Integrative dentistry: nutrition, vitamin D, movement and sleep

Hello, I am Daniel Robles, dentist, 44 years old, and I reckon I have been on a diet for 45 of them. I cannot remember the first time I put myself on one, but I have a friend who says I am thin in odd-numbered years and out of shape in even ones. Maybe that is why my Instagram algorithm no longer puts football, cars or women in bikinis under my nose (well, that one it still does), and instead, for a good while now, I cannot stop seeing the importance of supplementation, habits, the microbiota, sucking on a rock of salt, hugging trees and walking barefoot in the whole-body health of the patient, and the importance of integrative medicine.

A year ago I started my umpteenth diet, because I was in an even-numbered year, and I found a nutritionist who pulled off something the others never managed: adherence to a habit, and in my case to two, dietary and nutritional, plus building sport and physical exercise into my day as something fundamental. Oddly enough it has not been the diet on which I lost weight fastest, nor even the one on which I have lost the most weight in the year and a bit I have been at it, but it is the diet on which I have felt best overall. My sense is that I am healthier, I rest better, my blood work says I am improving levels that had been off for many years, and all of this got me thinking: is it true that nutrition and other habits matter this much?

And to top it all off, my friend Antonio is dead set on convincing me about vitamin D deficiency and the importance of supplementation in bone metabolism, which is fundamental at my age, and although I am olive-skinned and live in a sunny country like Spain, Antonio is right: I had two tests done and I am well below the normal range.

Anyway, since I was not sleeping well either, one night I started thinking and decided it was time to read literature from orthopedics, trauma and other specialties, looking for links with dentistry, and my surprise was enormous. Studies associate low vitamin D with lower ISQ values, although part of that difference was already present on the day of implant placement, while studies of early implant failure remain uncertain. Outside dentistry, hospital and surgical nutrition guidelines propose protein targets for older or unwell populations, some observational studies associate early mobilization with better outcomes after other operations, and growth hormone is released in pulses linked to deep sleep. None of these sources compares rest with light activity after oral surgery.

A lot of very interesting information, with scientific backing that is a long way from the shamanic air this sort of claim usually carries among professionals in our sector.

But since I do not want to give you a dissertation on bone biology and physiology, but rather to plant in you the same itch I planted in myself, I am going to give you a couple of examples that will make you understand what I mean.

When we treat a patient in the clinic who is going to have a surgical procedure, whatever it may be, the procedure carries with it a process of healing, repair and regeneration of the operated tissues, and my recommendations were always the same: rest for 3 to 5 days, a soft cold diet (this is a very Spanish thing, but here that means gazpacho, yogurt, ice cream, cold soup) and carry on with the medication and the usual instructions about not rinsing, and so on. And off I went, pleased as punch, thinking that if one of these treatments ran into trouble it could only be because of habits affecting the site locally, such as tobacco or alcohol, or because of my own poor choice of technique or materials, or at most because of some underlying condition of the patient such as diabetes, without asking whether that illustrative recommendation met each patient's nutritional needs.

Easier still: have a look at this chart.

Here you can see an illustrative model of one day on that diet, compared with a protein range borrowed from guidelines for hospitalized, older or major-surgery patients. The selected foods do not represent every soft diet and this comparison does not prove protein deficiency, impaired healing or treatment failure after oral surgery. The image of standing on the nutrient hose frames a question, not a demonstrated mechanism: if a patient eats little or repeats only a few foods, is their protein intake adequate? Protein deficiency can impair collagen synthesis and capillary formation, but it does not follow that extra protein speeds healing in someone already eating enough, and no oral-surgery outcome trial validates this comparison.

If we also add the ice cream we have always been told is good because of the local cold, it is worth remembering that there is no clinical evidence that the sugar in an ice cream impairs oral healing in non-diabetic patients. The more cautious concern is displacement: within an already limited intake, it may replace foods that provide more protein and micronutrients.

Vitamin D, which many more of us are short of than we would think in a country like this one, plays a fundamental role in the intestinal absorption of calcium, which is the basic building block of bone, and it regulates osteoblastic and osteoclastic activity. If there is not enough vitamin D, the active absorption of dietary calcium drops a great deal. Screening for and correcting a documented deficiency under professional supervision is reasonable general patient care, but no trial has shown that supplementation lowers implant failure rates.

Magnesium and zinc are related to mineralization, enzymatic activity and bone metabolism. Manganese has similar biological plausibility, but its support comes largely from animal and laboratory studies and does not show that supplementation improves clinical outcomes. Vitamin K is related to osteocalcin activity and to the organization of the mineral in bone that is being formed.

On another front, reading the articles that talk about the advantages and the regeneration mechanisms that relative exercise awakens at a systemic level during the recovery of a patient who has had surgery, I was blown away by the results, and I began to understand why my mother-in-law, after her hip operation, was practically being told to get up and walk 12 hours later.

And I kept thinking of the doctoral thesis of my friend David Chávarri: an animal experiment with 40 implants in the tibiae of 10 rabbits over six weeks. Five rabbits ran on a treadmill, starting at 5 minutes a day and progressing to two 10-minute sessions in the final two weeks; the other five remained in cages. This was mechanical loading of the tibia, not a comparison of rest and activity after human oral surgery. The buttress arrangement was reported as a qualitative trend, the buttress theory.

This animal study shows a response of tibial bone to mechanical loading, but it cannot support guidance on movement or exercise after human oral surgery. It offers a mechanistic hypothesis, not a postoperative prescription.

So then, why tell a patient: now rest for a few days? Or are we simply afraid of answering the question "doctor, can I take sick leave?". And I will go further: do any of us ask about our patients' average activity in a day, so as to understand how sedentary or active they are? With everything we now know about the benefits of physical activity, why does the medical history only ask about the medication they take or their past history?

And the last can of worms I would like to open in these lines of intrusive thoughts I am learning from is sleep, and I do not mean dreaming of an early retirement, though there is that too, but quality over quantity in the hours we sleep. What is more, I somehow think the general population is starting to give sleep monitoring some importance, or at least that is how it looks given the number of smart bands being sold.

Sleeping well coincides with growth hormone pulses linked to deep sleep. The nocturnal melatonin peak appears to fall with age, but studies disagree on whether total 24-hour production changes. In laboratory and animal studies, melatonin has been related to mesenchymal-cell differentiation into osteoblasts and lower oxidative stress; that does not demonstrate a clinical benefit in human oral healing.

Throughout my degree and all the training I have had since, over more than 25 years, I have always heard that the mouth is part of a whole, but nobody ever really talks about that whole. For the first time, the general, integrative view of our patients brings us closer to the reality that our treatments have to be personalized and adapted not only to the pathological needs of the mouth, but to the circumstances. We are not aware of how habits, age, hormonal changes such as menopause, and lifestyle can alter our results.

And since we are starting somewhere, why not start with two easy changes? First, ask the patient: what does a day in your life look like? For example, if someone is on Ozempic, do you think their diet will cover the necessary minimums? In a patient who works a different shift every week, do you think they will sleep well?

And second, perhaps we should add this conversation about habits to our usual prescription, without replacing medication or clinical instructions when they are indicated.