- Email: [email protected]
Bone health and oral health
CLINICAL PRACTICE
N U T R I T I O N
Bone health and oral health Elizabeth Krall Kaye, PhD, MPH
steoporosis and osteopenia are defined by low bone mass, deteriorating bone architecture and bone fragility. These diseases are among the most prevalent chronic conditions in the United States. One and one-half million osteoporosis-related bone fractures occur in the United States each year—more than the number of new cancer cases and twice the number of strokes. Ten million Americans have the more severe form, osteoporosis, and another 34 million have osteopenia, which puts them at increased risk of osteoporosis. As the population ages, the prevalence of osteoporosis and osteopenia is expected to increase 50 percent by the year 2020.1 Osteoporosis results from an imbalance in the rates of bone formation and resorption that cause
O
616
JADA, Vol. 138
http://jada.ada.org
ABSTRACT Background. Low bone mass in the skeleton, which increases the risk of osteoporotic fracture, also may be associated with periodontal bone loss and tooth loss. Osteoporosis and periodontal disease share several common risk factors, including older age, smoking and perhaps insufficient dietary intakes of calcium and vitamin D. Conclusion. Research supports the idea that osteoporosis independently influences alveolar bone height loss. Strategies for reducing osteoporosis risk also may help retard alveolar bone loss. Meeting dietary intake recommendations for calcium and vitamin D is one strategy that is appropriate for a broad segment of the population. Clinical Implications. A healthy lifestyle has multiple benefits for the mouth and throughout the body. Dental professionals can play a role in preventing osteoporosis by reinforcing this message. Key Words. Periodontal diseases; tooth loss; bone mineral density; osteoporosis; dietary calcium; vitamin D. JADA 2007;138(5):616-9. Dr. Kaye is a professor, Department of Health Policy and Health Services Research, Boston University School of Dental Medicine, 715 Albany St., 560, Room 338, Boston, Mass. 02118, e-mail “[email protected]”. Address reprint requests to Dr. Kaye.
May 2007
Copyright ©2007 American Dental Association. All rights reserved.
CLINICAL PRACTICE
N U T R I T I O N
bones to lose mineral mass. Along with the loss of ulations are needed before we fully understand if minerals, they also lose strength and the ability and how osteoporosis affects periodontal disease. to withstand low-level trauma. The consequences Patients with osteoporosis tend to have fewer of fracture in elderly people include increased risk teeth, and advanced systemic bone loss may affect of death, long-term nursing home care or permathe type of tooth replacement that can be supnent limitations in mobility and performance of ported. While osteoporosis is not seen as a daily living activities. Many of the risk factors for contraindication for implant placement, more osteoporosis are environmental and, therefore, research into its relationship with long-term are preventable. Established risk factors include implant survival is needed. If osteoporosis predisolder age; being female, postmenopausal, or Cauposes patients to alveolar bone loss, then clinicasian or Asian; a low body mass index; cigarette cians should identify common therapies and moduse; alcoholism; inadequate calcium and vitamin ifiable risk factors that may provide opportunities D intakes; physical inactivity; taking medications for oral disease prevention. Hormone replacement such as glucocorticoids and anticonvulsants; and and bisphosphonates prescribed for osteoporosis anorexia nervosa.2,3 Although management or prevention osteoporosis and osteopenia can may reduce alveolar bone loss Patients with osteoporosis affect people of all ages, they and tooth loss,5,6 but these tend to have fewer teeth, occur most often in middle-aged therapies are not appropriate and elderly people,1 the same and advanced systemic bone for everyone. The risk of segment of the population that