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Nutrition, dietary guidelines andoptimal periodontal health
E L I Z A B E T H K. KA Y E
Nutrients derived from the diet perform as antioxi-
dants, co-enzymes in energy production and meta-
bolic processes, and components of tissue structures
that keep the bodys systems functioning properly
and maintain good overall health, including oral
health. Nutrients that are thought to be especially
important for maintaining the periodontium have
been the focus of epidemiological studies for many
years. For example, folate, vitamin A and vitamin C
ensure proper development and repair of mucosal
and connective tissues; protein, calcium and phos-
phorus are incorporated into the structures of
collagen, teeth and bone; omega fatty acids and
vitamin D help to regulate immune function (22, 47).
Epidemiological studies have not consistently found
significant associations between periodontal disease
incidence or prevalence and the intake levels of theseand other nutrients (66). However, it is important to
consider the range of nutrient intakes or biomarkers
in any given study population and how they relate to
recommended levels when evaluating the evidence.
This information is often lacking in studies of nutri-
tional associations in periodontal research.
There are a number of reasons why baseline levels
of nutrient intake or biomarkers of nutrient avail-
ability influence the likelihood of detecting an asso-
ciation. Relationships between nutritional status and
disease outcomes are usually non-linear and typically
exhibit a threshold effect (14). When two or moregroups defined by nutritional status are contrasted,
there is a much lower chance of finding significant
differences in disease if all groups are adequately
nourished. Blood levels of some nutrients (e.g. cal-
cium) are under negative feedback loop regulation by
hormones, and associations with disease are more
likely to be detected at extreme levels. Finally, asso-
ciations between a single nutrient and disease may
be dependent on the adequacy of a second or even
multiple nutrients, as seen in the inter-relationships
of calcium, vitamin D and protein with respect to
bone mineral density (15).
One of the goals of nutritional research in general,
and nutritional epidemiology in particular, is to be
able to formulate population dietary guidelines and
recommended intake levels that will promote overall
health, not just address nutritional deficiencies. As
more research on nutrition and multiple disease
outcomes is performed, including on periodontal
disease, the cumulative knowledge is used to revise
definitions of an optimal diet. The recommendations
for vitamin D are an example of this process. The
recommended dietary intake (RDA) for vitamin D in
adults was previously 400 IU day or less, a level
originally based on the amount of cod liver oil needed
to prevent rickets (59). However, it is now known thatvitamin D status is associated with a large number of
health outcomes, including cancer, cardiovascular
disease, inflammatory diseases, motor function and
the occurrence of falls. Current intake recommen-
dations, up to 1000 IU day, take this multidisci-
plinary research into account (48). There has also
been an upward shift in the serum vitamin D level
that is considered optimal (48).
In order to evaluate and revise recommended die-
tary intakes, it is necessary that intake ranges in a
study population are well described. This review of
studies of nutrition and periodontal disease aims tomove beyond the question of whether or not signif-
icant associations exist, and examine the research
needed to address the questions below.
How did the intake or biomarker ranges in the
study population influence nature of the associ-
ation, or lack of one, that was reported?
Can we conclude that current recommended
dietary intakes are sufficient to avoid increased
risk of periodontal disease onset and progression?
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Periodontology 2000, Vol. 58, 2012, 93111
Printed in Singapore. All rights reserved
2012 John Wiley & Sons A/S
PERIODONTOLOGY 2000
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If not, do higher doses in the form of dietary
supplements confer a benefit?
A number of methodological issues in terms of the
study design, collection and analysis of dietary data
also affect the interpretation of study results and the
ability to reach conclusions about dietary recom-
mendations. These issues will be briefly discussed
first, with reference to more thorough reviews.
Study design
Design strategies for clinical and epidemiologi-
cal studies can be classified as observational or
experimental (intervention). The observational study
category includes ecological, cross-sectional, case
control and cohort (prospective) studies and case
reports. Heaton & Dietrich (25) provides an in-depth
review of each designs strengths and weaknesses
elsewhere in this volume. The most common study
designs that have been used in studies of nutrition
and periodontal disease fall into one of the categories
described briefly below. Major strengths and limita-
tions are noted.
Observational studies
Cross-sectional
Exposure and disease outcome in individuals is as-
sessed at single point in time.
Strength: useful for generating hypotheses; gen-
erally less expensive than cohort and experimen-tal studies
Limitation: inability to establish the temporal
sequence of exposure and disease events.
Cohort
The exposure status of individuals is known at study
onset, and participants are followed over time to as-
sess new cases of disease.
