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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.

    99

    Dietary guidelines and periodontal health

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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

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    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

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    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)