CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
THE RELATIONSHIP BE~IEEN CALCIUM AND ALVEOLAR BONE LOSS
IN WOHEN AGED 40 TO 60 YEARS
A thesis submitted in partial satisfaction of the
requirements for the degree of Master of Science in
Home Economics
by
Elaine Paulson
Hay 1986
The thesis of Elaine Paulson is approved:
LilieGrossn1an
Ann R. Stasch, Ph.D., Chair
California State University, Northridge
ii
ACKNOWLEDGEHENTS
I
would like to express my appreciation to Dr. Ann Stasch for
her guidance and encouragement.
Her inquisitive mind, friendship and
marvelous sense of humor have made these past three years most
pleasant.
My thanks to Dr. Marjory Joseph for her expertise and advice on
research techniques and statistical analysis.
The extra hours spent
were very much appreciated.
I would also like to thank Dr. John K. Evens for his cooperation
in allowing me to conduct my survey utilizing his patients and my coworkers for their help and cooperation, especially Denise Brunette for
her constant encouragement and excellent assistance with data
collection.
My love and deepest appreciation to my daughter Marisa, for
putting up with part-time mothering and helping whenever possible, and
to Ron, whose caring and support made this project feasible.
iii
TABLE OF CONTENTS
Page
ACKNOvaEDGID1ENTS •
iii
LIST OF TABLES •
•
v
vi
LIST OF FIGURES
ABSTRACT •
vii
CHAPTER
1•
Introduction
2.
Review of Literature
1
•
Methodology
8
27
4.
Results and Discussions •
5.
Summary, Conclusions and Recommendations
•
33
44
BIBLIOGRAPHY •
48
APPENDICES •
53
A.
Cover Letter
54
B.
Questionnaire •
56
c.
Interview •
60
D.
Periodontal Chart •
62
E.
Milligrams of Calcium in Dietary Items on
Questionnaire • •
•
64
•
iv
LIST OF TABLES
Table
Page
1.
2.
3.
4.
.....
Calcium Supplement Intake . . . .
Past Dairy Consumption Scores . . .
Periodontal Code •
.......
......
.....
Experimental Data Relating to Postmenopausal
Women • • • • • • • • • • • • • • • • • • . . . . .
v
35
36
39
42
LIST OF FIGURES
Figure
1.
Page
Alveolar Bone Loss Scoring System • • • • • • • • • • •
vi
30
ABSTRACT
THE RELATIONSHIP BETWEEN CALCIUM AND ALVEOLAR BONE LOSS
IN WOMEN AGED 40 TO 60 YEARS
Elaine Paulson
Master of Science in Home Economics
Calcium deficiency is considered to be one of the important
factors contributing to the development of osteoporosis.
Postmeno-
pausal women have a high incidence of osteoporosis and low mean daily
calcium intakes.
Alveolar bone loss may be an indicator of osteo-
porosis and this research sought to determine if there was a relationship between past and present calcium intake and alveolar bone loss in
!
women aged 40 to 60 years.
Selected female dental patients were
./
surveyed and examined.
Statistical analysis indicated that there was
no significant relationship.
The mean daily calcium intake met the RDA only when supplements
were taken in addition to dietary sources.
Calcium carbonate, the
most commonly taken supplement, was prescribed either by the subject
or a physician and had generally been taken for a year or less.
vii
Half of the sample had alveolar bone loss indicative of some
degree of periodontal disease.· Homen in the 50 to 60 year age group
taking estrogen had less alveolar bone loss than those not taking
estrogen in the same age group.
The majority of the sample were not currently consuming dairy
products and Chi square analysis of past dairy consumption with
familial history of osteoporosis showed no significant association.
viii
CHAPTER 1
Introduction
Periodontal disease is the leading cause or tooth loss in the
adult population and the main criterion in evaluating the extent of
the disease is assessing the degree or alveolar bone loss that has
occurred.
Loss of alveolar bone is a long slow process that continues
ror many years before the actual loosening and loss of teeth occurs.
The manifestation of aging in the skeletal system is characterized by increased resorption activity and decreased bone formation.
This results in reduced bone density, and in some cases, can cause
increased fragility of the skeletal structure and a propensity to bone
fracture, a condition known as osteoporosis.
The underlying etiologies of osteoporosis and periodontal disease
are both poorly understood.
Carranza (1979) reported that the changes
in alveolar bone are similar to changes that occur in the rest of the
•
skeletal system.
Bone loss is an insidious process and the patient
may be asymptomatic for many years before clinical manifestations,
such as a f~acture or loss of a tooth, become apparent.
There is increasing evidence that long-term calcium deficiency is
a probable risk factor for age-related osteoporosis.
Hhen calcium
intake is inadequate calcium must be withdrawn from the bones to
maintain body homeostasis.
Early nutrition may be important in deter-
mining peak adult bone mass and may have considerable influence on
rracture susceptibility in the elderly.
1
Heaney, Gallagher, Johnston,
2
Neer, Parfitt, and Whedon (1982) stated that the intake of calcium
decreases with age in many adults and that males consume up to twice
as much calcium as females.
Rapid bone loss in women is closely
associated with menopause and there are indications that estrogen
withdrawal produces an increase in the calcium intake requirement.
Women are particularly susceptible to osteoporosis and the Recommended
Dietary Allowance of 800 mg (Food and Nutrition Board, 1980) may need
to be revised.
Periodontal disease, with its accompanying alveolar bone loss,
occurs generally after the age of 40 years.
Daniell (1976) noticed a
high frequency of edentulism among patients with postmenopausal osteoporosis.
signs.
Detection of both diseases is difficult without clinical
There are some indications that peak bone mass is attained and
bone loss begins earlier in alveolar bone; therefore, alveolar bone
loss may be an early indicator of osteoporosis (Albanese, 1977).
Justification
It is well established that many women suffer from postmenopausal
osteoporosis.
Considerable debate in recent years has centered around
the treatment of the disease, with estrogen replacement therapy and/or
calcium supplementation most generally recommended.
Research has
indicated that inadequate calcium intake up to age 35 years has an
influence on the strength of the bone and its resistance to osteoporosis in later years.
Alveolar bone loss with the eventual loss of
teeth is prevalent after age 40 years and may be an early sign of
osteoporosis.
Dental research regarding the use of calcium to treat
alveolar bone loss has been controversial.
About 20 years ago,
research suggested that bone loss around the teeth was caused by
0
•
3
calcium deficiency,
but some of the more current research questions
that premise maintaining that periodontal disease is caused mainly by
local factors.
Women are primarily affected by osteoporosis and a
deficiency in daily calcium intake is common after puberty.
A compar-
ison of the present and past calcium intake of women in the age
bracket surrounding menopause (mean age 50 years), with the degree of
alveolar bone loss present, would help to determine if a relationship
exists between calcium intake and alveolar bone loss.
If there is
more alveolar bone loss in women with deficient calcium intakes, this
relationship could prove beneficial in the early diagnosis of a possible suseptibility bo osteoporosis.
Statement Qt
~
Problem
The purpose of this study was to determine if there was a relationship between past and present calcium intake, both dietary and
supplemental, and the degree of present alveolar bone loss.
''~omen
who
were considered perimenopausal, menopausal, or postmenopausal, aged 40
to 60 years, were the subjects.
Significant alveolar bone loss could
be an indication of nonclinical osteoporosis.
A review of literature provided a background for this complex and
many-faceted problem.
The function of calcium in the body, calcium
requirements for women, and the need for calcium balance have been
described.
In addition, the normal age-related decrease in skeletal
mass, the development of postmenopausal osteoporosis, and the role of
calcium with these two entities was discussed.
A description of
alveolar bone and its function, relation to osteoporosis, and the
influence calcium has on alveolar bone loss was also included.
4
Hypotheses
For this reasearch study the following hypotheses were developed:
Alternate Hypothesis
There will be a significant relationship between calcium intake
and alveolar bone loss in women aged 40 to 60 years.
NY.U. Hypothesis
There will be no significant relationship between calcium intake
and alveolar bone loss in women aged 40 to 60 years.
Ob1ectives
The following objectives were also investigated as part of this
research study:
1.
To what degree does alveolar bone loss occur in women aged 40
to 60 years?
2.
Does the daily calcium intake of women aged 40 to 60 years
meet the RDA of 800 mg?
3.
Do women aged 40 to 60 years generally take calcium
supplements?
4.
Who prescribed the supplement?
What is the length of time that women aged 40 to 60 years
have been taking calcium supplements?
5.
What type of calcium supplement is taken the most?
