Chronic periodontitis, dantamoolaroga, indicates chronic systemic inflammation and reduces longevity

Abstract

A narrative review of chronic periodontitis, a dysfunctional inflammatory disease of the gums finds it is linked to over 60 systemic diseases and has been shown to reduce lifespan. Termed dantamoolaroga in Ayurvedic medicine, the causative vitiated doshas for the 17 types of dantamoolaroga have been described and give leads as to systemic imbalances behind the diseases. By improving periodontal (gum) health, improvements in type 2 diabetes, cardiovascular and other chronic inflammatory markers have been shown. Systemic chronic inflammation is the underlying cause of non-communicable diseases, including periodontitis, cardiovascular diseases, respiratory, diabetes and metabolic diseases, cancer and others, now contributing over 70% of worldwide deaths. It is found that oral health reflects systemic health and provides a window into general health. As personalised medicine is being developed to assess the multiple pathophysiological factors underlying systemic chronic inflammation, it is noted that Ayurveda has a comprehensive approach to diagnosis with the 10 fold assessment (Dashavidha Praiksha) and eight fold examinations (Astasthana Pariksha) being considered the original personalised medicine. There are Ayurvedic clinical correlates and causes of systemic chronic inflammation assisting clinical evaluation and treatment planning. Ayurvedic diagnostic measures for general health and periodontal health need validation in today's terms to strengthen the scientific credentials and enable better clinical use of both systems in an integrative manner. Inclusion of clinical assessment of periodontal health status at consultation, particularly for any chronic disease, is strongly recommended to gain insight into a widespread systemic chronic inflammation marker. The multiple Ayurvedic clinical measures for chronic inflammation provides potential for lines of research that complement the current molecular based approaches.

1. Introduction

A key issue in utilising the Rasayana or rejuvenation knowledge within traditional Ayurveda is developing clinical application data on its use in people with various modern diseases and lifestyle issues, in order to lengthen the “health span,” rather than simply the “lifespan” [1]. Non communicable diseases (NCD) contribute annually to 74% of world-wide deaths. A group of four diseases: cardiovascular, cancers, respiratory and diabetes (including kidney deaths caused by diabetes) account for over 80% of all premature NCD deaths. The common underlying pathological process to these diseases is systemic chronic inflammation [[2], [3], [4]]. Periodontitis is a chronic, multifactorial, inflammatory disease associated with a dysbiotic dental biofilm, resting in progressive periodontal attachment and bone loss [5]. Periodontitis has been linked to over 60 systemic diseases in 2022 [6], increased from 50 in 2019 as more research is completed [7] A partial list includes diabetes, cardiovascular disorders, a range of different cancers, arthritis, mental health issues, pregnancy outcomes, earlier all-cause mortality [8]. Furthermore, effective treatment of periodontitis improves cardiovascular surrogate and direct outcomes [9]. This is also shown for diabetes outcomes [10,11]. With this relationship between periodontitis and systemic diseases, research efforts have looked at the underlying chronic dysfunctional inflammatory response [12] and markers for clinical use to determine its effects on various organs and tissues. This has led to investigations of using personalised medicine techniques of gathering large datasets on each individual about their genome, proteome, metabolome, degradome, microbiome, and inflammasome. Combining this with traditional clinical measures of periodontitis and allostatic measures. Allostatic load is the result of cumulative increases in internal and external stressors including physiologic, environmental, and socioeconomic and lifestyle stresses that combine negatively to impact homeostasis [13]. Baima et al. (2022) have shown [6] that a number of markers link periodontitis to accelerated biological ageing. Discussing the personalised approach to chronic inflammatory conditions with the example of periodontitis, it was stated that rather than treating symptoms of a particular disease the need was to rebalance the underlying factors within that particular individual. This is reflecting the increasing interest in personalised, preventive, predictive and participatory medicine (P4) in a range of areas of general medicine [14]. The utility of the high tech “big data” approaches in helping the socially disadvantaged and those unable to access the high-end services has however, been questioned [15].