osteonecrosis of the jaw assoloss may affect the type of has the highest risk of chronic ciated with long-term bisphostooth replacement that can periodontal disease and tooth phonate use7 limits widebe supported. loss. spread use of this drug. Despite several decades of Calcium and vitamin D are research, there is no consensus key nutrients for bone health, about whether people with osteoporosis and and vitamin and mineral supplementation are osteopenia have greater risks of alveolar bone loss important components of any osteoporosis treatand tooth loss. Many studies of this topic were ment or prevention plan. Calcium is a major mincross-sectional studies or performed as secondary eral in hydroxyapatite, and vitamin D is one of analyses of longitudinal data. As a result, these several hormones that regulate calcium metabostudies may have been underpowered, been lism. Recommendations for calcium intake conrestricted to special populations, lacked informasider estimates of how much of it is needed to tion on confounders, relied on self-reports of tooth build peak bone density in children and young loss or used indirect measures of alveolar bone adults and to slow down bone loss in older adults. loss such as clinical attachment level. The The Food and Nutrition Board, Institute of MediWomen’s Health Initiative (WHI), a large 15-year cine of the National Academies’ recommendations prospective investigation of postmenopausal for calcium range from 500 to 800 milligrams per women that began in 1991, included an oral ancilday for children and from 1,000 to 1,300 mg/day lary study specifically designed to study oral bone for adolescents and adults.8 Calcium is found in 4 loss. After preliminary analyses, investigators low concentrations in a wide variety of foods, but classified the participants according to their peridairy foods and fortified juices are major sources odontitis status (yes or no) and osteoporosis (Table).9 One 8-ounce glass of milk or 1.5 ounces status at the hip (yes or no) at baseline and of natural cheese provides about 300 mg of callooked at alveolar bone height loss around poscium. Tools that consumers can use to track daily terior teeth three years later. They found that calcium intake include the Calcium Calculator10 women with osteoporosis had more than three and MyPyramid interactive Web site.11 times the amount of alveolar bone height loss Vitamin D is produced in the skin from a form than did women who did not have osteoporosis, of cholesterol. On exposure to ultraviolet radiaregardless of whether they also had periodontitis. tion, this compound is converted to a vitamin D These findings suggest that systemic bone status precursor, absorbed into the bloodstream and may influence the progression of alveolar bone ultimately converted to its biologically active form loss independently. Final analyses in the entire ABBREVIATION KEY. WHI: Women’s Health Initiative. WHI cohort and prospective studies in other popJADA, Vol. 138 http://jada.ada.org Copyright ©2007 American Dental Association. All rights reserved.
May 2007
617
CLINICAL PRACTICE
N U T R I T I O N
TABLE
Calcium and vitamin D content of common foods.* CALCIUM (MILLIGRAMS/SERVING)
VITAMIN D (MICROGRAMS/SERVING)
Milk—Whole, Low-Fat or Skim (1 Cup)
300
2.5
Yogurt—Plain, Low-Fat or No-Fat (6 Ounces)
340
—†
Yogurt—Fruit-Flavored (6 Ounces)
260
—
Cheddar Cheese (1.5 Ounces)
300
0.13
Mozzarella Cheese (1.5 Ounces)
300
—
American Cheese (1.5 Ounces)
235
—
Macaroni and Cheese (1/2 Cup)
90
—
115
—
90
—
Orange Juice—With Added Calcium (1 Cup)
300
—
Orange Juice—With Added Calcium and Vitamin D (1 Cup)
300
2.5
Cottage Cheese (1/2 Cup)
80
—
Broccoli—Cooked or Raw (1 Cup)
60
—
Bread—White or Wheat (2 Slices)
50
—
2-1,000
1.0-1.3
22
0.5
Salmon—Canned With Bones (3 Ounces)
180
13.3
Sardines (3 Ounces)
325
2-5.8
FOOD (SERVING SIZE)
Cheese Pizza (1 Slice) Ice Cream (1/2 Cup)
Breakfast Cereal Fortified With Vitamin D (3/4 to 1 Cup) Egg Yolk (1)
Agriculture.9
* Source: U.S. Department of † —: Marginal amount or insufficient data.