6. Do women aged 40 to 60 years consume dairy products? If not,
when did they stop?
7.
Do women with a family history of osteoporosis have more
alveolar bone loss?
8.
Do postmenopausal women who take estrogen have less alveolar
bone loss than those who don't?
5
Assumptions
The following assumptions were made for this research study:
1.
Alveolar bone loss is more prevalent after age 40 years.
2.
The method for measuring alveolar bone loss developed by
Dunning and Leach (1960) will provide a valid and meaningful
assessment of the degree of bone loss.
3. Accurate and consistent measurements of the degree of alveolar
bone loss will be assessed and recorded by the researcher.
4.
The questionnaire is a valid means of collecting data on
current calcium intake.
s.
The interview is a valid means of collecting data on past
intake of calcium.
Limitations
The following are the limitations involved in this research study:
1.
The etiology of periodontal disease is multifactorial and
this research was limited to the study of calcium only and
its relationship to alveolar bone loss.
2.
The etiology of osteoporosis is multifactorial and this study
concentrated mainly on the relationship of calcium to bone
loss.
3.
The sample was selected from patients in a single dental
practice who had regular dental care and no significant
medical or dental problems.
4.
Many factors affect calcium absorption and this study was
limited to calcium intake from dietary and supplemental
sources only.
6
Definition of Terms
Appendicular skeleton:
Axial skeleton:
The bones of the extremities
The bones of the head and neck
Cortical ..!2..QM:
Dense, hard bone with microscopic spaces
that forms the external layers of the skeleton; predominates in
the appendicular skeleton
Edentulous:
Without teeth
Epiohysis:
A center for ossification at each extremity of long
bones
Femoral
~:
The part of the thigh bone or femur that connects
the head with the body of the femur
Gingiva:
The gum tissue
Kyphosis:
Exaggeration or angulation of the normal posterior
curve of the spine; gives rise to a condition commonly known as
"dowager's hump"
Mandible:
Maxilla:
The lower jaw
The upper jaw
Hetacarpal:
Morbidity:
The bones of the hand
The rate of disease or proportion of diseased persons
in a given locality
Mortality:
The proportion of deaths from a particular disease
Oophorectomy:
The surgical-·removal of one or both ovaries
Peridontal disease:
A gradual breakdown of the supporting
structures of the teeth, which includes the alveolar bone,
the
gingiva, and periodontal ligament
Periodontal probe:
A dental instrument, graduated in millimeter
7
increments that is inserted under the gingiva to measure the degree of
bone loss
Phalanx:
Any one of the bones of the fingers
Radiograph:
Radius:
An x-ray photograph
The outer and shorter bone of the arm, which revolves
partially about the ulna (the inner bone)
Trabecular
~:
Spongy bone in which the matrix forms connecting
bars or plates that traverse the internal cavities of the skeleton;
also referred to as cancellous bone;
skeleton
predominates in the axial
CHAPTER 2
Review of Literature
Major Functions .Qf. Calcium 1n.
~ ~
The most abundant essential mineral in the human body is calcium
and 99% of the total is in bones and teeth.
The remaining one percent
is found in body fluids and cells (Martin, 1983).
The amount of
calcium in an adult man's body is between 950 and 1300 grams, while
the adult woman with a smaller body size contains less -- between 770
and 930 grams (Jagerstad, 1982).
Calcium is an essential nutrient for growth, maintenance, and
reproduction throughout the life cycle.
It imparts mechanical
strength and structural support to the bones and teeth, accounting for
about 1.5 to 2% of the total body weight of an adult (Albanese, 1981).
Serum calcium is vitally important for the regulation of cellular
activities such as blood clotting, hormonal actions, nerve and muscle
function, and cellular motility.
Bone is constantly being remodeled
and as much as 700 mg of calcium may enter and leave the bones daily.
The constant resorption of existing bone and deposition of new bone
during adult life allows for a continuous maintenance of blood calcium
levels (Martin, 1983).
Age-Related Decrease 1n. Skeletal
~
The most rapid phase of bone dimensional growth, characterized by
an increase in bone length and width, occurs from conception until
closure of the epiphysis.
This is approximately age 12 years in
8
9
females and age 15 years in males.
A period of bone consolidation to
increase the bone mass lasts for the next 15 to 20 years.
During this
time, increased bone thickness and density will increase the skeletal
mass by about 10 to 15% (Heaney et al., 1982)e Growth and consolidation for skeletal maturity is
~eached
at about 35 years of age for
cortical bone and probably earlier for trabecular bone (Parfitt,
1983).
Peak bone mass is influenced by sex, nutrition, exercise,
race, and general health.
Bone mass is 30% higher in men than women
and about 10% higher in blacks than whites with individual variations
in each group (National Institute of Arthritis, Diabetes, and Digestive and Kidney Diseases, 1984).
Between the ages of 30 and 40 years resorption of existing bone
begins to exceed formation of new bone, resulting in a net loss of
bone (Heaney et al., 1982).
The imbalance in remodeling causes bone
loss to continue throughout life.
Bones retain their basic organiza-
tion but lose both mineral and organic matrix resulting in an
increased fragility {National Institute of Arthritis, Diabetes, and
Digestive and Kidney Diseases, 1984).
Parfitt (1983) stated that age
related bone loss is a "universal phenomenon of human biology that
occurs regardless of sex, race, occupation, economic development,
/
geographical location, historical epoch, or dietary habits."
Bone loss in trabecular and cortical bone differs in rate and
age.
There is a relatively rapid loss of trabecular bone early in
life (ages 20 to 40 years) and comparatively little loss of cortical
bone, with the situation reversing after age 55 years (Jowsey, 1977).
Marcus {1982) reported that the axial skeleton, which includes the
pelvis and vertebral column, is comprised of approximately 70% trabec-
10
ular bone.
Evaluations of age-related changes suggest that loss of
bone mass in the axial skeleton precedes that of appendicular bone.
The appendicular skeleton, which contains mainly cortical bone, begins
a decline in bone mass at approximately 50 years of age.
In a study
conducted by Riggs, Wahner, Dunn, Mazess, Offord, and Mel ton ( 1981)
the vertebral mineral density of 105 women showed a linear decrease
from ages 20 to 80 years, with an overall bone loss of 45%.
A signif-
icant loss of vertebral mineral was also found in the pre-menopausal
subjects.
Vertebral density declined in a linear fashion in men also,
with a noticeably lower lifetime loss of 14%.
Lukert (1982) concurred
that
in women loss of bone from vertebrae (trabecular bone) begins in
young adulthood and continues linearly throughout life, while in
the appendicular skeleton (cortical bone) there is little bone
loss until menopause, at which time loss accelerates until age 65
years when it begins to decelerate.
In conclusion Marcus (1982) suggested that factors that influence bone
loss must be considered over the entire span of adult life.
If dif-
ferences in bone mass between the sexes and ethnic groups can be
detected by the age of 20 years, it would be wise to evaluate factors
that affect bone loss during adolescence or earlier.
Postmenopausal Osteoporosis
When the bone mass decreases sufficiently below that expected for
an
individual
of a given
age, race, or sex, resulting in structural
bone failure and a propensity to fracture, that condition is known as
osteoporosis.
The decrease in skeletal mass or quantity of bone is
present without a change in the quality of bone (Albanese, 1977).
As
many as 20 million people in the United States have osteoporosis and
about 1.3 million fractures related to osteoporosis occur annually
11
among individuals aged 45 years and older (National Institute of
Arthritis, Diabetes, and Digestive and Kidney Diseases, 1984).
The
overall reduction of mass in both cortical and trabecular bone is
considered to be the major factor is osteoporotic fractures and
affects mainly the axial skeleton:
the·vertebrae, ribs, pelvis and
femoral necks (Lukert, 1982).
Riggs and Melton (1983) suggested that two distinct syndromes of
osteoporosis exist and are differentiated by the type and location of
the affected bones.
One is postmenopausal osteoporosis which affects
five to ten percent of women in early menopause.
Excessive trabecular
bone loss is manifested in fractures in the thoracic and lumbar vertebra! bodies.
These vertebral compression fractures eventually cause
spinal vertebral collapse with a loss of body height and/or the development of kyphosis.
The other form of osteoporosis is senile osteo-
porosis which involves both aging men and women and results from a
cumulative age-related bone loss of both trabecular and cortical bone.
Sites composed of both bone types, such as the pelvis and radius,
exhibit an increase in fracture rate, especially in women.
Schwartz, Anwah, and Levy (1985) reported that
osteoporosis is the most common metabolic bone disorder in the
United, States, particularly affecting Caucasian women after the
menopause. It is estimated that one in three postmenopausal
American women has osteoporosis.