The lack of comprehensive scientific data linking and understanding genetics, metabolic, social factors, stress, and others, is reviewed comprehensively by Carbonara et al., 2022. They conclude that it will require many years of research to comprehensively scientifically link the multiple systems. It is mentioned that traditional health systems in Asia and India have used the personalised approach, within their context, over many years [16].

Ayurveda is arguably the oldest, continuously used personalised medical system. Its clinical based comprehensive approach aims to rebalance the various systems within an individual, rather than simply treating the symptoms of a disease [17]. Ayurveda has a perspective of a common pathway underlying all pathology, the shatkriyakal. This is the six-step disease process underlying all pathology. Different stages within that process are compared with chronic inflammation which is described as underlying many chronic diseases [[18], [19]]. Dysfunctional chronic inflammation damages tissues and when persistent and continually present in the background, has been termed Systemic Chronic Inflammation (SCI) as a pathological entity in its own right [[2], [19], [20]]. There are similarities with ama and chronic inflammation [21,22]. Indeed, there are similarities with jirna jwara, a chronic fever of unknown cause that has persisted beyond 21 days. This becomes a pathology in its own right rather than purely a symptom. Systemic Chronic Inflammation has been noted by Nair et al., 2024 as a key model to demonstrate integration of Ayurvedic Sciences approach with Systems Biology and Personalised Medicine. Ayurvedic signs, symptoms and causative factors related to chronic inflammation include dietary, lifestyle (daily routine) factors, coping mechanisms, incomplete elimination of toxins, incomplete resolution from infectious diseases, sedentary lifestyle, disrupted gut microbiome and dysfunctional gut [23].

An Integrative approach with Ayurveda providing clinical macro level features of chronic inflammation and Systems Biology approaches providing finer detail through to the micro level can provide a gradient of effects and thus precise measures to manage the pathology.

2. Aim

This narrative review aims to highlight the potential role of oral health as a leading indicator of systemic chronic inflammation (SCI), considered the key underlying issue behind most chronic diseases, resulting in shortening of health span and lifespan. With the comprehensive clinical assessment of Ayurveda and complimented with physio-pathological biomarkers providing an “integrative approach”, there are means for a detailed precise understanding the individual's health status providing a clear pathway for corrective measures to improve the health and the lifespan.

3. Oral health and general health

Oral health as a leading indicator of general health can be regarded as the mirror of systemic health [[23], [24], [25]] The World Health Organisation recognises oral health as a “key indicator of overall health, wellbeing and quality of life” [23,25]. The oral cavity is one of the most important interaction windows between the human body and the environment. The changes of oral microbiota in the state of systemic diseases are gradual and repeatable, reflecting general health [[26], [27], [28]]. It is of note that periodontitis is the 6th most common disease of mankind [8]. Surveys indicate that in the older population in India the incidence is 100% [29]. The WHO documents the worldwide prevalence of diseases and impact on health [30]. Within Australia the incidence of chronic periodontitis is well documented to increase with age. With a definition of periodontitis utilising a clinical attachment loss 4 mm or more, in the Australian adult population older than 15 years the incidence is 52.7%. The age group 55–74 years is 76.4% [31]. Yet, often oral health is overlooked when assessing health status and the countries that have data, found there is little if any training of medical practitioners in oral health at the undergraduate level [32,33]. Documentation of oral health training in Ayurvedic doctors’ undergraduate course work has not been located.

Periodontitis is a common condition worldwide that can confound treatment of systemic conditions. By successfully treating periodontitis there is improved outcomes in cardiovascular measures, diabetic measures, and reduces systemic inflammation and markers [34,35].