in the kidney. Therefore, it is not strictly necessary to obtain vitamin D from the diet. However, for people who are exposed to sunlight infrequently or inconsistently, such as elderly, homebound or institutionalized people, dietary sources are essential to supplement endogenous production and maintain serum vitamin D levels within the normal range. Healthy, active people also may benefit from having dietary sources of vitamin D during winter months. Adequate intake of vitamin D is 5 micrograms per day for people younger than 50 years; it increases to 10 µg/day for people aged 51 to 70 years and to 15 µg/day for people 71 years and older.8 Daily intakes should not exceed 50 µg/day. In the United States, milk is fortified with vitamin D so that one 8-ounce cup provides 2.5 µg. Other good sources of vitamin D are shown in the table. For optimal bone health, it is important to balance intakes of both calcium and vitamin D. A high calcium intake may offer little benefit if a person’s vitamin D status is poor. 618
JADA, Vol. 138
The probable interrelationship of systemic and oral bone loss has led researchers to investigate whether consuming the recommended levels of calcium and vitamin D slows periodontal disease progression. Future research should include randomized vitamin and mineral supplementation trials to address this. Until that is known, it is important to stress the importance of balanced nutrition for bone health and overall health in patients of all ages. There is no evidence that excess intakes of either calcium or vitamin D will offer additional benefit, but actual consumption falls far below the recommended levels in a large proportion of the population, especially women. CONCLUSIONS
Dental professionals can play a role in osteoporosis prevention by reinforcing to their patients that a healthy lifestyle has multiple benefits throughout the body. A healthy lifestyle includes physical activity, avoiding smoking, maintaining a healthy weight and making sure that dietary
http://jada.ada.org May 2007 Copyright ©2007 American Dental Association. All rights reserved.
CLINICAL PRACTICE
intakes—especially those of calcium and vitamin D—meet recommendations. ■ 1. National Osteoporosis Foundation. America’s bone health: The state of osteoporosis and low bone mass. Available at: “www.nof.org/advocacy/prevalence/index.htm”. Accessed March 13, 2007. 2. Lane NE. Epidemiology, etiology, and diagnosis of osteoporosis. Am J Obstet Gynecol 2006;194(2 supplement):S3-11. 3. Grinspoon S, Thomas E, Pitts S, et al. Prevalence and predictive factors for regional osteopenia in women with anorexia nervosa. Ann Intern Med 2000;133(10):790-4. 4. Geurs NC, Lewis CE, Jeffcoat MK. Osteoporosis and periodontal disease progression. Periodontology 2000 2003;32:105-10. 5. Krall EA. The periodontal-systemic connection: implications for the treatment of patients with osteoporosis and periodontal disease.
N U T R I T I O N
Ann Periodontol 2001;6(1):209-13. 6. Jeffcoat MK. Safety of oral bisphosphonates: controlled studies on alveolar bone. Int J Oral Maxillofac Implants 2006;21(3):349-53. 7. Kuehn BM. Reports of adverse events from bone drugs prompt caution. JAMA 2006;295(24):2833-6. 8. Food and Nutrition Board, Institute of Medicine of the National Academies. Dietary reference intakes tables: The complete set. Available at: “www.iom.edu/?id=21381”. Accessed March 13, 2007. 9. Agricultural Research Service, U.S. Department of Agriculture (USDA). USDA National Nutrient Database for Standard Reference, Release 18. Available at: “www.nal.usda.gov/fnic/foodcomp/Data/ SR18/reports/sr18page.htm”. Accessed March 13, 2007. 10. International Osteoporosis Foundation. Patients and public: IOF calcium calculator. Available at: “www.iofbonehealth.org/ patients-public/calcium-calculator.html”. Accessed March 20, 2007. 11. U.S. Department of Agriculture. Steps to a healthier you. Available at: “www.mypyramid.gov”. Accessed March 13, 2007.
JADA, Vol. 138 http://jada.ada.org Copyright ©2007 American Dental Association. All rights reserved.