They concluded that, because of postmenopausal osteoporotic changes
reducing the strength of their bones, 20% of American women will have
a hip or vertebral fracture.
Riggs et al., (1981) stated that half of
the female population by age 65 years had vertebral bone mineral
density below the fracture threshold, and therefore would be considered to have "asymptomatic osteoporosis."
12
Three groups of women (14 who had undergone oophorectomy during
young adulthood, 14 normal peri menopausal, and 14 normal postmenopausal) were compared by Richelson, Wahner, Melton, and Riggs (1984)
to determine whether aging or estrogen deficiency was the most important determinant of postmenopausal bone loss.
Results indicated that
bone loss and the loss for each group was approximately the same
amount.
It was proposed that most of the bone loss following natural
menopause for the first 10 or 15 years is attributable to estrogen
deficiency rather than to aging itself.
Brody, Farmer, and White
( 1984) questioned the role of menopause as a key event in the pathogenesis of osteoporosis.
Data from the National Hospital Discharge
Survey for the years 1974 to 1979 were analyzed and Brody et al.
(1984) reported that
the rate of hip fracture among while females rises sharply
between ages 40 and 44 and then continues at the constant rate of
acceleration doubling every five to six years throughtout life
with no deviation during, or in the years immediately following,
menopause.
It was suggested that research efforts should focus on the period of
time prior to menopause in order to postpone the onset of the osteoporotic process.
Aloia, Vaswani, Yeh, Ross, Bllis, and Cohn (1983) advised that
I
the treatment of osteoporosis has been relatively unsatisfactory,
therefore more attention must be placed on prevention.
Risk factors
for postmenopausal osteoporosis must be identified and attempts need
to be made to reduce their prevalence.
In a study of 80 white women
who had undergone menopause one to six years earlier, a wide range was
found in total body calcium and bone mineral count suggesting that the
major determinants of bone mass have already been defined by the time
13
of menopause.
In conclusion Aloia et al. (1983) proposed that
bone mass in the postmenopausal period reflects the cumuiative
interaction of genetic and environmental factors that have
influenced bone gain in childhood by bone loss during aging.
These findings were reinforced in a later study by Aloia, Cohn,
Vaswani, Teh, Yuen, and Ellis (1985) where risk factors were compared
between 58 postmenopausal osteoporotic women and 58 age-matched normal
women.
The osteoporotic women had lower total body calcium levels and
bone mineral content of the radius, had undergone an earlier menopause, had a higher frequency of smoking, and had breast-fed less
often.
The results affirmed that there are changeable risk factors
for the development of osteoporosis and their influence on the peak
bone mass attained at skeletal maturity should be considered an important factor in determining the incidence of osteoporosis after
menopause.
Schwartz et al. (1985) conducted a cross-sectional survey of 116
physicians assessing their methods of treatment for postmenopausal
osteoporosis.
The general consensus was that the multifactorial
etiology and insidious onset of postmenopausal osteoporosis did not
allow for early patient detection or a single established treatment
plan.
Calcium supplementation was the most frequent method of
treatment ~nd was used by 84.5% of the sample.
It was generally felt
by the physicians surveyed that postmenopausal osteoporosis was
treatable and that the rate of bone loss could be slowed down or even
halted.
In agreement with Aloia et al. (1983; 1985), Schwartz et al.
(1985) reported
if patients could build up sufficient bone mass by menopause or
delay postmenopausal bone loss, then much of the morbidity and
mortality of postmenopausal osteoporosis could be averted.
14
Calcium Requirement snA Balance
Calcium requirement,
as defined by Marcus ( 1982),
is the
"quantity of dietary calcium required to preserve calcium balance" and
in the heal thy adult calcium balance should be 'zero', i.e.,
output equals input. Calcium requirement is influenced by the
efficiency of gastrointestinal, renal and skeletal handling of
calcium, and by the hormonal milieu which regulates these
processes.
The Food and Nutrition Board ( 1980) recommended a calcium intake of
800 mg per day for adults over the age of 18 years.
The RDA is based
on the concept of calcium balance and is meant to meet the needs of
populations grouped by sex and age and are not the requirements for
specific individuals.
the RDA of 800 mg.
excreted daily:
tion).
Kreutler (1980) explained the rationale behind
A total of approximately 320 mg of calcium are
175 mg (urine), 125 (feces), and 20 mg (perspira-
The average absorption rate of calcium is 30 to 40%; there-
fore, a daily intake of 800 mg is recommended to maintain calcium
balance at zero.
Carroll, Abraham, Dresser (1983) estimated that 50%
of females 15 years of age or older consumed no more than 75% of the
RDA for calcium and that after age 35 years, more than 75% of the
women in the United States had calcium intakes below the RDA of 800
mg.
Heaney et al. ( 1982) stated that the body's need for calcium is
regulated by the efficiency of intestinal calcium absorption,
increasing when dietary calcium is low and decreasing when dietary
calcium is high.
Under normal circumstances calcium homeostasis is
maintained despite marked variations in dietary intake but, after
middle age the efficiency of intestinal calcium absorption decreases.
Heaney, Recker, and Saville (1977) evaluated the dietary calcium
15
intake of 130 normal perimenopausal women aged 35 to 50 years for
calcium balance performance.
of 30 mg.
Results showed a daily negative balance
A higher intake of calcium produced a positive balance,
while a lower intake a negative balance.
It was concluded that the
current RDA of 0.8 g is low by 'a.t least 0.4 g and that the intake of
calcium required to produce an average zero calcium balance in perimenopausal women is 1.241 g daily.
· The following year, Heaney et al. (1978) extended their analysis
to an evaluation of the effect of menopause and the associated change
in estrogen status on the calcium balance performance.
The subjects
were divided into premenopause, postmenopause-untreated, and postmenopause-estrogen replaced categories.
The average calcium intake
was the same in all three groups, with the means ranging from 0.630 to
0.659 gm/day.
Calcium balance was negative in all three groups, but
most negative in the estrogen deprived postmenopausal women.
Calcium
intake was calculated for zero balance and the authors reported that
premenopausal and treated postmenopausal women needed 0.990 gm/day and
the untreated postmenopausal women had a calcium requirement of 1.504
gm/day.
They concluded that estrogen had a positive effect on balance
and intake requirement and that the current RDA underestimates the
calcium requirement of the middle-aged woman.
Spencer, Kramer,
Lesniak~
De Bartolo, Norris, and Osis (1984)
studied 181 males, with daily calcium intakes ranging from 234 to 2320
mg, in order to determine the amount of calcium needed to attain
calcium equilibrium.
Calcium balance was achieved at 1200 mg and it
was recommended that a calcium requirement of 1200 mg would be preferable to the presently recommended amount of 800 mg per day.
16
In an evaluation of the paleolithic diet Eaton and Kenner (1985)
estimated that the daily calcium intake of preagriculatural man was
1579.2 mg.
Their analysis of the range and content of food consumed
by the ancestors of man for 4 million years provided a basis to
determine what human beings are genetically "programmed" to eat,
digest, and metabolize.
Paleolithic calcium intake far exceeded that
of today's RDA and could be considered a reference standard for modern
human nutrition.
Heaney et al. (1982) reported that about 45% of the adult's
skeletal mass is formed during the adolescent growth spurt and that
peak bone mass is achieved at age 30 to 35 years.
Bone mass continues
to increase after dimensional growth is complete; therefore, Heaney et
al. (1982) recommended that "an intake found to be sufficient to
maintain zero balance in young adults can no longer be considered to
provide adequate nutrition."
A degree of positive calcium balance
should be the criteria until age 30 to 35 years.
The Food and Nutri-
tion Board (1980) recommended an RDA of 1200 mg for ages 11 to 18
years but decreased the RDA to 800 mg at age 19 years.
The effect of calcium intake during early and middle adulthood on
age-related bone loss and bone fractures in later years was studied by
Matkovic, Kostial, Simonovic, Buzina, Brodarec, and Nordin (1979).
Two regions in Yugoslavia, cho-sen for their similar variables, differed greatly in the customary calcium intake of their populations.
Bone mass was higher at all ages in both men and women in the "high
calcium district."
The difference in bone mass was present at the age
of 30 years and did not increase thereafter.
Matkovic et al. ( 1979)
concluded that "most of the difference in the amount of bone occurred
17
at the phase of bone growth when additional calcium could have
enhanced bone formation."
in both regions.
