. The funding only covers the
human resources used for the development of this research; it does not
include funds for the publication of this or any other article, so there
is currently no open access policy linked to this grant. Therefore, we
compliant with the subscription publication route.
Declarations
Conflicts of interests/Competing interests We have no conflicts of in-
terests to declare.
Human and Animal Rights and Informed Consent Not applicable. We
use secondary data that do not require informed consent to be used,
according to the International Ethical Guidelines for Health-related
Research Involving Humans prepared by the Council for International
Electronic
database
Algorithm Filters
Journal of Clini-
cal Periodon-
tology
(“Plant-based diet” OR "Vegan diet" OR "vegetarian diet" OR "dash diet" OR "mediterranean diet" OR "okinawan diet"
OR "healthy diet" OR "anti-inflammatory diet" OR "nordic diet" OR "baltic sea diet" OR "recommended finnish diet"
OR vegan OR vegetarian OR veganism OR vegetarianism) OR ( "western diet" OR "artificial diet" OR "carbohydrate
loading diet" OR "cariogenic diet" OR "casein free diet" OR "atkins diet" OR "carbohydrate diet" OR "fiber free diet"
OR "gluten free diet" OR "high calorie diet" OR "high glycemic index diet" OR "high salt diet" OR "lipid diet" OR
"low iodine diet" OR "Obesogenic diet" OR "unhealthy diet" OR "poor diet") AND ("periodontal disease" OR "gingiva
disease" OR "Alveolar bone loss" OR "Alveolar bone level" OR "pocket depth" OR "gingival index" OR "plaque index"
OR "Periodontal pocket depth" OR "clinical attachment level" OR "clinical attachment loss" OR "Periodontal index"
OR "periodontal parameters" OR "gingivitis" OR "Periodontitis" OR "periodontal condition" OR "bleeding on probing"
OR “Clinical periodontal parameters”)
Advanced search
Journal of
Periodontal
Research
(“Plant-based diet” OR "Vegan diet" OR "vegetarian diet" OR "dash diet" OR "mediterranean diet" OR "okinawan diet"
OR "healthy diet" OR "anti-inflammatory diet" OR "nordic diet" OR "baltic sea diet" OR "recommended finnish diet"
OR vegan OR vegetarian OR veganism OR vegetarianism) OR ( "western diet" OR "artificial diet" OR "carbohydrate
loading diet" OR "cariogenic diet" OR "casein free diet" OR "atkins diet" OR "carbohydrate diet" OR "fiber free diet"
OR "gluten free diet" OR "high calorie diet" OR "high glycemic index diet" OR "high salt diet" OR "lipid diet" OR
"low iodine diet" OR "Obesogenic diet" OR "unhealthy diet" OR "poor diet") AND ("periodontal disease" OR "gingiva
disease" OR "Alveolar bone loss" OR "Alveolar bone level" OR "pocket depth" OR "gingival index" OR "plaque index"
OR "Periodontal pocket depth" OR "clinical attachment level" OR "clinical attachment loss" OR "Periodontal index"
OR "periodontal parameters" OR "gingivitis" OR "Periodontitis" OR "periodontal condition" OR "bleeding on probing"
OR “Clinical periodontal parameters”)
Advanced search
Periodontology
2000 (“Plant-based diet” OR "Vegan diet" OR "vegetarian diet" OR "dash diet" OR "mediterranean diet" OR "okinawan diet"
OR "healthy diet" OR "anti-inflammatory diet" OR "nordic diet" OR "baltic sea diet" OR "recommended finnish diet"
OR vegan OR vegetarian OR veganism OR vegetarianism) OR ( "western diet" OR "artificial diet" OR "carbohydrate
loading diet" OR "cariogenic diet" OR "casein free diet" OR "atkins diet" OR "carbohydrate diet" OR "fiber free diet"
OR "gluten free diet" OR "high calorie diet" OR "high glycemic index diet" OR "high salt diet" OR "lipid diet" OR
"low iodine diet" OR "Obesogenic diet" OR "unhealthy diet" OR "poor diet") AND ("periodontal disease" OR "gingiva
disease" OR "Alveolar bone loss" OR "Alveolar bone level" OR "pocket depth" OR "gingival index" OR "plaque index"
OR "Periodontal pocket depth" OR "clinical attachment level" OR "clinical attachment loss" OR "Periodontal index"
OR "periodontal parameters" OR "gingivitis" OR "Periodontitis" OR "periodontal condition" OR "bleeding on probing"
OR “Clinical periodontal parameters”)
Advanced search
Table 5 (continued)
Organizations of Medical Sciences (CIOMS) in collaboration with the
World Health Organization (WHO) in Geneva, 2016.
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