4. Diagnostic markers for periodontitis

With this background on the significance of periodontitis for systemic health, work has been done to find simple rapid point of care screening tests. To detect chronic periodontitis at its earliest stage the salivary marker, activated metallo-matrix proteinase 8 [aMMP8] has been studied closely. It assists in determining the degree of severity assigning risk in the recently internationally recognised system for Staging and Grading periodontitis [36,37]. It was found that adolescents with increased level of aMMP8 developed chronic periodontitis. This is enabling early detection of progression of the degree of chronic inflammation in gum tissues. It has been tested in medical clinics and found to be a simple effective means of screening [38]. Another test is measuring the keystone opportunistic pathogen, P. gingivalis in the gum tissues. Increased levels in the mouth correlate with increased periodontal disease activity [39]. The levels of polymorphonuclear neutrophils in saliva, a key marker of inflammatory status, have been shown to be a good marker of gingival and periodontal inflammation. A simple chairside test has been developed [[40], [41], [42], [43]]. A self-reported oral health (SROH) questionnaire survey has also been found to accurately screen for periodontitis [[44], [45]]. See Table 1. Self Reported Oral Health Measures. It has been compared with aMMP8 tests and found to be useful at detecting the presence or absence of disease but not the degree of severity [46]. As a simple questionnaire with 8 questions, it is suggested that it be adapted to specific country or location requirements. Verhulst (2019) discusses the process of adaptation by the Dutch and benefits of the screening questionnaire [47]. As a simple and effective screening tool that can be readily adapted throughout the world in different health systems, it offers advantages compared with obtaining technical tests with associated costs and supply line issues in more remote areas. Also, mobile phone photos and adaptors for intraoral pictures and a range of commercial products such as Apps and attachments for mobile phones enable telehealth, whereby images can be sent to dental health professionals for assessment of periodontal and dental health that can be used in institutional settings, aged care facilities, hospitals, clinics or remote areas. Mobile phones and pictures of peoples’ oral conditions has successfully been trialled in India in rural and underprivileged settings to screen for oral cancer [48].

Table 1.

Self Reported Oral Health Measures

Modified from Eke et al., 2013.

Ref: Eke et al.J Dent Res92(11):1041–1047, 2013
Item and abbreviation	Response
1. Do you think you have gum disease?	Yes	No	Refused	Don't know
Abbrev. Have gum disease
2. Overall, how would rate the health of your teeth and gums?	Excellent	very good	good fair poor refused	don't know
Abbrev. Teeth/gum health
3. Have you ever had treatment for gum disease such as scaling and root planing, sometimes called "deep cleaning"?	Yes	No	refused	don't know
Abbrev. Had gum treatment?
4. Have you ever had any teeth become loose on their own, without an injury?	Yes	No	refused	don't know
Abbrev. Loose teeth
5. Have you ever been told by a dental professional that you have lost bone around your teeth?	Yes	No	refused	don't know
Abbrev. Lost bone
6. During the past 3 months have you noticed a tooth that does not look right?	Yes	No	refused	don't know
Abbrev. Tooth does not look right.
7. Aside from brushing your teeth with a toothbrush, in the last 7 days, how many times did you use dental floss or any other device to clean between the teeth?	no. times	no. days used	refused
Abbrev. Floss use?
8. Aside from brushing your teeth with a toothbrush,In the last 7 days, how many times did you use a mouthwash, or other dental rinse product that you use to treat dental disease or dental problem?	no. times	no. days used	refused
Abbrev. Mouthwash?

More recently the System Immune-Inflammation Index (SII) and System Inflammation Response Index (SIRI) have conclusively been linked with prevalence of chronic periodontitis from review of large datasets from NHANES studies [49,50]. These require simple blood tests to calculate the indices that indicate underlying chronic inflammation in a number of systemic illnesses [51,52]. The indices have demonstrated diagnostic and prognostic value.

5. Ayurvedic diagnosis, and description of periodontitis

Ayurvedic description of gum inflammation is clinically based and has only had limited investigation in relation to current approaches to chronic periodontitis [53]. Athavale [54] describes 17 conditions of “dantamoolaroga” based upon Sushruta Samhita, Vagbhat, and Yogaratnakar. Of 17 conditions of “dantamoolaroga” or diseases of the gums and roots of the teeth, the current discussion relates to six with chronic inflammatory features.