May 2007
619
N U T R I T I O N
Bone health and oral health Elizabeth Krall Kaye, PhD, MPH
steoporosis and osteopenia are defined by low bone mass, deteriorating bone architecture and bone fragility. These diseases are among the most prevalent chronic conditions in the United States. One and one-half million osteoporosis-related bone fractures occur in the United States each year—more than the number of new cancer cases and twice the number of strokes. Ten million Americans have the more severe form, osteoporosis, and another 34 million have osteopenia, which puts them at increased risk of osteoporosis. As the population ages, the prevalence of osteoporosis and osteopenia is expected to increase 50 percent by the year 2020.1 Osteoporosis results from an imbalance in the rates of bone formation and resorption that cause
O
616
JADA, Vol. 138
http://jada.ada.org
ABSTRACT Background. Low bone mass in the skeleton, which increases the risk of osteoporotic fracture, also may be associated with periodontal bone loss and tooth loss. Osteoporosis and periodontal disease share several common risk factors, including older age, smoking and perhaps insufficient dietary intakes of calcium and vitamin D. Conclusion. Research supports the idea that osteoporosis independently influences alveolar bone height loss. Strategies for reducing osteoporosis risk also may help retard alveolar bone loss. Meeting dietary intake recommendations for calcium and vitamin D is one strategy that is appropriate for a broad segment of the population. Clinical Implications. A healthy lifestyle has multiple benefits for the mouth and throughout the body. Dental professionals can play a role in preventing osteoporosis by reinforcing this message. Key Words. Periodontal diseases; tooth loss; bone mineral density; osteoporosis; dietary calcium; vitamin D. JADA 2007;138(5):616-9. Dr. Kaye is a professor, Department of Health Policy and Health Services Research, Boston University School of Dental Medicine, 715 Albany St., 560, Room 338, Boston, Mass. 02118, e-mail “[email protected]”. Address reprint requests to Dr. Kaye.
May 2007
Copyright ©2007 American Dental Association. All rights reserved.
CLINICAL PRACTICE
N U T R I T I O N
bones to lose mineral mass. Along with the loss of ulations are needed before we fully understand if minerals, they also lose strength and the ability and how osteoporosis affects periodontal disease. to withstand low-level trauma. The consequences Patients with osteoporosis tend to have fewer of fracture in elderly people include increased risk teeth, and advanced systemic bone loss may affect of death, long-term nursing home care or permathe type of tooth replacement that can be supnent limitations in mobility and performance of ported. While osteoporosis is not seen as a daily living activities. Many of the risk factors for contraindication for implant placement, more osteoporosis are environmental and, therefore, research into its relationship with long-term are preventable. Established risk factors include implant survival is needed. If osteoporosis predisolder age; being female, postmenopausal, or Cauposes patients to alveolar bone loss, then clinicasian or Asian; a low body mass index; cigarette cians should identify common therapies and moduse; alcoholism; inadequate calcium and vitamin ifiable risk factors that may provide opportunities D intakes; physical inactivity; taking medications for oral disease prevention. Hormone replacement such as glucocorticoids and anticonvulsants; and and bisphosphonates prescribed for osteoporosis anorexia nervosa.2,3 Although management or prevention osteoporosis and osteopenia can may reduce alveolar bone loss Patients with osteoporosis affect people of all ages, they and tooth loss,5,6 but these tend to have fewer teeth, occur most often in middle-aged therapies are not appropriate and elderly people,1 the same and advanced systemic bone for everyone. The risk of segment of the population that osteonecrosis of the jaw assoloss