The rate of bone loss with age was the same
The incidence of femoral neck fractures was signifi-
cantly higher in the "low-calcium district" and reflects the reduced
cortical bone mass attained earlier.
In conclusion it was proposed
that calcium intake is an important determinant of bone mass in young
adults and that cortical bone mass in middle life is determined by the
peak bone mass attained at 30 to 40 years of age.
Draper and Scythes
(1981) agreed and recommended that any nutritional strategy should be
aimed at maximizing the mass of the skeleton at maturity and that the
influence of dietary calcium upon the development of peak bone mass at
maturity determines later suseptibility to osteoporosis.
Calcium
~
Postmenopausal Osteoporosis
Avioli ( 1981) proposed that calcium deficiency is an important
factor in the development of fracture-prone postmenopausal osteoporosis and that the diet of the average woman was relatively deficient
in calcium.
Negative calcium balance in the years preceding menopause
contributed to loss of bone mass and it was suggested that calcium
intake should be between 1.0 to 1.5 g per day to maintain a positive
calcium
bal~nce.
Spencer, Kramer, and Osis ( 1982) stated that a decrease in the
intestinal absorption of calcium with aging is one of the reasons for
bone loss and may significantly contribute to the development of
osteoporosis.
Gallagher, Riggs, Eisman, Hamstra, Arnaud, and Deluca
(1979) found that increased bone loss in postmenopausal osteoporotic
women may be a combination of decreased calcium absorption plus the
effects of menopause.
The amount of dietary calcium necessary to
18
prevent negative calcium balance increases with age and is much higher
than the amount consumed by most elderly persons.
Osteoporotic
patients may require an even higher amount of calcium to prevent
negative calcium balance.
Aloia et al. (1983) suggested that an increase in bone resorption
caused the negative calcium balance following menopause.
It was
proposed that reduced efficiency of calcium absorption in the postmenopausal years can be overcome by increasing calcium intake and that
the increased intake of calcium should be encouraged in the perimenopausal years to help prevent postmenopausal osteoporosis.
Heaney et
al. (1982) stated that the deterioration in calcium balance after
menopause can be "offset either by estrogen replacement or by
increased calcium intake."
An increase in calcium intake of 500 mg
per day will produce the same balance effect as moderate doses of
estrogen.
Marcus ( 1982) maintained that the events of menopause were not
the sole cause of age-related bone loss, as men normally lose bone
mass also.
The fact that premenopausal women lose bone confirmed that
reduction of estrogen is not the only factor contributing to osteoporosis.
Changes in trabecular bone begin as early as the third decade,
necessitating an increase in calcium intake to maintain balance.
The effect of calcium supplementation on postmenopausal bone loss
has been controversial.
In 1977, Recker, Saville, and Heaney divided
60 postmenopausal women into three groups:
treated, and calcium carbonate treated.
intervals over a 2-year period.
a control, sex hormoneBone mass was measured at
The treated subjects had measurably
decreased bone loss when compared to the control subjects.
The effect
19
of calcium supplementation was not as strong as that of sex hormone
therapy but the researchers concluded that calcium supplementation
could be recommended safely as a preventive measure.
John~on
Lee, Lawler, and
(1981) supplemented the diets of 20 elderly females with
calcium-rich foods and a calcium compound for a six-month period.
An
increase in bone density was found in 11 of the subjects and the
authors recommended the use of calcium as a therapeutic modality in
the treatment of osteoporosis.
Opposite results were found when Nilas, Christiansen, and Rodbro
(1984) separated 103 early postmenopausal women into three groups with
differing calcium intakes.
The daily total intake of dietary and
supplemental calcium ranged from 1000 to 2000 mg.
Bone mineral con-
tent was measured every three months for a 2-year-period and a similar
fall in bone mineral content was observed in all three groups.
It was
concluded that calcium intake had very little effect on loss of bone
calcium in early menopause.
Recker and Heaney (1985) studied the effects of a conscious
increase in milk intake as a form of calcium supplementation.
Two
groups of healthy postmenopausal women, one receiving milk supplementations and the other a control, were observed for two years.
Measurements to determine calcium balance and bone metabolism were
taken and results showed that'. calcium balance in the supplemented
group improved.
The rate of bone remodeling was suppressed, but not
to the extent found with calcium carbonate in a previous study (Recker
et al. ( 1977).
that
In conclusion, Recker and Heaney ( 1985) recommended
20
milk is an appropriate source of calcium to support bone health
in postmenopausal women and that the accumulated evidence on the
efficacy of calcium supplements can be safely applied to milk.
Spencer. et al. (1984} proposed that increased calcium intake can
be achieved with dairy products or calcium supplements.
Supplements
administered as calcium salts differ in their availability of calcium
for absorption.
Calcium gluconate and calcium lactate contain 10%
calcium, while calcium carbonate contains 40% calcium; therefore,
fewer calcium carbonate tablets would be needed to achieve a certain
calcium intake.
Summarizing a recent symposium on vitamin pills versus food,
Dosti (1986) reported that concern over osteoporosis was the probable
cause of a tenfold increase in calcium supplement intake by Americans
since 1980.
One of the lecturers, Dr. Robert P. Heaney, pointed out
that the carbonate, gluconate, lactate, and citrate that are consumed
with supplements are substances whose long-term effects are not known.
In addition the high dose of calcium consumed with supplements may
upset the balance of other nutrients, such as iron and zinc, in the
body.
Food sources offer a natural balance of nutrients and are the
best channel for proper calcium absorption.
Calcium is found in many
foods but 75% of the calcium intake of Americans is from milk
products.
Dr. Heaney also emphasized that adequate nutrition ia
important to maintain existing-· bone mass and that calcium won't cause
more bone to develop, but it can help to keep existing bone from
depleting.
Avioli (1984) also advised that bone resorption may be retarded,
but not restored, by calcium replacement and recommended that an
adequate supply of calcium through diets and supplements should be
21
stressed in the third and fourth decades of life.
Calcium supplements
improve the calcium balance of perimenopausal and postmenopausal women
and an improvement in calcium balance can be related to an increase in
skeletal mass.
Function Q( Alveolar
~
The part of the mandible and maxilla that contains the teeth is
made of alveolar bone.
This bone forms and supports the tooth sockets
which are called alveoli.
The inner wall of the socket is made of
thin cortical bone, while the rest of the bone around the tooth is
spongy, trabecular bone.
Alveolar bone is in a constant state of flux
and the balance between bone formation and bone resorption is regulated by local and systemic influences.
Changes occur in alveolar
bone with aging that are similar to changes in the remainder of the
skeletal system.
Resorption activity is increased while bone forma-
tion is decreased and bone porosity may result.
A decrease in the
height of the alveolar bone results in less support for the teeth
which can eventually lead to tooth loss (Carranza, 1979).
Albanese
(1977) stated that periodontal disease involved the loss of toothbearing bone and affected about 80% of the adult population in the
United States.
Approximately 50% are edentulous by age 60 years.
Bone loss that occurs with age is accompanied by loss of alveolar
bone, but rapid bone loss with generalized osteoporosis can play a
major role in the progression of periodontal disease.
Alveolar~~
Osteoporosis
Groen, Manczel, and Shaprio (1968) examined 38 patients (mostly
female) with presenile osteoporosis to determine their periodontal
22
condition.
The age range was between 43 and 78 years.
Results of the
oral examination showed that 27 had severe periodontal disease,
had no signs of periodontal disease and nine were edentulous.
two
Both
osteoporosis and periodontal disease are clinical entities which are
multifactorial in etiology.
Results confirmed the theory that chronic
destructive periodontal disease and presenile osteoporosis often occur
together and the hypothesis was offered that the two conditions could
be manifestations of the same disease, localized in one case in the
jaw, and in the other case, in the spinal column.
A similarity
between the vertebral bodies and the alveolar bone as being structures
exposed to pressure more than muscular pull was mentioned and offered
as an explanation of the frequent coincidence of the two conditions.
The reduction of bone mass in the mandible following tooth
extraction is discussed by Rowe (1983) in relation to age-related bone
loss and the pathologic condition of osteoporosis.
Local factors that
cause continual reduction in the alveolar bone may be influenced by
systemic factors, thus creating an environment conducive to accelerated loss of mandibular bone.
The pattern of resorption, which con-
tributed to remodeling during growth, becomes more extensive with age
and may be the cause of tooth loss.
The physiologic condition of age-
related bone loss and the pathologic condition of osteoporosis need to
be considered by the dentist when treating the elderly suffering from
continual loss of bone support for dentures.
