Relationship of osteoporosis to excessive

residual ridge resorption

J. Crystal Baxter, D.M.D., M.D.S.”
University of Illinois, School of Dentistry, Chicago, Ill.

M any patients exhibit continuing bone resorp-

tion under well-made dental prostheses. This situa-
CALCIUM METABOLISM
Approximately 99% of the total body weight of
tion is frustrating to the dentist who has exercised calcium is present in the skeleton. The remaining 1%
utmost care as to tissue support, occlusion, and other is found in the cell membranes and extracellular
mechanical factors in making the prostheses. These fluid. It is this small percentage of calcium that is
patients return with complaints of discomfort and vital to all life processes. The calcium in the cell
inability to tolerate their prostheses, showing rapid, membranes is necessary for the transport of
inexplicable bone loss. Any occlusal trauma results nutrients. The calcium in the extracellular fluid
in bone and tissue changes that are out of proportion controls nerve and muscle functions and plays a part
to the irritation. Most of these patients are post- in blood clotting mechanisms and other vital meta-
menopausal women. bolic processes.” The serum calcium must continual-
ly be kept within a physiologically optimal range,
OSTEOPOROSIS and the concentrations must be maintained within
If mechanical factors related to the patient’s very narrow limits for normal function. Without
prosthesis have been ruled out, the cause may be proper mineral cell activity, homeostasis would fail
systemic. Various factors may be synergistic in caus- with cell death following.
ing the patient’s problem. One systemic condition Calcium can be obtained only through dietary
which should not be overlooked is osteoporosis, the sources, but it is lost by the body through several
disease which is most likely to exacerbate the den- mechanisms. One to 200 mg per day is lost by renal
tist’s problem in the treatment of older patients. clearance, and another 125 to 180 mg is lost in the
Osteoporosis occurs in approximately one-third of digestive juices.” Women lose additional calcium due
women over 60 years of age;’ 26% have osteoporotic to several factors. (1) They are more prone to go on
fractures by 60 years of age and 50% by 75 years of reducing diets with a decrease in the amounts of all
age.’ Osteoporosis also increases in men with aging, nutrients ingested. (2) During pregnancy, the fetus
to a lesser degree than it does in women. According requires 400 mg calcium per day; during breastfeed-
to Jowsey,’ osteoporosis may become one of the most ing, an additional 300 mg of calcium per day is
common problems of health of the geriatric patient required. (3) Loss of estrogen and changes in hor-
in the future. monal balances at menopause also cause accelerated
Osteoporosis can be described as a lack of bone calcium loss.” Any loss of calcium results in loss of
density or poverty of bone tissue.’ The disease is bone density, resulting in an osteoporotic state.
considered ideopathic, but it can be attributed to
nutrition to a large degree.$ Extensive corticosteroid ORAL MANIFESTATIONS AND CALCIUM
NUTRITION
therapy can cause a secondary form of the disease, as
the decrease of bone mass leads to increased porosity, It is important to realize that there may be acute
brittleness, and easily resorbed and fractured or chronic oral manifestations of osteoporosis.
bones.’ Studies of patients with periodontal disease con-
firmed the coincident appearance of vetebral osteo-
Read before the American Prosthodontic Society, New Orleans,
porosis and periodontal disease. In addition, most
LA. patients with osteoporosis were found to be edentu-
*Assistant Professor, Department of Prosthodontics. lous.” When skeletal depletion occurs as a result of

