Effects of a calcium and vitamin D supplement on alveolar ridge resorption in immediate denture patients

SECTION

EDITORS

LOUIS BLATTERFEIN

REMOVABLE PROSTHODONTICS

5. HOWARD PAYNE GEORGE A. ZARB

Effects of a calcium and vitamin D supplement on alveolar ridge resorption in immediate denture patients Kenneth E. Wical, D.D.S., M.S.D.,” and Peter Brussee, D.H.S.“* Loma Linda University, Loma Linda, Calif.

L on-e1ations between excessive resorption of alveolar bone and inadequate dietary levels of calcium were documented by Wical and Swo0pe.l Sorensen? reported the results of a similar investigation of 55 edentulous patients. She found a positive correlation between severe ridge resorption and a combination of low calcium intake and low dietary calcium-phosphorus ratio. She also found a significant positive correlation between minimal ridge resorption and a combination of high calcium intake and high calcium-phosphorus ratio in the diet. Jowsey3. ” has reported studies showing that low dietary calcium intake, low calcium-phosphorus ratios, and vitamin D deficiencies are significant factors in general skeletal bone loss, and that calcium supplementation can retard the progress of osteoporotic disease. Stein and Beller,5 Riggs and associates,” Horsman and associates,7 and Albanese” have also published studies indicating similar results. The question has subsequently been raised: “might calcium supplementation limit, retard, or prevent undesirable loss of denture-supporting alveolar bone?” The purpose of this study was to test the hypothesis that a daily calcium and vitamin D supplement would tend to reduce the rate and extent of alveolar bone resorption following extractions of teeth. THE CLINICAL TRIAL The subjects completing this study were 46 patients from the prosthodontic clinic of the School Read before the Pacific Coast Society of Prosthodontists, Newport Beach, Calif. *Associate Professor and Chairman, Department of Removable Prosthodontics, School of Dentistry. **Graduate student, Department of Nutrition, School of Health. This investigation was supported by a grant from Marion Laboratories, Inc., Kansas City, MO.

4

JANUARY

1979

VOLUME

41

NUMBER

1

of Dentistry, Loma Linda University. All patients experienced the extraction of several teeth and the immediate placement of dentures. They were closely followed with clinical and radiographic examinations for at least 1 year following final extractions. Throughout the study period of 1 year, each subject received a medication in tablet form. Half of the subjects took three tablets daily of a supplement which provided a total of 750 mg of calcium (calcium carbonate from oyster shell) and 375 USP units of vitamin D, (Ergocalciferol) each day. Half of the subjects took the same number of tablets of a placebo preparation consisting of lactose and methyl cellulose. A computer-generated randomization schedule was used to determine the distribution of the study drug and the placebo among the subjects. The tablets of the two preparations were identical in appearance and coating, and were identified only by code numbers on their containers. This was a double-blind study, as neither investigators or patients had access to the medication code key.

Radiographic examination Panoramic radiographs of each patient’s jaws were made before extractions, a few days after extractions, and at approximately 3-month intervals until the final radiographs were made 1 year after the extractions. The radiographs used in this study were all made with the same S. S. White Panorex machine.* To assure reproducibility between successive films, each subject was seated in the same position in the machine for each film, using an S, S. White Panocentric head positioner* to orient the patient’s face and chin the same for each exposure. To further ensure consistency, all of the more than *S. S. White

Co., Philadelphia,

00’22-3913/79/010004

Pa.

+ OB$OO.80/0~ 1979 The C. V. Mosby Co

CALCIUM,

VITAMIN

D, AND

RESORPTION

. Panoramic radiographs extractions /boHom).

1 week following

200 radiographs were made by only two professional dental assistants especially trained in the operation of the Panorex X-ray unit. The film used for all of the pictures were Du Pont Pan-O-Screen.* The uniform exposure time was 18 seconds. The voltage varied from 75 to 90 KVP, and the current varied from 10 to 13 mamp, depending on the size of the patient’s head, and determined from standard reference tables. All of the film developing was done by an automatic processing machine.