• 1.Dantaveshtha-chronic suppurative gingivitis, disturbed Doshas: raktaja,
• 2.Upakusha-recurrent acute suppuratives gingivitis, Pittaja and Ruktaja
• 3.Sheetada – chronic suppurative recessive gingivitis, Kaphaja and Raktaja
• 4.Soushira – suppurative periodontitis. Kaphaja and Raktaja (by Suhsruta), Pittaja and Raktaja (by Vagbhat)
• 5.Mahasoushira – acute necrotising gingivitis superimposed on chronic gingivitis Tridoshaja
• 6.Paridara – atrophic gingivitis Tridoshaja

Athavale reviews the classic texts and lists doshas disturbed for each condition, including Rakta disturbances in a number of these conditions. The descriptive clinical terms from the Ayurvedic texts have not yet been compared in detail with the recent internationally agreed staging and grading diagnostic sieve of periodontitis. This new system is designed to provide scope for personalised medicine approaches with the use of a range of biomarkers [55]. The Ayurvedic clinical diagnostic personalised approach would potentially align well with the periodontal staging and grading framework.

Chronic inflammation in ayurvedic terms has been reviewed extensively by Nair et al., 2024. Detailing the clinical features of chronic inflammation with causative factors and symptoms as manifest in a number of inflammatory diseases, including ulcerative colitis and Crohn's Disease [23]. This Ayurvedic perspective on causative factors and clinical symptoms of chronic inflammation complements blood markers such as the Systemic Immune Inflammation Index and others. Building on this approach, the dantamoolaroga group of chronic periodontal diseases can be added as another manifestation of underlying chronic systemic inflammation and often an early warning clinical presentation.

“Shitada”, translated as “gingivitis”, is the primary or early stage of Dantamulagata Roga which affects the Dantavestha (Gums).

Shitada refers to vitiation of kapha and rakta, the causative factors of the condition. General systemic causes of kapha and rakta vitiation will increase risk of shitada, especially if kavagunya exists in gum tissue.

The general causes include dietary factors, that aggravate, such as guru (Heavy), Madhura (sweet), Shita (cold), Ruksha (rough) food intake. Also atishitambu (very cold water) lead to vitiation of kapha dosha with formation of ama (incompletely digested or metabolised food forming auto-toxicants)

With vitiation of pitta by consumption of Katu (Pungent), Amla (Sour), Lavana (Salty), Kshara (alkaline) it ultimately leads to Raktadushti (vitiation of blood).

The iatrogenic factors of improper administration of Vamana (Emesis Therapy), Virecana (Purgation Therapy), Dhumapana (Medicated smoke), Siravedha (Blood Letting) are listed as aggravating the doshas whereby shitada and dantamoolarogas can result.

The vitiated Kapha and Rakta are responsible for producing all Dantamulagata Rogas. This also includes the aetiological factors Aharaja (Dietary), Viharaja (Lifestyle) and Manasika (Mental). Abegunasekara (2020) summarises the etiological factors in table format and then proceeds to list the samprapti (pathogenesis) of shitada, also leading to dantamoolaroga [27].

6. Screening oral health by primary care health workers

Due to the widespread nature of chronic periodontitis and effects on at least 60 systemic heath issues, it is strongly encouraged that primary health care workers of all backgrounds, take into account oral health. Including oral health as part of a general health review is strongly encouraged due to its influence on systemic health and vice versa. An example is the International Group for Diabetes made a recommendation in 2012 to screen for oral health in all diagnosed cases of diabetes [10]. This is due to the recognition of the significant influence of oral health on diabetes. As part of an Ayurvedic comprehensive personalised holistic approach it is essential to include oral health status to complete the health picture. In a systems review, oral health or dental health is usually included as part of an asthi dhatu review [[28], [56], [57], [58]].

7. Measures of general systemic chronic Inflammation (SCI)

To detect the early changes and signs of systemic chronic inflammation is an urgent research goal [2]. Measures of acute phase inflammatory cytokines have not been found to be helpful in investigating systemic chronic inflammation over the longer term and links to chronic disease patterns. More promising is use of a multi omics, multi-level testing over a longer period of time to identify risk markers. Yet it has been described as early days in this line of investigation [2].