Strengths: direct measurement of disease events
establishes the temporal sequence of exposure
and outcome; efficient for studying rare expo-
sures; can study multiple diseases.
Limitations: expensive; large losses to follow-up
may affect validity.
Experimental studies
Intervention studies
The investigator assigns treatment (exposure) to
participants, who are then followed to measure dis-
ease events. Not all intervention studies use random
allocation of treatment or have a control group.
Randomized controlled trial
The investigator randomly assigns treatment or
control status to participants who are then followed
to measure disease events.
Strength: successful randomization ensures that
the treatment and control groups are comparableexcept for the exposure being studied.
Limitations: many of the limitations of cohort
studies also apply to intervention studies; in
addition, participants may not be representative
of the general population; harmful exposures
cannot be studied using intervention studies.
Although it has often been noted that more cohort
and experimental studies are needed (51), cross-
sectional studies still outnumber cohort and inter-
ventional studies in the literature on nutrition and
periodontal disease.
Methods to assess dietary intakeand nutritional status
Research into diet and periodontal disease requires
valid and reliable means to measure and describe
dietary intake. The optimal nutritional assessment
tool for a specific research question depends on
many factors, including whether one wishes to esti-
mate recent diet or habitual diet, total diet vs. a few
key nutrients or intake vs. nutrient availability, plusthe motivational level of the participants and the
expense. However, gathering and interpreting infor-
mation about an individuals food intake is fraught
with difficulties. Diet is a complex, ever-changing
mixture of nutrients, non-nutritive compounds and
contaminants that can have significant beneficial or
harmful effects on health. Furthermore, the reporting
of food intake by study participants is susceptible to
memory errors and bias, and all dietary intake tools
rely to some degree on memory and cooperation for
accurate information. Nutrient intake and biological
availability are not necessarily equivalent, as a per-sons age, medical conditions, meal composition and
other factors can affect the bodys ability to absorb
and utilize nutrients.
Several tools for assessing dietary intake and
nutritional status exist for use in clinical and epide-
miological studies. Each has unique assumptions,
strengths and limitations. Dietary assessment and
analysis methods and nutritional biochemical mark-
ers have been extensively described (21, 42, 49, 76).
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The primary strengths and limitations of those most
commonly used in epidemiological studies of nutri-
tion and periodontal disease are summarized below.
24 h recall
In this method, a trained interviewer elicits from the
study participant a detailed list of all foods and bev-
erages consumed within a 24 h period. As the datagathered refer to diet within the past day, little can
be assumed about the long-term diet, and foods that
are eaten infrequently but contribute significant
amounts of a nutrient (e.g. carotenes) are likely to be
missed. The 24 h recall method imposes relatively
little burden on the participant, making it easier to
obtain a representative sample of the population,
provides no opportunity for the participant to ac-
tively change his or her eating behavior, and the re-
call period is brief and recent enough that, with
prompting, most people can easily remember what
they ate. The principal use of 24 h recall in research is
to describe mean nutrient intakes at the population
level. The cross-sectional NHANES III and NHANES
surveys since 1999 derive nutrient intake data by 24 h
recall (1, 50, 53, 54).
Food diaries
The problem of memory encountered with a 24 h
recall can be bypassed by having the participant
prospectively write down details of each food and
beverage as it is consumed. Accuracy is enhanced ifall portions are weighed or measured. Like the 24 h
recall method, the information only represents cur-
rent diet. Typically, 37 days of recording are rec-
ommended, with both weekday and weekend days
represented. Recording for periods longer than a
week introduces participant burden, which may have
the adverse effects of changing the very diet that one
wishes to assess, and increasing errors of omission,
but these problems can be alleviated by splitting the
recording period into several short, non-consecutive
intervals. Food diaries are often the reference method
when validating food frequency questionnaires.
Food frequency questionnaires
A food frequency questionnaire consist of a list of
commonly eaten foods and beverages, and a response
grid for each item on which the respondent checks off
their typical frequency of consumption, usually over a
6-month period or longer. Absolute nutrient intakes
derived from food frequency questionnaires (FFQs)
are often under-estimated relative to the other
methods. Food lists are not comprehensive, fewer
details are collected about the items on the list, the
consumption frequency response grid is often col-
lapsed into categories (e.g. 13 times month, 2+
times day), and items often combine several foods
that have similar nutrient content but may not be
eaten with equal frequency. Because of these limita-
tions, it is recommended that rank values or percen-tiles of nutrient distributions be used rather than
absolute values to define intake level. The analysis of
food group consumption frequency is also possible.