Bone resorption data At the end of cal panorex film were compared bone resorption

the study, the immediate postsurgiand the 12-month postsurgical film to obtain data on the amount of which occurred in the jaws during

*E. I. DuPont

de Nemours

& Co., Wilmington,

THE JOURNAL

OF PROSTHETIC

DENTISTRY

Del.

extractions

itcpi and

12

months foil owing

the l-year interval between the radiographs (Fig. 1). Changes in the height and outline of the alveolar bone between the dates of the t\vo films were recorded by the following method. The first radiograph was placed on a lighted view box, and a sheet of transparent tracing film was placed over it. Anatomic landmarks such as the outline of the maxillary sinuses, the shadows of the zygomatic and palatal bones. the lower borders of the mandible, the mental foramen, and the mandibular nerve canals were traced with black pencil. Also, the outlines of the fresh extraction sockets in the bones were traced with broken black lines. Then the outlines of the alveolar processes in the quadrants of the jaws where teeth were extracted were traced with a sharp red pencil. Next. the same tracing film was superimposed over the I:‘-month postsurgical radiograph and

5

WICAL

AND

BRUSSEE

*254

- - - : 4/22/76

-:

S/12/77

Fig. 2. Tracings of the l-week and 12-month radiographs. oriented correctly by means of the anatomic landmarks previously recorded. Then the outlines of the alveolar processes as shown in this second radiograph were traced with a sharp blue pencil. The space between the red tracing and the blue tracing represented the loss of vertical height of the bone during the l&month interval (Fig. 2). To obtain quantitative data which would represent the amount of bone resorption shown in the radiographs, the area between the red and blue tracings, extending 5 cm on each side of the midline, was measured by means of a polar compensating planimeter.* The polar planimeter is a precision instrument used by engineers, statisticians, and physicists for the accurate measurement of areas of plane surfaces which have irregular borders (Fig. 3). All measurements were repeated and checked for consistency. The data obtained from the measurements of the areas on the tracings are expressed in square millimeters. It should be understood that these figures represent only the relative loss in height of the alveolar process, as no method of measuring actual total quantitative loss of bone tissue by resorption has yet been found. Still, these data, indicating the change in vertical height of the bone, are useful and reliable for a comparative study such as this one. Since there is an expected correlation between recent extractions and the amount of bone change, the number of immediate extractions in each study *Charles Bruning Co., Schaumburg, Ill.

area was recorded. The total area of bone loss in each arch, divided by the number of extractions in the same area, provided data described as “bone loss per extraction.”

Dietary data The amounts and ratio of calcium and phosphorus in the diet have previously been shown to correlate with resorption of alveolar and skeletal bone.‘-’ Thus the daily intakes of these minerals by the subjects of this study were also considered. Seven-day diet records were obtained from 32 of the subjects near the end of the study, when eating habits had returned to normal. These records were verified as being reliable by means of an oral review with each patient. After the record of each food item on the patients’ lists was transferred to computer cards, analyses of the diets were performed with an IBM 370-158 computer which had been programmed with coded tables of food values from U.S. Department of Agriculture Handbook No. 456.’ The calcium and phosphorus data from the computer printouts were tabulated for the subjects of each of the study groups so that possible nutritional differences between the groups could be analyzed.

Correlation of prosthodontic treatmwnt Following placement of immediate dentures at the time of extractions, each patient was seen at regular intervals by a dentist to make sure that the dentures were satisfactory. The dentures were adjusted and relined whenever necessary so that, throughout the

JANUARY 1979

VOLUME

41

NUMBER1

CALCIUM, VITAMIN D, AND RESORPTION

Fig. 3. The planimeter

is used to measure

the area between

the l-week

and the It-mor:lh

tracings.

study period, no complaints of poor fit or denture irritation were made. All of the dentures for all of the subjects were judged by both patients and dentists to fit and function well.

entire

Attrition

of subjects

Of 60 subjects originally enrolled in the study, five moved away, four stopped taking their medication because of alleged gastric disturbances (two on calcium and two on placebo), two refused the final radiographs, two dropped out because of lack of interest, and one suffered a fatal heart attack. The remaining 46 subjects completed the study.