may affect the type of has the highest risk of chronic ciated with long-term bisphostooth replacement that can periodontal disease and tooth phonate use7 limits widebe supported. loss. spread use of this drug. Despite several decades of Calcium and vitamin D are research, there is no consensus key nutrients for bone health, about whether people with osteoporosis and and vitamin and mineral supplementation are osteopenia have greater risks of alveolar bone loss important components of any osteoporosis treatand tooth loss. Many studies of this topic were ment or prevention plan. Calcium is a major mincross-sectional studies or performed as secondary eral in hydroxyapatite, and vitamin D is one of analyses of longitudinal data. As a result, these several hormones that regulate calcium metabostudies may have been underpowered, been lism. Recommendations for calcium intake conrestricted to special populations, lacked informasider estimates of how much of it is needed to tion on confounders, relied on self-reports of tooth build peak bone density in children and young loss or used indirect measures of alveolar bone adults and to slow down bone loss in older adults. loss such as clinical attachment level. The The Food and Nutrition Board, Institute of MediWomen’s Health Initiative (WHI), a large 15-year cine of the National Academies’ recommendations prospective investigation of postmenopausal for calcium range from 500 to 800 milligrams per women that began in 1991, included an oral ancilday for children and from 1,000 to 1,300 mg/day lary study specifically designed to study oral bone for adolescents and adults.8 Calcium is found in 4 loss. After preliminary analyses, investigators low concentrations in a wide variety of foods, but classified the participants according to their peridairy foods and fortified juices are major sources odontitis status (yes or no) and osteoporosis (Table).9 One 8-ounce glass of milk or 1.5 ounces status at the hip (yes or no) at baseline and of natural cheese provides about 300 mg of callooked at alveolar bone height loss around poscium. Tools that consumers can use to track daily terior teeth three years later. They found that calcium intake include the Calcium Calculator10 women with osteoporosis had more than three and MyPyramid interactive Web site.11 times the amount of alveolar bone height loss Vitamin D is produced in the skin from a form than did women who did not have osteoporosis, of cholesterol. On exposure to ultraviolet radiaregardless of whether they also had periodontitis. tion, this compound is converted to a vitamin D These findings suggest that systemic bone status precursor, absorbed into the bloodstream and may influence the progression of alveolar bone ultimately converted to its biologically active form loss independently. Final analyses in the entire ABBREVIATION KEY. WHI: Women’s Health Initiative. WHI cohort and prospective studies in other popJADA, Vol. 138 http://jada.ada.org Copyright ©2007 American Dental Association. All rights reserved.
May 2007
617
CLINICAL PRACTICE
N U T R I T I O N
TABLE
Calcium and vitamin D content of common foods.* CALCIUM (MILLIGRAMS/SERVING)
VITAMIN D (MICROGRAMS/SERVING)
Milk—Whole, Low-Fat or Skim (1 Cup)
300
2.5
Yogurt—Plain, Low-Fat or No-Fat (6 Ounces)
340
—†
Yogurt—Fruit-Flavored (6 Ounces)
260
—
Cheddar Cheese (1.5 Ounces)
300
0.13
Mozzarella Cheese (1.5 Ounces)
300
—
American Cheese (1.5 Ounces)
235
—
Macaroni and Cheese (1/2 Cup)
90
—
115
—
90
—
Orange Juice—With Added Calcium (1 Cup)
300
—
Orange Juice—With Added Calcium and Vitamin D (1 Cup)
300
2.5
Cottage Cheese (1/2 Cup)
80
—
Broccoli—Cooked or Raw (1 Cup)
60
—
Bread—White or Wheat (2 Slices)
50
—
2-1,000
1.0-1.3
22
0.5
Salmon—Canned With Bones (3 Ounces)
180
13.3
Sardines (3 Ounces)
325
2-5.8
FOOD (SERVING SIZE)
Cheese Pizza (1 Slice) Ice Cream (1/2 Cup)
Breakfast Cereal Fortified With Vitamin D (3/4 to 1 Cup) Egg Yolk (1)
Agriculture.9
* Source: U.S. Department of † —: Marginal amount or insufficient data.