0022-3913/81/080123 + 03$00.30/00 1981 The C. V. Mosby Co THE JOURNAL OF PROSTHETIC DENTISTRY 123
 BAXTER

stimulation by the parathyroid gland, alveolar bone mg/day. Wical and Brussee” treated patients with
is effected prior to the ribs, vetebrae, and long 750 mg of calcium and 375 USP units of vitamin D,
bones.7 (Ergocalciferol) per day for 1 year. When compared
The diet of the patient can be a very important to a similar nonsupplemented group, the reduction
factor in preventing or controlling osteoporosis. The of bone loss was an impressive 34% in the maxillae
intestine loses some of its ability to absorb calcium and 39% in the mandible. Future studies must be
with age. The condition of lactose intolerance undertaken to determine whether supplementation
becomes more prevalent. In patients with this condi- can actually reverse bone density. The fact that
tion, milk products cause gastric distress and are supplementation of calcium and D, can arrest osteo-
subsequently avoided.” One study of a group of 87 porotic bone loss is already well documented.“. ’
osteoporotic patients showed that one-third of the Nutritional supplementation of dietary calcium
patients did not drink milk at all.s and vitamin D, should be part of the treatment plan
A factor equally important to actual calcium for prosthodontic patients. More patients are living
intake is the calcium-phosphorus ratio. This ratio longer, and the chances of osteoporosis appearing
should be approximately 1: 1, but it is usually found increase with each year of life. Dietary supplementa-
to be much greater. Excesses of phosphorus in the tion of calcium and D, is painless and inexpensive,
diet cause a secondary hyperparathyroidism which and it is suggested that the supplementation should
causes additional bone resorption. Wical and be initiated at an early age for best results. Patients
Swoope lo studied a group of edentulous patients and who are edentulous at an early age due to periodon-
related bone loss to calcium-phosphorus ratios. Their tal disease would be prime candidates for early
study showed that patients with low calcium intake supplementation. With the cooperation of the
and calcium-phosphorus imbalances had severe patient, the dentist may be able to control or
mandibular bone resorption. The American diet decrease excessive mandibular atrophy, resulting in
exacerbates calcium-phosphorus imbalances. Most fewer “dental cripples” in the future.
popular foods contain much phosphorus and little A supplementation of 750 to 1,000 mg per day
calcium. High phosphorus foods such as refined calcium and 375 IU vitamin D, is suggested. Cal-
breads, cereals, and meat are staples of the American cium may be contraindicated in patients who are
diet. Even those foods high in calcium, such as milk, undergoing digitalization. D, supplementation in
nonprocessed cheeses, and vegetables, contain almost patients with coronary disease, impaired renal func-
an equal amount of phosphorus.” tion, and atherosclerosis is cautioned. In patients
with no such conditions, a supplementation of 375
TREATMENT AND PREVENTION BY IU is well within conservative limits, as the toxic dose
NUTRITIONAL SUPPLEMENTATION of D, is 200,000 IU/day.
It is difficult to convince patients to drastically Ideally, a team-effort approach with the patient’s
alter their dietary intake. The large amounts of physician should be utilized to diagnose and treat
phosphorus-containing foods available today make bone loss.
total dietary control of the calcium-phosphorus ratio
impractical. Thus, nutritional supplementation of SUMMARY AND CONCLUSION
the diet is the logical and convenient alternative. There are many systemic factors which contribute
Studies have shown that nutritional supplementa- to alveolar bone loss and decreased ability to tolerate
tion can yield impressive results. Various regimens dental prostheses. Osteoporosis should be considered
have been documented as helpful in increasing bone as a possibility. Observation of the high numbers of
density or arresting bone loss. Albanese” used a osteoporotic fractures in the geriatric population
supplement of 750 mg of calcium and 375 IU of serves to illustrate the scope of this problem. The
vitamin D per day over a S-year period and found condition of osteoporosis results in bone loss in the
that the supplemented patients showed cessation of maxillae and mandible as well as in other bones of
bone loss or an increase of up to 12% in bone density the body. It is highly feasible that the disease makes
when compared to a test group showing continued a strong contribution to the deterioration of the
bone loss. In another study,** 2.5 gm of calcium dental health in the geriatric patient.
carbonate was administered daily to menopausal The American diet is too low in calcium and too
women, with a resulting prevention of bone loss. high in phosphorus. Added to the high incidence of
Jowsey”, ” suggests calcium supplementation of 1,000 lactose intolerance, it is difficult to control the

124 AUGUST1981 VOLUME 46 NUMBER t

OSTEOPOROSIS IN RESIDUAL RIDGE RESORF’TION

mineral content of a patient’s diet by simple modifi- 5. Albanese, A.: Calcium nutrition in the elderly. Postgrad
Med 63:167, 1978.
cation of eating habits. Dietary supplementation is a
6. Lutwak, L.: Periodontal Disease. In Winich, M., editor:
convenient and inexpensive alternative. Nutrition and Aging. New York, 1976, Wiley Publishers, pp
Rampant residual ridge resorption is a multifacto- 145-153.
ral problem. It is part of the responsibility of the 7. Krook, L., Lutwak, L., and Walen, J. P.: Human periodon-
dentist to consider all factors involved in this state. tal disease. Morphology and response to calcium therapy.
The dentist would serve the patient well by working Cornell Vet 62:32, 1972.
8. Bullamore, J. R., Gallegher, J. C., and Wilkinson, R.: Effect
in conjunction with the patient’s physician in the of age on calcium absorption. Lancet 2:.535, 1970.
diagnosis and treatment of osteoporotic states. The 9. Jowsey, J.: Osteoporosis: Dealing with a crippling bone
dentist has much to gain in the systemic treatment of disease of the elderly. Geriatrics 32:41, 1977.
the “impossible denture patient,” for it is the dentist 10. Wical, K., and Swoope, C.: Studies of residual ridge resorp-
who must endure the frustrations of treating such a tion. Part II: The relationship of dietary calcium and
phosphorus to residual ridge resorption. J PROSTHETDENT
patient.
32:13, 1974.
11. Heaney, R., and Reeker, R.: Presentation at a meeting of
REFERENCES Endocrine-Metabolic Committee to the United States Food
and Drug Administration. Feb. 18, 1977.
1. Jowsey, J.: Prevention and Treatment of Osteoporosis. In
12. Wical, K. E., and Brussee, P.: Effects of a calcium and
Winich, M., editor: Nutrition and Aging. New York, 1976,
vitamin D supplement on alveolar r.dge resorption in
Wiley Publishers, pp 131-143.
immediate denture patients. J PROSTHETDENT 41:4, 1979.
2. Gordon, G. S., and Vaugh, C.: The role of estrogens in
osteoporosis.Geriatrics 32:42, 1977. Reprint requeststo:
3. Jowsey, J.: Osteoporosis: Its nature and the role of the diet. DR. J. CRYSTALBAXTER
Postgrad Med 60~75, 1976. UNIVERSITYOF ILLINOIS
4. Lutwak, L.: Continuing need for dietary calcium throughout SCHOOLOF DENTISTRY
life. Geriatrics 29:171, 1974. CHICAGO, IL 60680

THE JOURNAL OF PROSTHETIC DENTISTRY 125