Cercoro 2019 [12], stated that periodontitis may contribute to, induce and/or maintain the systemic state of Low-Grade Inflammation (equivalent to SCI) and, furthermore, Low Grade Inflammation may also be a risk factor for periodontitis. This detailed description of periodontal and systemic chronic inflammation is but one part of the range of factors effecting ageing. Baima et al., 2022 [6] summarised the underlying factors common to all chronic non communicable disease. These same underlying factors have been reviewed with an Ayurvedic perspective [59].

See Table 2. Current Markers of Ageing and Potential Ayurvedic Markers.

Table 2.

Current markers of ageing and potential ayurvedic markers.

Cellular Markers of Systemic and Gum Ageing	Potential Ayurvedic Diagnostic Clinical Markers
1. Mitochondrial dysfunction	bala (& energy), mental gunas, agni, ama, rasa
2. Oxidative stress	agni, ama, mental gunas,
	jatharagni and sense impressions, mental emotional
	digestion. Misuse of senses.
3. Lack of proteostasis	agni, ama
4. Lipolysis	agni, ama, kapha status, sara of tissues
5. Genomic irregularities incl. epigenetic alterations	prakruti, vikruti
6. Telomere shortening in peripheral wbc.s	prakruti, vikruti, lifestyle factors- dinacharya, rutacharya,
	stress- mental gunas, diet.
7. Microbiome pathological profile	diet, incl. spices, herbs, food incompatibilities, body and
	mind status when eating
	digestion -agni, ama, microbiome- oral and gut.
8. Immunologic markers increased	ojas- immune strength,
9. Cellular senescence	ojas, bala, physical fitness, psychological stress levels (gunas)
	prakruti balance cf. vikruti.

The pathophysiological measures: like genomic irregularities, mitochondrial dysfunction, cellular senescence, altered protein expression, immunological markers, oxidative stress, pathological microbiota profile, telomere shortening in peripheral blood monocytes, lipolysis, and many other factors listed in Table 2 are mostly specialised tests, with limited or variable availability.

Ayurveda clinical measures cover the areas being tested and investigated, however the relationship between the specialised test results and Ayurvedic clinical measures remain to be fully documented. Of the Ayurvedic clinical diagnostic measures some have been validated. However, studies combining a number of validated Ayurvedic measures in comprehensive clinical investigations have not been located. Indeed, the general lack of research in Ayurvedic diagnostic areas has been reviewed recently [60]. It was stated that there is a need to develop and validate Ayurvedic diagnostic markers and presents potential means to progress that. Some suggested Ayurvedic markers that can cover the biophysical markers are prakruti and vikruti for genetic and epigenetic changes. Others are listed in Table 3 “Ayurvedic Comprehensive Clinical Measures to Assess & Monitor Health, Well Being and Ageing.”

Table 3.

Ayurvedic Comprehensive Clinical Measures to Assess & Monitor Health, Well Being and Ageing.

Classically by the 10 fold client comprehensive assessment and 8 fold clinical examination techniques provides clinical measures of health and well being.

Preliminary Details:

Essential demographic data that effects health

Name, age, address- residential, work- type, location, hours, shift work?

Marriage status, children, relatives, social network? recreation?

Tenfold assessment (Davidsha Pariksha)

Medical history, of all systems regarding any illness, past and present, and types and names of medicines used.

Substances? Alcohol, tobacco, etc.

Presenting concern, history, symptoms, signs, and relieving, aggravating factors.

Motivating factors in health and disease and daily life.