Ward, Stephens, Harrison, and Lurie (1977) examined 80 edentulous
patients to determine whether a relationship could be found between
the degree of alveolar bone resorption in the mandible and the degree
of osteoporosis as expressed by the metacarpal index.
Established
23
radiographic indices were used and no correlation was found between
osteoporosis and the amount of alveolar bone res portion.
Opposite
results were found in a similar study by Rosenquist, Baylink, and
Berger (1978), where the bone calcium mass in the radius of 12 edentulous male patients with mandibular bone loss·was measured.
The values
were compared with an age-matched control group with a healthy dentition.
The patients with alveolar bone loss had less radial bone mass
than tha controls.
skeletal mass.
Loss of radial bone reflects a decrease in
Local factors involved in alveolar atrophy would not
affect the radius.
Therefore, it was concluded that systemic factors
contributed to the bone loss both in the mandible and the radius.
Chestnut and Kribbs (1982) reported that edentulous patients
experienced a significant loss of mandibular alveolar bone.
They
suggested that if a relationship existed between generalized osteoporosis and alveolar bone loss, therapeutic measures used to treat
osteoporosis could possibly be of value in preventing dental bone
loss.
These observations were confirmed by Kribbs, Smith, and
Chestnut (1983) when the total body calcium and regional bone mass
(distal radius) were compared with the dental status (mandibular bone
density and height, and number of teeth lost) in 30 postmenopausal
(
osteoporotic women.
Results showed a significant relationship between
the density of alveolar bone and skeletal osteoporosis and it was
recommended that therapeutic measures for osteoporosis could have an
effect on alveolar bone loss.
Similar observations were made by Daniell (1983) when 208 women,
aged 60 to 69 years, were divided into three groups based on their
current degree of severity of osteoporosis; i.e., non-osteoporotic,
0 .
24
early osteoporotic, or osteoporotic.
The osteoporotic women had
required new dentures three times as frequently after age 50 years
than the non-osteoporotic women.
Results strongly supported the con-
cept that a weakened bone structure (osteoporosis) was a major factor
in postmenopausal tooth loss.
It was suggested that treatment of
women with diminishing bone mass may serve to preserve the alveolar
bone that anchors the teeth.
Alveolar~~
Calcium
Wical and Swoope (1974) stated that trabecular bone was the
primary source of available calcium to maintain serum calcium balance.
The sites that supply mobile calcium are the jaws, ribs, bodies of the
vertebrae and the ends of the long bones, with alveolar bone being
affected first.
Albanese (1983) proposed that the remodeling rate of
alveolar bone was considerably greater than that of the flat bones of
the skull and that osteoporosis caused by deficiencies of calcium was
often seen first in the alveolar bone.
Alveolar and finger (phalanx
S-2) bone densities were measured in 326 male and female subjects age
15 to 75 years.
The rise and fall of bone density in both sites was
parallel and indicative of normal age-related bone loss; however, peak
bone mass Mas attained and bone loss began at an earlier age in
alveolar bone.
Calcium intake was determined for females ages 45 to
70 years and were compared with their alveolar bone densities.
It was
concluded that optimal bone density was closely related to a dietary
calcium intake of 800 to 1000 mg per day.
Patients who had a
prolonged dietary calcium deficiency also demonstrated loss of alveolar bone before that of finger bone.
25
The mean daily intake of calcium in 44 edentulous subjects was
analyzed by Wical and Swoope (1974).
The group with minimal alveolar
bone resorption had a higher mean daily intake (933 mg) than the group
with severe resorption (533 mg); thus a correlation was found between
low calcium intake and alveolar ·bone resorption.
A more recent study,
done by Wical and Brussee (1979), investigated the relationship
between a daily calcium and vitamin D supplement and the rate and
extent of alveolar bone resorption following extractions of teeth.
A
total of 46 subjects were followed with clinical and radiographic
examinations for 1 year.
Half of the subject received a calcium
supplement and the other half a placebo.
The supplemented group had
an average of 36 percent less resorption and it was concluded that the
rate and severity of alveolar bone resorption is related to the
adequacy of calcium intake.
Supplementation was recommended for those
whose diet was deficient in calcium.
In an attempt to evaluate some possible predictors of osteoporosis, Renner, Boucher, and Kaufman ( 1984) analyzed the diets of 11
postmenopausal edentulous patients who had severe alveolar bone
resorption.
The diets were all deficient in calcium, despite the fact
that 50% took vitamin and mineral supplements.
I
It was concluded that
.
the diets were deficient for adequate skeletal homeostasis.
In an early study Krook, Lutwak, Whalen, Henrikson, Lesser, and
Uris {1972), supplemented the diets of 10 patients who had periodontal
disease with 1000 mg of calcium daily for 180 days.
After treatment
clinical and radiographic examinations showed an improvement in the
alveolar bone.
It was proposed by Krook et al. (1972} "that excessive
resorption of alveolar bone is the primary event in periodontal
26
disease and that it is caused by dietary calcium deficiency."
Uhrbom
and Jacobson (1984) repeated the experiment by Krook et al. (1972)
under more stringent conditions with a control group and detailed
documentation.
The periodontal status and radiographically registered
alveolar bone levels were evaluated and recorded for 66 patients at
the beginning and at the end of a six-month period.
divided randomly into two groups:
daily, and the other a placebo.
The patients were
one receiving 1000 mg of calcium
Results showed calcium consumption
was low among one-third of the patients (compared with the RDA of 800
mg) and no statistical difference was found between the two groups at
the beginning or at the end of the six months.
It was advised that
calcium supplementation for 180 days did not influence the periodontal
status.
Burt, Depaola, Nizal, and Vogel ( 1984) summarized the effect of
nutrition on periodontal status.
Alveolar bone loss accompanies the
osteoporotic condition seen in the elderly because it is one of the
most labile bones in the body and destructive periodontal disease is
associated with resorption of alveolar bone.
Geriatric oral health
problems may be associated with dietary deficiencies or excesses and
the rate of alveolar bone loss may be slowed down by the daily intake
l
of 1000 to 1500 mg of calcium per day, but it is not clear whether
calcium has any effect.
In conclusion it was stated that dietary
patterns have not been identified that promote periodontal disease.
High intake of vitamins and minerals to treat periodontal disease is
not recommended and more studies are needed to clarify the relationship between nutritional status and periodontal disease.
CHAPTER 3
Methodology
A correlational study was conducted to determine if there was a
relationship between alveolar bone loss and calcium intake in women
aged 40 to 60 years.
Sample Selection
The sample comprised 65 female patients from the general dental
practice of Dr. John K. Evens, with his consent.
Criteria used in
selection were that the patients had to be in the 40 to 60 year age
category and have a history of regular dental check-ups in the practice.
All subjects exhibited good general oral health and those with
current dental or medical problems were not asked to participate.
~
Collection Procedure
Data were collected over a five-month period from patients who
came in for their regularly scheduled recall appointments for a prophylaxis and check-up.
When they arrived for their appointment, the
research was briefly described and they were asked if they would like
to participate.
Upon agreement the patient was given a questionnaire
/
with a cover letter (Appendix A) explaining the research, and asked to
complete the form. During the appointment time the questionnaire was
reviewed, a brief interview about past calcium intake was conducted,
and calculations of alveolar bone loss were charted.
27
28
Questionnaire
A pilot study was conducted on 10 subjects resulting in revision
and refining of the questionnaire.
The data collected by use of the questionnaire (Appendix B)
included information about the weekly consumption of calcium-rich
foods, calcium supplementation, menopause, and familial history of
osteoporosis.
Interview
After the questionnaire was reviewed at the beginning of the
appointment a brief interview (Appendix C) was conducted to determine
tha pattern of life-time calcium consumption through dairy products.
Patients were asked if they had consumed dairy products during
childhood.
If they ans\otered yes, they were asked if they still did,
or when did they stop?
Each patient was assigned a dairy consumption
score based on the following criteria:
dairy consumption score
Hardly ever or never consumed.
........
Consumed up to age 20 years ••
• • 3
... • 2
Consumed up to age 40 years.
Consumed up to age 60 years.
Alveolar~~
• 4
....
• 1
Measurement
The degree of alveolar bone loss was calculated using the guidelines developed by Dunning and Leach (1960).
Each tooth was evaluated
clinically with the use of a periodontal probe to determine the degree
of bone loss and those results were compared to, and confirmed by, the
patient's radiographs.
29
An individual bone score was assigned to each tooth according to
the criteria established by Dunning and Leach (1960).
trates the scoring criteria.
Figure 1 illus-
These scores, ranging from zero to five,
were entered on a standard periodontal chart used in the dental practice (Appendix D).