FFQs are often self-administered, with minimal
instruction time needed, and are formatted so the
completed forms can be scanned electronically. These
properties make them very useful in large-scale epi-
demiological studies. FFQs readily allow study of
associations of disease with food groups in addition to
nutrients. Pitiphat et al. (62) and Merchant et al. (44)
derived intake data on types of alcoholicbeverages and
whole-grain foods, respectively, from FFQs that com-
prised more than 100 food items. Shortened FFQs can
be developed that impose less of a burden on the
participant if all that is desired is a measure of the in-
take of one specific food, such as green tea (36), or
nutrients found in a limited number of foods, such as
calcium and vitamin D (52). However, these shortened
FFQs limit theability to control for other nutrients that
act as confounders of the dietdisease relationship.
Biomarkers
Assessment of dietary intake alone is not always the
best indicator of a persons nutritional exposure. As
noted above, all methods used to measure food in-
take have issues regarding memory or participant
motivation that introduce error and bias. In addition,
the amount of a nutrient that is actually available for
use by the bodys tissues is influenced by many
factors other than intake, including endogenous
production, variation in intestinal absorption, nutri-
entnutrient and nutrientmedication interactions,
disease status, and smoking. To be a useful biomar-
ker, the level of a nutrient or its metabolite in bodyfluids and tissues must correlate moderately well
with changes in dietary intake over a wide range of
intakes. The ability to measure nutrient availability
objectively is the main advantage of using a nutrient
biomarker to predict intake, but not all nutrients have
meaningful biomarkers (42).
In summary, the 24 h recall and food record
methods provide the best information about absolute
intakes but only measure current diet. The FFQ is
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better structured to assess habitual diet, but this
comes at the cost of reduced accuracy. The ability of
a biomarker to reflect recent or long-term dietary
intake is nutrient-specific. Cohort and experimental
studies can circumvent these weaknesses to some
extent by using the tools in combination and at re-
peated intervals throughout the study.
Analysis of dietary intake data
Compliance with dietaryrecommendations
Information derived from FFQs, 24 h recall and food
diaries can be converted into estimates of daily
nutrient intakes by use of food composition tables, or
into patterns of food group consumption. Estimates
of nutrients and food groups can then be compared
with dietary guidelines and recommended intakes to
evaluate the adequacy of the diet. In the USA, severalstandards have been established for this purpose. The
estimated average requirement (EAR) is the value that
is estimated to meet the requirements of 50% of the
population, and is used to estimate the prevalence of
intakes that are likely to be inadequate (56). The data
used to define the EAR consider multiple health
outcomes, not only nutritional deficiencies. The rec-
ommended dietary allowance is the EAR plus two
standard deviations, and represents the intake level
that will meet the needs of 9798% of the population
(56). Not all nutrients have an RDA because there
may be a lack of studies or because the existing re-search is inconclusive. If an RDA is not defined, there
may be an adequate intake value for the nutrient; this
is the level that is believed to meet the needs of all the
population (56). RDAs and adequate intake values are
appropriate benchmarks against which an individ-
uals nutrient intakes are evaluated.
Other guidelines exist for evaluating diet on the
basis of food groups. The US Dietary Guidelines for
Americans and USDA Food Pyramid Guide provide
recommendations for composition and number of
servings per day from the grain, vegetable, fruit, milk
and meat bean food groups (79). The healthy eating
index is an index of overall diet quality that uses the
food pyramid recommendations to score overall diet
and ten dietary components (32).
Adjustment for covariates
Most observational studies adjust estimates of peri-
odontal disease risk for other characteristics that
potentially confound the results. This is important
because higher intakes of certain nutrients and foods
may be surrogate measures for a healthy lifestyle. The
concordance of overall diet quality with other health
habits, particularly smoking (63), is strong, and in-
takes of specific nutrients and foods such as omega 3
fatty acids and fish are correlated with physical
activity, obesity and social status (31, 69).