Data analysis After all of the data were recorded the medication code was unsealed, and the subjects were divided into two groups depending on whether they had received the calcium supplement or the placebo.

THE JOURNAL OF PROSTHETIC DENTISTRY

The primary object of the study was to compare amount of bone loss per extraction the mean between the supplement group and the placebo group. The measurements of bone resorption from the radiographs were tabulated and averaged for the subjects of both groups. Student’s t-test was used to determine the significance of the differences between the means. The two groups were also compared, with t-tests, for similarities in sex, age. number of extractions, and dietary intakes of calcium and phosphorus.

Sources of errors Discernible differences in the relationships of fixed anatomic structures were noted when comparing some pairs of initial and final films. This represented an experimental error due to slight differences in the position of the patient’s head at the times of the separate exposures.

7

WICALANDBRUSSEE

Table I. Comparison

of the two study groups

sex

No. of extractions

Subject age (years)

Group

No. of subjects

Male

Female

Mean

Range

SD

Mean

Range

SD

Supplement Placebo

23 23

14 11

9 12

58.5 60.5

39-79 40-73

11.2 9.2

11.8 10.6

3-23 4-20

6.0 3.5r

t *Difference

0.81 >.20*

0.64 >.20*

P is not significant.

Table II. Area of bone loss per extraction,

Table IV. Area of bone loss per extraction

from radiographs, arches

for mandibular

for maxillary

Group

No. of subjects

Supplement Placebo

23 23

t P *Difference

and mandibular

Bone loss per extraction (mmz) Mean

Range

SD

12.7 19.8 3.41 <.005*

7.0-25.7 5.1-35.0

5.2 8.3

Bone loss per extraction (mml)

Group

subjects

Mean

Range

SD

Supplement Placebo

16 17

13.6 22.2 2.38 <.025*

4.7-25.7 5.1-49.0

5.7 12.9

t *Difference

is significant.

is significant.

for maxillary

arch only

Group

No. of subjects

Supplement Placebo

20 20

t P

Bone loss per extraction (mm?) Mean

Range

SD

11.8 17.6 2.78 <.01*

4.0-28.0 8.2-31.5

5.9 6.8

is significant

Another potential source of error was occasional difficulty in establishing the exact midline of the images of the jaws during the process of cropping out the unusable center panel of the panoramic radiograph. To assess the magnitude of these errors and determine if they would significantly alter the results of the experimental findings, an analysis was made of the differences in image size between each pair of radiographs. Six sets of measurements were made on each of the films between corresponding clearly defined anatomic landmarks. Two left-to-right horizontal measurements were made, one each in the maxillary and mandibular arches. Four vertical measurements, one in each of the four quadrants of every film, were also taken with vernier calipers and recorded.

8

No. of

P

Table III. Area of bone loss per extraction

*Difference

arch only

Analysis of all of the pairs of measurements revealed that the net difference in image size between the first and last radiographs for the supplement group was -0.58%. The net difference in image size between the radiographs for the placebo was -0.63%. Errors within groups tended to cancel each other out, and the degree of error between the groups was not significant. We therefore accepted the “bone loss per extraction” data as being reliable for comparison between the experimental and control groups.

RESULTS Table I shows that there was no significant differences between the two groups in sex, age, and number of extractions. A significant reduction in the severity of alveoiar bone resorption in the supplement group is revealed in Tables II to IV. The differences ranged from 34% less in the maxillae to 39% less in the mandible, with an average difference of 36% less resorption when both dental arches are considered. The mean basic daily dietary intakes of calcium and phosphorus, not counting the suibplement, were quite similar for both groups (Table V). Although the two groups were statistically comparable, individual subjects in both groups exhibited wide variations in mineral intakes, as would be expected in a random selection of subjects.

JANUARY1979

VOLLfME41

NUMBER I

CALCIUM,

VITAMIN

D, AND

RESORPTION

Table V. Mean daily dietary intakes of calcium and phosphorus, not including

Group Study Placebo 1

No. of subjects 13 19

P

Calcium

Phosphorus

(mg)*

supplement Ca/P Ratio

(mg)

Mean

Range

SD

Mean

Range

SD

Mean

Range

SD

680 620 0.70 >.201

230-1160 320-1000

250 210

1180 1070 1.19 >.1ot

750-1510 630-1490

230 530

0.6 0.6

0.3-0.8 0.4. 0.X

0.1 0.1

*Dietary sources only, not including tDifference is not significant.