A mean score was calculated representing the
average amount of alveolar bone loss for all present teeth, and each
patient was assigned a periodontal score.
A bone score of zero indicates no bone loss and a score of five,
complete bone loss.
Evaluation of alveolar bone loss is difficult as
there are many variables.
Tilting of teeth in their sockets, differ-
ences in the actual length of the roots of the teeth, and aberrations
in the radiographs are some of the variables.
For the purposes of
this study a periodontal score from 0 to 2.0 was not considered
unusual bone loss.
Scores of 2.1 to 5 were considered an indication
of possible periodontal disease.
Statistical Methods
Data from each questionnaire were tabulated and entered on a
master chart.
The daily dietary intake of calcium was calculated from
the weekly consumption entered by the subjects.
Milligrams per
serving (Appendix E) were totaled and then divided by seven to obtain
the milligrams of calcium ingested daily.
milligra~s
All of the subjects entered
of supplemental calcium intake on a daily basis so no
further calculations were necessary.
The dietary and supplemental
scores were added together for a total daily intake of milligrams of
calcium.
Information about the type of supplement taken, for how long
Q '
30
Figure 1
Alveolar Bone Loss Scoring System
No bone loss •
..... .....................
0
Incipient bone loss or notching of alveolar crest
Bone loss approximating one-fourth of root length or pocket
formation one side not over one-half root length
•
Bone loss approximating one-half of root length or pocket
formation one side not over three-fourths root length;
mobility slight
•••••••••••••••••••
•
4
•
...
2
3
Bone loss approximating three-fourths of root length or pocket
formation one side to apex; mobility moderate • • • • •
4
Bone loss complete; mobility marked
5
• • • • • • • • • • • • • • •
31
taken, and who prescribed the supplement, were entered on the chart.
Data about menopause, whether it had occurred naturally or surgically,
and if estrogen replacement therapy was used, were charted.
In addition to entering the mean scores of alveolar bone loss for
each subject, those periodontal scores were divided into five groups,
ranging from the least severe (1) to the most severe (5) amount of
bone loss for the sample.
dontal code.
The number assigned was called the perio-
The purpose was to allow for a larger variety of statis-
tical analyses.
The groups were as follows:
Periodontal Code
1.0 to 1.5
1.6 to 2.0
2.1 to 2.5
2.6 to 3.0
3.1 to 3.5
.
• • . . . . . . • . . . .
. • .......• • . .......
..• .......• . .• .
.
......• .• •
....
• . . . . . . . . . . . . • . .
1
2
3
4
5
The mean periodontal scores were calculated for the aged 40 to 49
year old group and the aged 50 to 60 year old group.
In addition,
mean periodontal scores were tabulated for those subjects taking
estrogen and those subjects not taking estrogen in each age group.
A data file was created using the Statistical Package for the
Social Sciences (SPSS) program.
Frequency, percentage, and mean
scores were calculated for pas£ dairy consumption, periodontal score,
daily dietary calcium intake, daily calcium supplemental intake, total
daily calcium intake, familial history of osteoporosis, and the periodontal code.
The kind of supplement, how long it had been taken, who
32
prescribed it, and statistics concerning menopause were tabulated by
hand.
Pearson's Product Moment Correlation Coefficient was used to
determine if there were relationships between the periodontal score
and either the daily dietary calcium intake or the total daily calcium
intake.
Chi square tests were used to determine any significant
differences between the periodontal code and either familial history
of osteoporosis or past dairy consumption.
The minimum accepted level
of significance for all of the computer analyses was .05 or less.
CHAPTER 4
Results and Discussions
The research undertaken was designed to determine if a significant relationship could be found between calcium and alveolar bone
loss in 65 women aged 40 to 60 years.
Alveolar~~
.aru! Calcium
The alveolar bone loss of the subjects were coded into periodental scores and the calculated mean score was 2.06.
According to
the parameters set, the mean score indicated that the group, as a
whole, did not have unusual alveolar bone loss for their age.
There
was a t-lide range of individual scores, from .22 to 3.27; thus part of
the sample had scores above 2.0, indicating a tendency for alveolar
bone loss.
The mean scores for daily dietary calcium intake (577 mg), daily
supplemental calcium intake (491 mg) and the total daily calcium
intake (1069 mg) were determined.
Pearson's Product Moment Correlation Coefficient was used to
determine if significant relationships existed between periodontal
/
scores and the dietary calcium intake both with and without supplements of calcium.
The results showed no significance and are in
agreement with Uhrbom and Jacobson (1984) who found no difference in
alveolar bone levels after 180 days of controlled calcium
supplementation.
33
34
Periodontal
~
.aru1. Alveolar
~ ~
Periodontal code data were tabulated and are presented in Table
1.
According to the periodontal codes, 44.6% of the sample had bone
loss of 2.0 or less which was considered normal for this age group.
More severe bone loss was found in an additional 52.3% of the sample,
ranging from 2.1 to 3.0.
An additional 3.1% had bone loss ranging
from 3.1 to 3.5, indicating a more advanced state of bone loss.
Since
no correlation was found between calcium intake and the degree of
alveolar bone loss, it may be concluded that factors other than calcium intake had caused more than half of the sample to have alveolar
bone levels indicative of some degree of periodontal disease.
Calcium Requirement
The RDA of 800 mg was not met by 23 (35%) of the subjects.
Combination of the mean daily dietary intake of calcium (577 mg) with
the mean daily supplemental calcium intake {491 mg) resulted in a mean
total daily intake of 1069 mg of calcium which surpassed the RDA of
800 mg.
Heaney et al. (1977) stated that 1.241 g of calcium daily was
necessary to maintain adequate calcium balance in the perimenopausal
woman. The mean total daily intake of calcium of the sample (1069 mg)
does not meet this recommendation, but 32 subjects, almost half of the
sample (49%), had individual total daily calcium intakes of 1241 mg or
more.
Calcium Supplements
Data tabulated from the questionnaire and presented in Table 2,
indicated that 37 (56.9%) of the subjects took calcium supplements and
28 (43.1%) did not.
35
Table 1
Periodontal Code
Periodontal Code
Frequency
Percentage
1
(1.0- 1.5)
16
24.6
2
(1.6 - 2.0)
13
20.0
3
(2.1 - 2.5)
21
32.3
4
(2.6 - 3.0)
13
20.0
5
( 3.1 - 3.5)
2
_l:1
65
100.0
Total
36
Table 2
Calcium Supplement Intake
Frequency
Percentage
How Many Take Supplements
Yes
37
56.9
No
28
43.1
65
100.0
Total
Length of Time Supplement Taken
1 Year or Less
27
73.0
2 Years
5
13.5
3 Years
2
5.4
10 Years
2
5.4
25 Years
1
2.7
37
100.0
Health Food Store
1
2.7
Husband
1
2.7
Physician
17
45.9
Self
18
48.7
37
100.0
Chelated Calcium
2
5.4
Calcium Lactate
3
8. 1
32
86.5
37
100.0
Total
Who Prescribed Supplement
Total
Type of Supplement Taken
Calcium Carbonate
Total
37
Calcium supplementation was the most common method used to attain
a satisfactory daily intake of calcium by the sample.
Dosti ( 1986)
reported that high doses of calcium supplements may interfere with the
balance of other nutrients in the body.
All but one of the 32 sub-
jects that met the recommendations of Heaney et al. ( 1977) of 1.241
g/day took calcium supplements.
Conversely, all of the 23 subjects
that failed to meet the RDA of 800 mg did not take calcium supplements.
Data indicated that the subjects who took calcium supplements
met the RDA of 800 mg.
Hany also met the increase to approximately
1200 mg/day as recommended by Heaney et al. (1977), Spencer et al.
( 1984) and Eaton and Konner ( 1985).
The following analyses will be limited to those 37 (56.9%) subjects that took calcium supplements.
Supplements had been taken for 1
year or less by 27 (73%) of the subjects.
tion was:
The rest of the distribu-
2 years (5 subjects, 13.5%); 3 years (2 subjects, 5.4%); 10
years (2 subjects, 5.4%); and 25 years (1 subject, 2.7%).
Marcus
( 1982) stated that changes in trabecular bone begin as early as the
third decade of life, necessitating an increase in calcium intake at
that time to maintain calcium balance.
The recent publicity about
calcium and osteoporosis apparently has had a positive effect and it
seems reasonable to assume that some of the 73% that had taken supplements for a year or less were influenced by this factor.