Diet and periodontal health
Numerous reviews of associations between diet and
periodontal disease have been published, including
those by Schifferle (66) and van der Putten et al. (80),
who focused on studies of intakes of selected
vitamins and minerals in the elderly. These reviews
concluded that, due to limitations in study design
(mostly cross-sectional) and measurement of diet
(recent intake only), there are no consistent associa-
tions between dietary intake or serum levels of
vitamins B, C, D, calcium and magnesium and peri-
odontal disease in non-institutionalized elderly peo-
ple (80), and insufficient evidence to justify vitamin
and mineral supplementation in adequately nour-
ished individuals (66). The objective of the remainder
of the present review is to evaluate studies of diet and
periodontal disease from the perspective of how
usual recommended nutrient intake and normal
biomarker levels in the study population influenced
the nature of the association, or lack of one, that was
reported, and whether this information is helpful inconfirming or revising dietary recommendations. Not
all studies of nutrition and periodontal disease pro-
vide this information. The findings of studies that do
are summarized in Tables 15.
Selected vitamins
Folate
Adequate dietary intake levels of folic acid are re-
quired for synthesis of thymidylate, which is used in
the manufacture of DNA, and for synthesis of the
amino acid methionine. The EAR for folic acid is
320 lg day and the adequate intake value is
400 lg day (56). Normal serum folate levels, which
reflect only recent dietary intake (19), are 43317
nmol l (1.914 ng ml).
Usual intakes blood levels. In a sub-group of
NHANES 20002002 participants aged 60 years and
older, the odds of periodontal disease were reduced
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by approximately half among those with serum folate
levels above the median (>16 ng ml) relative to
those below the median (83). The odds were adjusted
for age, sex, race, education, body mass index,
bleeding on probing, chronic diseases, vitamin B12and homocysteine levels, smoking and alcohol. The
Table 1. Summary of studies of periodontal disease with respect to folate, vitamin C, vitamin A and vitamin E intake
Reference Study
design
Study
population
Periodontal
disease
gingivitis
definition
Nutritional
status
assessment
method
Nutrient Intake
serum
level*
Effect
estimate
Yu et al.
(84)
XS NHANES
20012002,
males and
females, age60 years,
n = 844
10% of sites
with
CAL > 4 mm
and 10% siteswith
PPD > 3 mm
Serum Folate Range (ng ml)
21.4
OR
1.0
0.77
0.53**0.53**
Nishida
et al. (54)
XS NHANES III,
males and
females, age
20 years,
n = 12,419
Mean
CAL 1.5 mm
24 h recall Vitamin C Range (mg day)
180
100179
6099
3059
029
OR
1.0
1.16**
1.21**
1.26**
1.30**
Chapple
et al. (11)
XS NHANES III,
males and
females, age
20 years,
n = 11,895
Mild
PD = CAL 3
mm + PPD 4
mm at 1
mesiobuccalsite
Severe PD =
CAL 5 mm at
2 mesiobuccal
sites +
PPD 4 mm at
1 site
Serum Vitamin C Median (lmol l)
8.5
24.98
39.75
52.2470.41
Trend
OR (severe)
1.0
0.67
0.63**
0.47**0.38**
0.71**
Vitamin A Median (lmol l)
1.33
1.68
1.92
2.20
2.69Trend
OR (severe)
1.0
0.66
0.80
0.69
0.690.88
b-carotene Median (lmol l)
0.11
0.17
0.26
0.41
0.73
Trend
OR (severe)
1.0
1.03
0.93
0.87
0.83
0.87
Vitamin E Median (lmol l)
16.42
20.06
23.45
27.9837.48
Trend
OR (severe)
1.0
0.90
1.39
1.270.89
0.92
XS, cross-sectional; PD, periodontal disease; CAL, clinical attachment loss; PPD, probing pocket depth; OR, odds ratio.*Values in bold include recommended intake or normal optimal serum ranges.**P < 0.05 relative to the reference group. Trend refers to an increase or decrease in odds ratio with increasing nutrient level.