-supplemental

calcium.

Table VI. Mean daily dietary intakes of calcium and phosphorus, including Calcium

(mg)

Phosphorus

supplemental

Ca/P Ratio

(mg)

Group

No. of subjects

Mean

Range

SD

Mean

Range

SD

Mean

Study Placebo

13 19

1430 620

980-1910 320-1000

2.50 210

1180 1070

750-1510 630-1490

230 260

1.2 0.6

Five subjects of the placebo group recorded calcium-phosphorus ratios of 0.7 or greater. An additional observation from the analyzed data was that the bone loss per extraction for these five patients ranged from 9.6 mm? to 16.1 mm’, with a mean of 13.5 mm’. Their bone loss figures compare quite favorably with the data for the supplemented

calcium

R

SD

0.9--1.5 0.4-0.8

0.2 0.1

The results of this study tend to reinforce the concept that the rate and severity of alveolar ridge resorption are related to the adequacy of the calcium intake and the calcium-phosphorus ratio of the diet. The results also suggest that for patients whose diet is deficient in calcium, a significant degree of protection against the undesirable resorption of alveolar bone may be gained from consistent use of the supplement containing calcium and vitamin D. Wical and Swoope’ suggested that the oral disease which Atwood”’ termed “reduction of residual ridges” is a manifestation of osteoporosis. This concept has been questioned by Ward and asso-

described osteoporosis of the maxillae and mandible from histologic studies and have also reported that “the loss of osseous substance in the jaws may be a further reflection of what is occurring in the other bones of the body.” Further research on the influence of continued calcium supplementation on long-term progressive alveolar resorption is desirable. However, in light of the rather consistent results of the limited dental studies to date and the lack of evidence that the jaw bones are either anatomically or metabolically dissociated from the rest of the skeleton, we feel that recent studies pertaining to skeletal osteoporosis are applicable to the discussion of oral bone and its resistance to resorption. In addition to the studies previously cited”-x indicating that bone loss has been retarded or reduced by the use of calcium supplements, other investigations, utilizing sophisticated methods for measuring bone density and volume, have produced significant findings. Coulston and Lutwak” and Lutwak and associatesl’ have reported that subjects receiving a 1 gm calcium supplement daily for 12 months showed an increase in bone density in the mandible of approximately 12.5%. Subjects in the same study receiving a placebo showed no significant changes. Albanese and associates’” in a series of several clinical trials

ciates” but is supported by Krook and associates,l’ Massler,‘:’ and Albanese,” who have reported both

lasting up to 3 years, documented density in subjects given calcium

similarities resorption

supplements, contrasting with age-related decreases in bone density in control subjects.

group. For purposes of comparison, the mean intakes of calcium by the two groups, including the supplement, and the resulting calcium-phosphorus ratios are given in Table VI.

DISCUSSION

Nedelman

THE JOURNAL

and correlations between alveolar bone and generalized skeletal osteoporosis. and Bernick’”