in the kidney. Therefore, it is not strictly necessary to obtain vitamin D from the diet. However, for people who are exposed to sunlight infrequently or inconsistently, such as elderly, homebound or institutionalized people, dietary sources are essential to supplement endogenous production and maintain serum vitamin D levels within the normal range. Healthy, active people also may benefit from having dietary sources of vitamin D during winter months. Adequate intake of vitamin D is 5 micrograms per day for people younger than 50 years; it increases to 10 µg/day for people aged 51 to 70 years and to 15 µg/day for people 71 years and older.8 Daily intakes should not exceed 50 µg/day. In the United States, milk is fortified with vitamin D so that one 8-ounce cup provides 2.5 µg. Other good sources of vitamin D are shown in the table. For optimal bone health, it is important to balance intakes of both calcium and vitamin D. A high calcium intake may offer little benefit if a person’s vitamin D status is poor. 618
JADA, Vol. 138
The probable interrelationship of systemic and oral bone loss has led researchers to investigate whether consuming the recommended levels of calcium and vitamin D slows periodontal disease progression. Future research should include randomized vitamin and mineral supplementation trials to address this. Until that is known, it is important to stress the importance of balanced nutrition for bone health and overall health in patients of all ages. There is no evidence that excess intakes of either calcium or vitamin D will offer additional benefit, but actual consumption falls far below the recommended levels in a large proportion of the population, especially women. CONCLUSIONS
Dental professionals can play a role in osteoporosis prevention by reinforcing to their patients that a healthy lifestyle has multiple benefits throughout the body. A healthy lifestyle includes physical activity, avoiding smoking, maintaining a healthy weight and making sure that dietary
http://jada.ada.org May 2007 Copyright ©2007 American Dental Association. All rights reserved.
CLINICAL PRACTICE
intakes—especially those of calcium and vitamin D—meet recommendations. ■ 1. National Osteoporosis Foundation. America’s bone health: The state of osteoporosis and low bone mass. Available at: “www.nof.org/advocacy/prevalence/index.htm”. Accessed March 13, 2007. 2. Lane NE. Epidemiology, etiology, and diagnosis of osteoporosis. Am J Obstet Gynecol 2006;194(2 supplement):S3-11. 3. Grinspoon S, Thomas E, Pitts S, et al. Prevalence and predictive factors for regional osteopenia in women with anorexia nervosa. Ann Intern Med 2000;133(10):790-4. 4. Geurs NC, Lewis CE, Jeffcoat MK. Osteoporosis and periodontal disease progression. Periodontology 2000 2003;32:105-10. 5. Krall EA. The periodontal-systemic connection: implications for the treatment of patients with osteoporosis and periodontal disease.
N U T R I T I O N
Ann Periodontol 2001;6(1):209-13. 6. Jeffcoat MK. Safety of oral bisphosphonates: controlled studies on alveolar bone. Int J Oral Maxillofac Implants 2006;21(3):349-53. 7. Kuehn BM. Reports of adverse events from bone drugs prompt caution. JAMA 2006;295(24):2833-6. 8. Food and Nutrition Board, Institute of Medicine of the National Academies. Dietary reference intakes tables: The complete set. Available at: “www.iom.edu/?id=21381”. Accessed March 13, 2007. 9. Agricultural Research Service, U.S. Department of Agriculture (USDA). USDA National Nutrient Database for Standard Reference, Release 18. Available at: “www.nal.usda.gov/fnic/foodcomp/Data/ SR18/reports/sr18page.htm”. Accessed March 13, 2007. 10. International Osteoporosis Foundation. Patients and public: IOF calcium calculator. Available at: “www.iofbonehealth.org/ patients-public/calcium-calculator.html”. Accessed March 20, 2007. 11. U.S. Department of Agriculture. Steps to a healthier you. Available at: “www.mypyramid.gov”. Accessed March 13, 2007.
JADA, Vol. 138 http://jada.ada.org Copyright ©2007 American Dental Association. All rights reserved.
May 2007
619