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Table 2. Summary of studies of periodontal disease with respect to calcium and vitamin D intake
Reference Study
design
Study
population
Periodontal
disease
gingivitis
definition
Nutritional
status
assessment
method
Nutri-
ent(s)
Intake
serum
level*
Effect estimate
Dietrich
et al. (16)
XS NHANES III,
male and
female, age
20 years,n = 11,202
Mean CAL
(mm)
Serum Vitamin D Range
(nmol l)
40.2
40.453.753.967.9
68.185.4
85.6
(reference)
b (M
50 years)
0.39**
0.23**0.06
0.09
0.00
b (F 50
years)
0.26**
0.100.00
0.10
0.00
Dietrich
et al. (17)
XS NHANES III,
male and
female, age
13 years,
never
smokers,
n = 6700
% mesio
buccal
sites per
subject
with BOP
Serum Vitamin D Median
(nmol l)
32.4
47.4
60.7
75.6
99.6
Trend
OR
1.0
0.98
0.90
0.88
0.80**
0.90**
Nishidaet al. (53)
XS NHANES III,male and
female, age
20 years,
n = 12,419
Mean CAL 1.5 mm
24 h recall Calcium Intake(mg day)
800
500799
2499
OR (M)
1.0
1.3**
1.3**
OR (W)
1.0
1.3**
1.5**
Krall (35) PRO,
7 years
VA Dental
Longitudinal
Study, males
only, mean age
63 years,
n = 550
PD pro
gression:
number of
teeth with
worsening
of ABL
from
20% to
>20% sincebaseline
FFQ Calcium Intake
(mg day)
1000
1000
Mean number of
teeth SE
ABL progression
2.6 0.2
2.0 0.1**
Miley
et al. (46)
XS Periodontal
maintenance
patients with
moderate to se-
vere PD, male
and
female, n = 51
(23 supplement
users, 28
non-users)
Mean
PPD, CEJ
AC
distance,
BOP,
furcation
involvement
FFQ and
supplement
questionnaire
Cal-
cium +
vitamin D
Use of
supple-
ment
Yes (1.7 g
1049 IU)
No (0.6 g
156 IU)
Yes
No
Yes
No
Yes
No
Mean (95% CI)
Probing depth (mm)
2.18 (2.02.4)
2.33 (2.12.6)
Attachment loss (mm)
1.80 (1.42.2)
2.01 (1.62.4)
% bleeding sites
60 (5269)
66 (5874)
CEJAC (mm)
1.71 (1.32.1)
2.04 (1.62.5)
XS, cross-sectional; PRO, prospective; PD, periodontal disease; CAL, clinical attachment loss; PPD, probing pocket depth; BOP, bleeding on probing; CEJAC,distance from cemento-enamel junction to alveolar crest; ABL, alveolar bone loss; FFQ, food frequency questionnaire; b, standardized regression coefficient frommultiple linear regression; M, males; F, females; OR, odds ratio; 95% CI, 95% confidence interval; SE, standard error.*Values in bold include recommended intake or normal optimal serum ranges.**P < 0.05 relative to the reference group.Values for calcium are in grams; those for vitamin D are in IU.
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upper limit of serum folate in the lowest quartile was
11.2 ng ml, which is well within the normal range
(Table 1). Since 1998, flour has been fortified with
folate in the USA, which may explain why the serum
levels were relatively high in all quartiles. A cross-
sectional study from Japan found inverse correlations
between the percentage of sites with bleeding on
probing and dietary folic acid intake, but no corre-
lation between dietary folic acid intake and thecommunity periodontal index (20). The authors re-
ported a mean intake (SD) of 372 199 lg day, but
there was no indication of how many participants
had inadequate intakes. This study restricted partic-
ipation to non-smokers with at least 20 teeth, which
may have excluded individuals with severe chronic
periodontitis from the study population. More stud-
ies that include younger age groups and measures of
dietary intake are required to determine whether
increasing intake above the current RDA will reduce
the risk of periodontal disease.
Ascorbic acid (vitamin C)
Ascorbic acid performs several key metabolic roles
that make it important for maintaining the integrity
of connective tissue. It is a co-factor for the hydrox-
ylation of proline and lysine, two proteins used to
manufacture collagen. Once hydroxylated, theseproteins form cross-links in the collagen molecule
that stabilize its structure. Vitamin C insufficiency
may affect immunocompetence. Ascorbic acid also
acts as an intracellular antioxidant to protect DNA
from oxidative damage. The role of ascorbic acid
deficiency in causing scurvy is well known, but it is
not certain whether milder degrees of insufficiency
have clinically important effects on the periodon-
tium. The EAR for vitamin C is 75 mg day (men) and
Table 3. Summary of studies of periodontal disease with respect to omega fatty acid intake
Reference Study
design
Study
population
Periodontal
disease
gingivitis
definition
Nutritional
status
assessment
method
Nutrient Intake serum level Effect estimate
Naqvi
et al. (50)
XS NHANES
19992004,
male
and female,age
20 years,
n = 9182
4 mm PPD
and 3 mm
CAL on any
mid-facial ormesial tooth
24 h recall
and supple
ment ques
tionnaire
Docosahexae
noic acid
Range (g day)
0
> 0 to < 0.04
0.04
OR
1.0
0.70**
0.77**
Eicosapentae
noic acid
Range (g day)
0
> 0 to < 0.01
0.01
OR
1.0
0.77**
0.84
Linolenic
acid
Range (g day)
< 0.91
0.911.67
> 1.67
OR
1.0
1.06
0.79
Rosensteinet al. (64)
RCT,12
weeks
Volunteers,males only,
age 18
60 years,
with
periodontal
disease,
n = 24
Changes inmean
gingival
index, mean
PPD
Threesupplement
groups plus
placebo
n-3, n-6
Placebo
Fish oil (3 g n-3)
Borage oil (3 g n-6)
Fish + borage oil
(1.5 g n-3 + 1.5 g n-6)
Placebo
Fish oil (3 g n-3)
Borage oil (3 g n-6)
Fish + borage oil
(1.5 g n-3 + 1.5 g n-6)
Mean gingivalindex change
0.68 (reference)
0.31
)1.04**
)0.07
Mean PPD change
0.02 (reference)
)0.41
)0.50**
)0.17
XS, cross-sectional; RCT, randomized controlled trial; PPD, probing pocket depth; CAL, clinical attachment loss; n-3, omega 3 fatty acid; n-6, omega 6 fatty acid; OR,
odds ratio.**P < 0.05 relative to the reference group.