OF PROSTHETIC

have clearly

DENTISTRY

illustrated

and

Lund and associateP

demonstrated

increased bone and vitamin D

reduced bone

9

WICAL

resorption and increased bone mineralization in osteoporotic patients given calcium and vitamin D. An increase in bone mineral content in patients treated with sodium fluoride, calcium, and vitamin D was described by Hansson and Roos.‘O Parsons and associates” reported a significant increase in the volume of trabecular bone in patients with osteoporosis when sodium fluoride, vitamin D, and calcium supplements were administered. The importance of prcviding supplemental vitamin D along with calcium in achieving retardation of bone resorption has been emphasized by Jowsey’ and Nordin and associates.” Adequate vitamin D is absolutely essential for absorption and metabolism of calcium. Vitamin D deficiency is common in patients not exposed to significant amounts of natural sunlight. Negative or inconclusive results in trials of calcium therapy r&rout vitamin D have been reported by Smith and associates,“’ Zanzi and associates,” and Aloia and associates.” No harmful side effects resulting from calcium supplementation have been reported by any of these investigators. Several have specifically noted the absence of side effects, even with daily dosages as high as 3 gm of calcium and with studies extending as long as 8 years. There seems to be no experimental basis for the age-old speculations that moderate to high calcium intake causes kidney stones, or conversely, that low-calcium diets prevent urinary calculi or other abnormal calcifications. However, many thousands of patients have been put on low-calcium diets for these reasons. For patients who demonstrate severe or rapid alveolar bone loss and whose dietary history suggests a low calcium intake and/or a high phosphorus intake, we believe that calcium and vitamin D supplementation will help to increase the resistance of the bone to both mechanical and biochemical stresses. A phosphorus-free calcium supplement is recommended to avoid perpetuating a calciumphosphorus imbalance, except in patients where total mineral intake, including phosphorus, is inadequate. Calcium in doses of 750 to 1000 mg and 375 to 400 IU of vitamin D daily may be continued indefinitely as long as the dietary inadequacy exists. In view of the increasing evidence of the efficacy and safety of this treatment and its relative convenience and economy, it is a rational procedure in the practice of prosthetic dentistry.

REFERENCES 1.

LO

on postextraction

alveolar

K. E., and Swoope,

32:13,

C. C.: Studies

of residual

ridge

Part II. The relationship of dietary calcium and to residual ridge resorption. J PROSTHET DEIV.~

1974.

2.

Sorensen, R. L.: A Study of Dietary Calcium and Phosphorus Intakes in Relation to Residual Ridge Resorption. Thesis, School of Health, Loma Linda University, Loma Linda, Calif., 1977.

3.

Jowsey, J.: Osteoporosis, its nature and the role of diet. Postgrad Med 60:75, 1976. Jowsey, J.: Osteoporosis: Dealing with a crippling bone disease of the elderly. Geriatrics 32:41, 1977. Stein, I., and Beller, M. L.: Therapeutic progress in osteoporosis. Geriatrics 25:159, 1970. Riggs, B. L., Jowsey, J., Kelly, P. J., Hoffman. D. L., and Arnaud, C. D.: Effects of oral therapy with calcium and

4. 5. 6.

vitamin D in primary 42:1139, 1976. 7.

8. 9.

10. 11.

12.

13. 14. 15.

16.

18.

osteoporosis.

Horsman, A., Marshall, of estrogen, calcium, postmenopausal

D dietary bone resorp-

Wical,

resorption, phosphorus

17.

The effect of a calcium and vitamin

BRUSSEE

tion is reported. Mean alveolar bone loss for patients receiving the supplement was 36% less than that for patients receiving a placebo medication in a l-year double-blind study of 46 immediate denture patients. Relationships between alveolar bone resorption, osteoporosis, and adequacy of dietary calcium-phosphorus ratios were discussed, and clinical implications of recent research findings were presented.

SUMMARY supplement

AND

woman.

J Clin Endocrinol

Metab

D. H., and Nordin, B. E. C.: Effects and vitamin D on bone loss in Calcif

Tissue

Res 24:Rll,

1977.

(SUPPl) Albanese, A. A.: Calcium nutrition in the elderly. Postgrad Med 63:167, 1978. Adams, C. F.: Nutritive Value of American Foods. Agriculture Handbook No. 456, Washington, D.C., 1975; U.S. Government Printing Office. Atwood. D. A.: Reduction of residual ridges: A major oral disease entity. J PROSTHETDENT 26~266, 197 1. Ward, V. J., Stevens, A. P., Harrison, A., and Lurie, D.: The relationship between the metacarpal index and the rate of mandibular ridge resorption. J Oral Rehabil 4:83, 1977. Krook, L., Whalen, J. P., Lesser, G. V., and Berens, D. L.: Experimental studies on osteoporosis. Methods Achiev Exp Pathol 7:72, 1975. Massler, M.: Oral problems in the aging patient. J Am Sot Geriatric Dent 12:12, 23, 1976. Albanese. A. A.: Osteoporosis. J Am Pharm Assoc 17:252, 1977. Nedelman, C. I., and Bernick, S.: The significance of age changes in human alveolar mucosa and bone. J PROSTHET DENT 39:495, 1978. Co&ton, A., and Lutwak, L.: Dietary calcium deficiency and human periodontal disease. Fed Proced 31:721, 1972. (Abst) Lutwak, L., Singer, F. R., and Urist, M. R.: Current concepts of bone metabolism. A report of a clinical case conference of the U.C.L.A. School of Medicine, Los Angeles, California. Annals Internat Med 80~630, 1974, Albanese, A. A., Edelson, A. H., Lorenze, E. ,J. Jr., and