Quality assessed: Ayurvedic Clinical Measure	Description	Means of Collecting Data
1. Prakriti	constitution, correlation with various biological markers	Questionnaire, observation,
	especially genetic.	Palpation
1.1 Vikruti (included with Prakruti)	epigenetic, current expression of Prakruti	As above
2. Sara	dhatu -tissue quality
	Systems review of 7 body tissue systems. asthi to include oral health.
	srotas systematic review. This is more of a functional view of dhatus.	Physical exam (palpation),
	mala	Observation
2.1. Sarira Samhanana (included with Sara)	body conformation. Compactness or build.	Questions, observations,
	includes, symmetry, proportion, nutritional status,
	General functioning and movement.
Pramana included here	body proportion measurements mathematically.	Observations, measurements,
3. Satmya	wholesomeness, response to external challenges.
	Tendency to adapt lifestyle conducive to health for your
	Constitutional and body type, includes sattvic choices.	Questions
4. Manas prakruti	proportion of maha gunas: Sattva, rajas, tamas
	satav- state of mind at present	Questionnaire, discussion,
		Observations
5. Bala Vyayama	strength of body in general & immune system.	Questions, discussion
	capacity for exercise and energy level and endurance.	Observations
6. Agni	Digestive strength	Questionnaire, discussion,
	Mental Agni, tissues agnis.	Observations
	Ama assessment.
7. Vaya: age	Chronological and biological	questions, functional tests
8. Kala	Progression and stage of any conditions,	questions, observations, tests
	Also seasonal factors influencing health
9. Desa	Environmental, ecological factors at home and work.	Questions, official reports on
10. Ahara	Diet in detail. Quality, quantity of food, time of day for meals,	Environment in those areas
	Setting where eating, range of tastes in each meal.	questions, discussion
	Diet that improves health, wellbeing.

8 fold exam. (Astasthana Pariksha)
Pulse	5. Voice, sound of
Tongue	6. Skin
Face	7. Urine
Eyes	8. Faeces

Agni clinical assessment can correlate to metabolic markers such as mitochondrial dysfunction, lack of proteostasis, lipolysis, and oxidative stress. There is still research work required to establish clear links between the Ayurvedic clinical measures and the range of specialised biochemical and physiological tests. The scientific approach to develop these paradigm specific validated markers is based upon an understanding of systems biology, wholes systems research with techniques that capture details of nonlinear dynamic systems [61]. An example is by Rioux and Howerter (2019) who provide a structured approach to Ayurveda dietetics as part of an assessment of Ayurveda and Yoga in management of obesity [62]. Nair et al. have provided and extensive list of ayurvedic signs and symptoms of chronic inflammation [23]. To combine the range of validated Ayurveda based diagnostic markers will provide a more rigorous clinical assessment to progress the science of Ayurveda.

The classic comprehensive Ayurvedic clinical diagnostic sieve, covers the full spectrum of items that would influence health. The Trividha Pariksha as means to gather information involves three general categories of assessment. 1. Darshanam: Visual inspection, 2. Sparshana, touch or palpation, and 3. Prashna-questioning.

Classically the 10-fold assessment (Dashavidha Pariksha), is utilised [[58], [63]]. This includes.

• 1.Prakruti: Constitutional balance in harmony with genetic potential. Vikruti: is the variation from ideal balance.
• 2.Dusya (vitiated dhatu, srota and mala by imbalanced dosha): Sara (tissue quality), dhatu (tissues), incl mala (excretory by products), and can include Sarira samahanana (build of the body, general functioning and movement) and Pramina (proportions of body parts)
• 3.Satmya acclimatisation to environmental variations. Resilience to external factors that effect well being.
• 4.Manas prakruti- (“satva”) mental emotional state and resilience.
• 5.Bala, >vyama. physical endurance, tolerance and immune factors
• 6.Agni and related is ama. Metabolic strength and amount of autotoxicity.
• 7.Vaya: age of patient
• 8.Kala: season as well as the progression or staging of the condition

Areas needing more detailed consideration today.

• 9.Desa environmental impacts on health
• 10.Ahara range of dietary factors.

Desa-the environmental factors influencing health and disease, an increasingly important issue around the world, and kala-stage of condition and seasonal factors at work and ahara-diet in detail, including a range of rasa (taste) at meals.

Following the tenfold initial assessment, the 8-fold clinical examinations (Astasthana Pariksha) is utilised. This provides means to evaluate a number of the 10 fold assessment items and observe changes over time and after interventions.