Since sup-
plementation was the most common method utilized by the subjects to
meet the RDA, the recent use of supplements indicates that many of the
sample were not receiving enough calcium during their third decade of
life.
Only three subjects had taken calcium supplements for 10 years
or more.
38
Calcium supplements were self-prescribed by 18 {48.7%) of the
subjects because they had heard or read that women needed calcium.
Many of the subjects \iere not sure how many milligrams they should
have daily.
Frequently, the amount taken was not the recommended
amount to supplement their dietary intake of calcium.
Physician-
prescribed calcium supplements were taken by 17 {45.9%} of the subjects.
Recommendations from medical sources resulted in a more satis-
factory total daily calcium intake for those 17 subjects.
Two other
sources of calcium supplement recommendations were indicated:
one
subject took calcium supplements recommended by her husband, and the
other, calcium supplements prescribed at a health food store.
Calcium carbonate was taken by 32 of the subjects (86.5%) and was
the type of supplement most often taken.
Calcium lactate was taken by
3 subjects (8.1%) and chelated calcium by 2 of the subjects (5.4%}.
Spencer et al. { 1984) recommended
calcium
carbonate as the ideal
choice for a supplement because it contains 40% calcium that is
available for absorption.
Calcium lactate contains only 10% calcium.
~
Dairy Consumption
The frequencies and percentages for the interview data collected
about past dairy consumption are presented in Table 3.
Results showed
that 32.3% (21 subjects) of the sample had never been consumers of
,•
dairy products.
Most of the subjects indicated that they didn't like
milk during childhood and still don't.
The majority of the women (29
subjects, 44.7%) had stopped consuming dairy products by the age of 40
years.
Many said that they had stopped drinking milk when they
graduated from high school or after the birth of their last child.
39
Table 3
•.
Past Dairy Consumption Scores
Frequency
Score
Percentage
4
(Hardly ever or never consumed)
21
32.3
3
(Consumed up to age 20 years)
12
18.5
2
(Consumed up to age 40 years)
17
26.2
1
(Consumed up to age 60 years)
15
23.0
65
100.0
Total
40
Most of the women felt that dairy products were fattening and added
too much cholesterol to their diets.
These were the primary reasons
given for the elimination of dairy products.
The remaining 23% { 15
subjects} of the sample indicated that they had always consumed dairy
products and continued to do so.
Recker and Heaney {1985) recommended that milk was important to
bone health and possibly more effective than calcium supplements and
Dosti { 1986} stated that the best channels for proper absorption of
calcium are from food sources.
The majority of the sample (77%) did
not consume dairy products in order to meet the RDA for calcium, and
had to rely on other dietary sources of calcium and/or calcium supplements.
Only 23% took advantage of dairy products as a source of
calcium.
The past dairy consumption score (Table 3) and the periodontal
code (Table 1) were analyzed statistically using Chi square to determine if there was any difference between those subjects that consumed
milk and those that did not and the degree of alveolar bone loss
present.
No statistical significance was found which is in agreement
with Burt et al. (1984), who stated that it was not clear whether
calcium had any effect on alveolar bone loss, and that more studies
were needed to clarify the relationship between nutritional status and
periodontal disease.
Osteoporosis
The majority of the sample (69.2%, 45 subjects) indicated that
there was no family history of osteoporosis, while five said that
there was and 15 indicated that they didn't know.
Osteoporosis is
41
multifactorial in etiology but it is known that it particularly
affects Caucasian women after the menopause (Schwartz et al. ( 1985).
The sample was composed entirely of Caucasian women and only five
indicated a familial history of osteoporosis.
about inheritance of osteoporosis.
The literature is vague
Chi square analysis showed no
significance between alveolar bone loss and known family history
concerning osteoporosis.
Menopause
Data from the questionnaire indicated that 54% of the sample were
postmenopausal, 31% from natural causes and 23% due to surgery.
The
data are presented in Table 4.
All of the women in the 50 to 60 year
age group were postmenopausal:
20 naturally and 9 due to surgery.
In
the 40 to 49 year age group, 6 were postmenopausal, all as a result of
surgery.
A total of 16 subjects were on estrogen replacement therapy:
4
in the 40 to 49 year age group and 12 in the 50 to 60 year age group.
Heaney et al. ( 1978) reported that postmenopausal women not taking
estrogen had calcium requirement of 1.504 g/day and those taking
estrogen had a daily calcium requirement of .990 g/day.
The mean
total daily.calcium intake for the sample not taking estrogen was 989
mg in the 40 to 49 year age group and 933 mg in the 50 to 60 year age
group.
Neither group met the recommendation of Heaney et al. (1978)
of 1.504 g/day.
The sample taking estrogen had a total mean daily
calcium intake of 738 mg for the 40 to 49 year age group and 1120 mg
f'or the 50 to 60 year age group.
A recommendation of .990 g/day was
proposed by Heaney et al. ( 1978) for \-lomen taking estrogen and this
42
Table 4
Experimental Data Related to Postmenopausal Women
Age in Years
40 to 49
50 to 60
Cause of Menopause
Surgical
6
9
Natural
0
20
4
12
Estrogen Replacement Therapy
Mean Total Daily Calcium
With Estrogen Therapy
738 mg
1120 mg
Without Estrogen Therapy
989 mg
933 mg
1.86
2.39
With Estrogen Therapy
1. 89
2.23
Without Estrogen Therapy
1. 79
2.50
Mean Periodontal Score
43
was met by the 50 to 60 year age group but not by the 40 to 49 year
age group.
The mean periodontal score in the 50 to 60 age group was 2.39.
Subjects who were taking estrogen had a mean score of 2.23, and those
not taking estrogen, a mean score of 2.50.
The decreased periodontal
score of those subject taking estrogen (2.23) indicated that there was
less alveolar bone loss and suggested a possible relationship between
estrogen therapy and alveolar bone loss.
These findings were in
agreement with those of Richelson et al. (1984) who proposed that most
of the bone loss following natural menopause was attributable to
estrogen deficiency rather than to aging itself.
Opposite results
were shown with the sample taking estrogen in the 40 to 49 age group.
The mean periodontal score (1.86) was increased in the estrogen
therapy group to 1.89 and was decreased to 1.79 in those not taking
estrogen.
"
'
CHAPTER 5
Summary, Conclusions and Recommendations
The main purpose of this study was to determine if there was a
relationship between alveolar bone loss and the calcium intake of
women aged 40 to 60 years.
The data were collected by means of a
questionnaire, an interview and an oral examination to determine the
degree of alveolar bone loss.
Osteoporosis and periodontal disease are pathologic conditions in
which loss of bone occurs.
Early detection is difficult and there is
no single established treatment plan due to the insidious nature of
both diseases.
Only when clinical manifestations occur is the patient
aware that there is something wrong.
Early alveolar bone loss may be
an indication of a suseptibility to osteoporosis.
Calcium is a mineral necessary for the strength of bone and is
currently promoted as being very important in the prevention of postmenopausal osteoporosis.
This research analyzed the present and past calcium intake of
perimenopausal, menopausal, and postmenopausal women.
The degree of
present alveolar bone loss was/determined through clinical and radiographic examinations.
A total sample of 65 women, aged 40 to 60
years, were surveyed and examined.
All of the women who participated
were enthusiastic and had many questions about calcium requirements.
The data were statistically analyzed by hand tabulation and the
SPSS computer program and results have been presented in this report.
44
45
Conclusions
Hypotheses:
The alternate hypothesis that was developed for this research
was:
Tbere Hill
~a
significant relationship between calcium intake
G51 alveolar hQn.e_ ~ .1n. women . ~ l!.Q. .t2.
.6.0. years.
The alveolar bone loss for the sample was expressed as a mean
periodontal score of 2.06.
A score of 2.0 for women aged 40 to 60
years was not considered unusual alveolar bone loss.
As a group the
women had relatively healthy supporting structures for their teeth.
The daily dietary calcium intake and the periodontal score for
each subject and the total daily calcium intake and the periodontal
score for each individual were tested for correlation using Pearson's
Product Moment Correlation Coefficient and a .05 level of significance
was acceptable.
No significance was found and the alternate hypothe-
sis was rejected.
The null hypothesis was accepted:
relationship between calcium intake
~
~
There~~
alveolar
significant
~ ~
in women
M .t..Q. .6..Q. years.
Obiectiyes:
I
Degree' .2!. Alveolar ~ .I.&M in Women .w.s1 .!Ul. ,iQ. .6.0. Years.
Half
of the sample did not have bone loss over 2.0 which was considered
normal for the age group.
More severe bone loss was observed in the
other half, which was indicative of some degree of periodontal
disease.