JANUARY 1979

VOLUME 41

NUMBER

I

CALCIUM, VITAMIN D, AND RESORPTION

Woodhull, M. L.: Problems of bone health in the elderly. NY State J Med 75:326, 1975. 19. Lund, B., Hjorth, L., Kjaer, I., Reimann, I., Friis, T., Anderson, R. B., and Sorensen, 0. H.: Treatment of osteoporosis of aging with 1 alpha hydroxycholecalciferol. Lancet 2 (7946):1168, 1975. 20. Hansson, T., and Roos, B.: Effect of combined therapy with sodium fluoride, calcium, and vitamin D on the lumbar spine in osteoporosis. Am J Roentgen01 126:1294, 1976. 21. Parsons, V., Mitchell, C. J., Reeve, J., and Hesp, R.: The use of sodium fluoride, vitamin D, and calcium supplements in the treatment of patients with axial osteoporosis. Calcif Tissue Res 22:236, 1977. (Suppl) 22. Nordin, B. E. C., Horsman, A., and Gallagher, J. L.: Effect of various therapies on bone loss in women. In Kuhlencordt, F., and Kruse, H. (editors): Calcium Metabolism, Bone, and Metabolic Bone Diseases. Berlin, 1975, Springer-Verlag Co., pp 233-242.

23.

Smith, D. A., Anderson, J. M., Aitken, J. M., and Shimmins, J.: The effects of calcium supplementation of the diet on bone mass in women. In Kuhlencordt, F., and Kruse, H. (editors): Calcium Metabolism, Bone, and Metabolic Bone Diseases. Berlin, 1975, Springer-Verlag Co., pp 278-282. 24. Zanzi, I., Aloia, J. F., Ellis, K. J., and Cohn, S. H.: Combined treatment of primary osteoporosis with oral sodium fluoride, estrogens, and calcium. Calcif Tissue Res 22:563, 1977. (Suppl) 25. Aloia, J. F., Zanzi, I., Vanswani, A., Ellis, K.J., and Cohn, S. H.: Combination therapy for osteoporosis. Metabolism 26~787. 1977. Reprint requests to:

DR. KENNETH E. WICAL LOMA LINDA UNIVERSITY SCHOOL OF DENTISTRY LOMA LINDA, CALIF. 92350

ARTICLES TO APPEAR IN FUTURE ISSUES cs

cal factors involved in maxillofacial Robert E. Gillis, Jr., D.M.D., D.M.D.

M.S.D., Wendell M. Swenson, Ph.D., and William

R. Laney,

Tempaz&ure rise in pulp chamber during fabrication of benpomry

!df-GzdqJ resin crowns Rafael Grajower, Ph.D., Sasson Shaharbani,

D.M.D.,

and Eliezer Kaufman,

D.M.D

Immediate denture using patient’s existing dentition Jose I. Granados, D.D.S., M.S.

The effects of age and full pal&al coverage on oral Joseph E. Grasso, D.D.S., M.S., and Frank A. Catalanatto,

Mobile mechanical irreversible hydzwolloid

D.M.D.

sgctulator

Jay G. Hanson, D.D.S., and Forrest R. Scandrett, D.D.S., M.S.

y hinged complete dentute for a severely undercut maxilky to a problem Joe H. Jaggers, D.M.D., and Maston Boyd, D.M.D.

Comp&sn tee!&

of the volume of crevicular fluid from restored and

Lee M. Jameson, D.D.S., MS. THE JOURNAL OF PROSTHETIC DENTEXRY

wch.