1. Pulse (Nadi pariksha)	5. Voice, sound of (Sabda pariksha)
2. Tongue (Jihva pariksha)	6. Palpation, includes skin (Sparsa pariksha)
3. Appearance, posture, including facial expression (Akrti Pariksha)	7. Urine (Mutra pariksha)
4. Eyes (Drik pariksha)	8. Faeces (Purisha pariksha)

There are various degrees of modern scientific validation for each marker. Extending this would strengthen the scientific robustness of the clinical assessments. These combine to provide a comprehensive personalised assessment. The tenfold assessment covers all the current omics assessments, however at a clinical level and not a biochemical molecular level. Thus, to assess the health span and lifespan of an individual Ayurvedic clinical measures can be used and ideally in combination with a range of biomedical measures. By having effective robust validated Ayurvedic diagnostic and measuring tools it becomes possible to determine effectiveness of rasayana methods in a paradigm specific way, with biomedical measures providing finer detail in specific areas. The management of healthy ageing has been described in classical Ayurveda and a key element is dinacharya, the daily routines that form the basis of healthy living throughout life contributing to a good healthspan and lifespan [64].

In relation to periodontitis [65], a number of rasayana herbs can help maintain and repair gum tissue, including amla, bilberry, and hawthorn root. In Ayurveda teeth and gums are considered part of asthi dhatu – the boney structures and herbs to strengthen bone tissue help strengthen teeth and gums include yellow dock root, alfalfa leaf, cinnamon bark, and turmeric root. Other more specific rasayana techniques for general support are extensively reviewed [66,67].

Apart from a wide range of herbal rejuvenators, important attention to mental attitudes that are conducive to good health is advised. This includes: Aachar-good conduct, Vichar-good thoughts, Vyahar-good interpersonal relationships, Ahar-good food habits. Whilst many of the rasayana herbs and medicines have been investigated, there is little, if any, research on the full range of Ayurvedic rasayana techniques and outcomes in modern times, thus providing a fertile area for research.

8. Clinical research of ayurvedic treatment

Ayurvedic treatments usually involve an individualised approach using multiple treatment and management measures, providing challenges for clinical research based upon controlling a few variables with large numbers in the study groups to provide statistically useful results. However, a promising clinical research technique is the N of 1 approach. Recently The Oxford Centre for Evidence Based Practice raised the N of 1 clinical trial to level 1 evidence, on par with meta-analyses [68,69]. Another group of research techniques that would be applicable is the “multiple baseline design” approaches [70,71]. These can be useful for ongoing treatments which are started at different times [72]. There are now powerful research tools for the style of personalised clinical research that is needed in Ayurveda [73,74]. They have great potential for Ayurveda, but the initial step is validating diagnostic terms and the clinical measures in a paradigm specific way that also relates to biophysical medicine.

9. Conclusion

The study of Rasayana in relation to lifespan and healthspan in the current time confronts populations with extensive range of diseases and stressors at all levels. This narrative review focussed on chronic periodontitis, a very prevalent condition with adverse effects on health span and lifespan, that can be overlooked. An important action for all primary care health practitioners is to screen for periodontitis. Where access to simple rapid point of care tests is available, they can provide screening of those at risk. A Self-Reported Oral Health questionnaire, adapted for local circumstances, is an effective means to determine risk without the need for specialised tests. If both type of tests can be used, then more useful diagnostic data will be obtained to stratify risk. Diagnosing chronic Periodontitis indicates Chronic systemic inflammation is present with increased risks of other diseases developing or being aggravated if present. Treatment of systemic diseases will be improved if chronic periodontitis is also addressed, in addition to other factors influencing Chronic Systemic Inflammation. Ayurveda diagnostic tools, selected from 10 fold assessment and eight fold clinical examinations are comprehensive and cover the key areas underlying Systemic Chronic Inflammation and other age accelerating parameters. However, some Ayurvedic clinical tests have been validated and more still need validation in a paradigm specific manner. Studies with a combination of validated Ayurvedic diagnostic markers, once completed, can provide the next level of evidence base. With further development of these comprehensive clinical assessment tools, Ayurveda has powerful means to monitor health span and lifespan and effectiveness of rasayana treatments. A number of lines of investigation are suggested.

Sources of funding

None.

Declaration of generative AI in scientific writing

During the preparation of this work the author has not used any generative AI and AI-assisted technologies in preparation of this manuscript. The author reviewed and edited the content as needed and takes full responsibility for the content of the publication.

Author contribution

Single author: GJS.

Conflict of interest

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.