Since no correlation was found between calcium intake and
alveolar bone loss, it may be concluded that other factors caused the
alveolar bone loss.
46
Daily Calcium Intake
~ ~
RQA Q! ~ mg.
The mean daily
calcium intake met the RDA only when dietary calcium and calcium
supplements were taken in combination.
Dietary sources alone were not
sufficient to meet the RDA.
Calcium Supplements .aw1 Women
~
llllU Years.
More than
half of the subjects took calcium supplements and, in most cases, the
supplements brought the total daily calcium intake up to acceptable
levels for women in the age group of 40 to 60 years.
Supplementation
was the desired method of obtaining calcium because the subjects felt
dairy products would cause weight gain and increase their cholesterol
intake.
About half of the women self-prescribed their calcium supple-
ments and were not sure about the amount of milligrams they needed
daily.
The other half were taking calcium supplements prescribed by a
physician and the daily amounts taken were closer to recommended
amount of calcium for women aged 40 to 60 years.
Most of the subjects had been taking calcium supplements for one
year or less.
This may have been a response to the recent publicity
concerning women and their calcium needs.
Peak bone mass is attained
at approximately 35 years of age and total daily calcium intake should
be of
conc~rn
before then in order to obtain maximum results in
prevention of osteoporosis.
Calcium carbonate was the supplement
taken by most of the subjects.
Consumption .Qf. Dairy Products
.Q¥.
Women
~
!l.Q. .t..Q. .6.Q. Years.
23% of the sample consumed dairy products on a regular basis.
Only
Approx-
imately one-third of the subjects stated that they never had consumed
dairy products and the remaining 44% basically stopped dairy consump-
47
tion before the age of 40.
The main reason given for non-consumption
was weight gain.
Family History 2!. Osteoporosis Md. Alyeolar
~ .~.&..§.§..
Despite
the fact that the sample was comprised entirely of Caucasian women,
only five indicated a family history of osteoporosis and no significance was found between that and alveolar bone loss.
Postmenopausal Women. Estrogen .aru1 Alveolar
~
I.m.
t1uch
controversy exists over the benefits of calcium versus the benefits
and risks of estrogen therapy in treating postmenopausal osteoporosis.
The results showed some indication that women taking estrogen had less
alveolar bone loss, therefore estrogen replacement therapy may prove
beneficial in treating both alveolar bone loss and postmenopausal
osteoporosis.
Recommendations
Recommendations for further research are:
1.
A study of the dietary and supplemental calcium intakes of
women under the age of 40 years to determine if their calcium
intake is enough to allow maximum peak bone mass development.
2.
An in-depth dietary study of women, aged 25 to 75 years, to
determine their calcium intakes in relation to variables such
as protein, vitamin D and phosphorus that can influence the
bioavailability of calcium.
3.
Survey a larger sample of women on estrogen replacement
therapy to determine if there is less alveolar bone loss than
in a comparable group of women who are not taking estrogen.
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Eaton, s. Boyd; Konner, Melvin.
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52
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APPENDICES
53
54
APPENDIX A
Cover Letter
55
Dear Patient,
I am currently enrolled at California State University at
Northridge as a candidate for a Master's Degree in Nutrition. The
topic of my research is the relationship of calcium intake to bone
loss around the teeth. There is some feeling that this condition can
be an early indication of a tendency toward osteoporosis. Hy study is
limited to women ages forth to sixty, since we seem to be the most
likely candidates for osteoporosis in later years.
Your participation in this study would be greatly appreciated.
It would involve completing the following questionnaire and allowing
me to take measurements on certain teeth to determine if there is any
bone loss patterne This is a relatively simple procedure and can be
accomplished quickly and easily as I clean and examine your teeth.
If you would like to participate, please fill out the questionnaire on the following pages which is designed to assess general
dietary and health patterns. All information collected will be
completely confidential.
Any questions about the research or the questionnaire can be
answered during your appointment. Thank you for your cooperation and
help.
Sincerely,
ifau_v~
Elaine Paulson, R.D.H., B.S.
56
APPENDIX B
Questionnaire
57
QUESTIONNAIRE
In the space provided, please indicate how many servings of each item
you presently consume weekly. Estimate the amounts to the best of
your ability. (1 cup = 8 oz)
Servins Size
Hille
1 cup
Buttermilk
1 cup
Hill<:shakes
1-1/2 cups
Chocolate Hilk
1 cup
Yogurt, lmvfat:
cup
plain
fruit flavored
1 cup
Cheese:
grated parmesan
1/4 cup
swiss or gruyere
1 oz.
all other hard cheeses
(cheddar, jack, mozzarella, muenster,
american, blue, etc.)
1 oz.
ricotta
1/2 cup
cot tag·3 cheese
1/2 cup
4 oz.
Tofu
Ice cream or Ice milk
1/2 cup
I
Canned sardines (vtith bones)
3 oz.
,•
Canned salmon (\·lith bones)
3 oz.
Spinach or Broccoli, cooked
1/2 cup
Collards, turnip greens,
bokchoy, cooked
1/2 cup
~'leekly
Consumpt; on
Q
'
58
If you are presently
follm,rinz:
a.
ta~cing
a Calcium supplement, please anm·T:3!' the
Hhat type of supplement are you takinG?
Calcium Carbonate (Caltrate 500, Cal~itab,
Biocal, Cal-Sup, Calciday, Oscal, Tums,
Allca-2 ohe\va ble, etc. )
Calcium Lactate
Calcium Gluconate
Chelated Calcium
Dicalcium Phosphate
Dolomite
Bone ileal
Other
(please specify)
If you do not
~now
the type,
please state brand nar.le.
b.
Hot-r many milligrarJs do you take daily?
or vleekly?
c.
How long have you been taking a Calcium
supple1:1ent?
d.
Uho prescribed the supplement?
Physician
Self
Other (~lease specify)
59
If you are postnenopausal, please check the following statements
that are applicable:
a.
How menopause occurred:
naturally
surgically
b.
Estrogen replacement therapy after menopause
Do you have a family history of osteoporosis?
yes
no
don't know
Thank you!
60
APPENDIX C
Interview
61
Interview
Did you consume milk and/or dairy products as a child?
yes
no
If yes, do you still consume dairy products?
yes
no
If no, at what age did you stop?
Subject was given a dairy consumption score:
Hardly ever or never consumed •
....• 4
Consumed up to age 20 • • • • • • • • • • 3
Consumed up to age 40 • • • • • • • • • • 2
Consumed up to age 60 •
(
• • 1
62
APPENDIX D
Periodontal Chart
63
Patient Name: _ _ _ _ _ _ _ __
1
2
S
4
I
1
I
I
I
11
11
12
13
14
15
11
-
·~~~~nn.~D
tL
'T
... •
~
1
•
to"
~
i
-
I~~
t
rOl
~~
,.
!!t,
~!!I
(~0J~j} ~ ll~tJ~~L~L~Q[~n i[~OL:t~ ~. ~ Il~PL~W~~®
to
h
~
~ ~
u v.v~~
H
v
u
t ~ tv ~ ~
\j \]
·-
·(\
fl~8~n
rv
~~~ ~ ~
'
,_
Y'-'
j,-.
~
~
,.
,.
17
~ i-~~~t~;, itl;ur~tr~wm~
I
[ pr
~ ~*~n~'ll: ny~r~p~
~~w
32
31
30
rrr~tr
21
21
27
21
25
u '
24
23
~
21
20
~ ~ .~
22
21
20
N1
~
-
~ i1£~P [~b
w li\1
1t
11
\N
17
-
64
APPENDIX E
Milligrams of.. Calcium in Dietary
Items of Questionnaire
".
65
Serving Size
Buttermilk
HG'. of Calcium
1 cup
300
cup
285
Milk shakes
1-1/2 cups
425
Chocolate Hilk
1 cup
284
plain
cup
415
fruit flavored
cup
345
grated parmesan
1/4 cup
300
swiss or gruyere
1 oz.
272
all other hard cheeses
(cheddar, jack, mozzarella, muenster,
american, blue, etc.)
1 oz.
200
ricotta
1/2 cup
337
cottage cheese
1/2 cup
77
Yogurt, lov1fat:
Cheese:
Tofu
4 oz.
Ice cream or Ice milk
1/2 cup
Canned sardines (with bones)
3 oz.
372
Canned salmon (with bones)
3 oz.
167
Spinach or Broccoli, cooked
1/2 cup
75
Collards, turnip greens,
bokchoy, cooked
1/2 cup
150
145
88