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Table4.
Summaryo
fstu
dies
offoo
dgroupsw
ithrespec
ttoperio
don
taldisease
Reference
Studydesign
Studypopulation
Periodontaldisease
gingivitisdefinition
Nutritionalstatus
assessmentmethod
Food
Intakelevel*
Effectestimate
Merc
han
t
eta
l.(44)
PRO
,
12years
Hea
lthPro
fess
iona
ls
Fo
llow-u
pStudy
,ma
les
on
ly,
age
40
75years
,
freeo
fPDa
tstart
,
n=
34
,160
Self
-reportHaveyou
ha
d
pro
fess
iona
lly
diagnose
d
perio
don
taldiseasew
ith
bo
ne
loss
?
FFQ
Who
legra
ins
Me
dian
(serv
ings
day)
0.3
0.8
1.3
1.93.4
RR
1.0
0.8
9
0.7
7**
0.8
1**
0.7
7**
Al-Za
hran
i(1)
XS
NHANESIII,ma
lean
d
fema
le,
age18years
,
n=
13
,665
CAL
3mm+
PPD4mm
at
1si
te
24hreca
ll
Da
iry
foo
ds
Me
dian
(serv
ings
day)
0.2
0.9
1.62.64.7
OR
1.0
1.0
7
0.9
8
0.7
8
0.8
0
Shimiza
ki
eta
l.(68)
XS
The
Hisayama
(Japan
)
Study
,ma
lean
dfema
le,
age
40
79years
,10
teet
h,
n=
942
CAL
5mma
t10%
of
sites;
PPD
4mma
t
20%
ofsi
tes
FFQ
Milk
Range
(g
day
)
02
7.9
28
89
.9
90
199.9
200
02
7.9
28
89
.9
90
199.9
200
%
subjectsw
ith
PPD4mm
21
19
19
20
CAL5mm
19
.5
22
17
21
Lact
icaci
d
foo
ds
(e.g.
yogurt
)
Range
(g
day
)
0 0.1
27
.9
28
54
.9
55
0 0.1
27
.9
28
54
.9
55
OR
PPD
4mm
1.0
0.5
9**
0.6
3
0.4
0**
CAL
5mm
1.0
0.7
1
0.6
3
0.5
0**
100
Krall Kaye
7/29/2019 Kaye 2012 DAO
9/19
60 mg day (women). The corresponding RDAs are
90 mg day and 75 mg day (56). Plasma values
reflect recent intake. Normal plasma values are 23
114 lmol l. Values 11 lmol l are
considered low, and values
7/29/2019 Kaye 2012 DAO
10/19
Table5.
Summaryo
fstu
dies
ofa
lco
ho
lw
ithrespec
ttoperio
don
taldisease
Reference
Studydesign
Studypopulation
Periodontaldiseasegingivitis
definition
Nutritionalsta
tusassessment
method
Intakelevel
Effectestimate
Teza
leta
l.
(74)
XS
Erie
Coun
ty(NY)
stu
dy,ma
lean
d
fema
le,
age
25
74years
,n=
1371
GBa
t>0.35%
ofsi
tes;severe
CAL>4
mm;severe
ABL4m
m
Alco
ho
l-spec
ifi
cquest
ionna
ire:
usua
lnum
bero
fdrin
kswee
k
Range
(drin
kswee
k)