REMOVABLE PROSTHODONTICS
SECTION EDITORS
LOUIS BLATTERFEIN S. HOWARD PAYNE
Calcium metabolism and osteoporotic
resorption: A protein connection
R. P. Blank, D.D.S.,* H. A. Diehl, Dr.HealthSc., M.P.H. (Nut&**
G. T. Ballard, D.M.D., M.S.,*** and R. C. Melendez, D.D.S., M.S.****
Naval Dental Clinic, Camp Pendleton, Calif., and Lifestyle Medicine Institute, Loma Linda, Calif.
lhe relationship of osteoporosis to alveolar and resid-
ual ridge resportion is of justifiable concern to the dental
profession. l-3 Although generalized bone loss is charac-
teristic of osteoporosis, the first sign may be alveolar
bone loss, followed by loss in the vertebrae and long
bones.‘T5It may be difficult to treat edentulous patients
who manifest the excessive residual ridge resorption
often associated with osteoporosis. Kribbs et a1.3demon-
strated a significant correlation between skeletal osteope-
nia and the density of residual ridges and alveolar bone
but not with residual ridge reduction or periodontal
disease per se. They concluded that any therapeutic
measures that control or have an effect on osteoporosis
could therefore exert an effect on residual ridge density.
A dentist, in a cooperative effort with a patient’s
physician, may be in a unique position to facilitate
prevention, early diagnosis, and treatment of this debili-
tating disease.‘s6
This article reviews osteoporosis, discussesthe interre-
lationship between dietary protein, calcium metabolism,
and osteoporosis, and suggests a treatment regimen for
this condition.
Osteoporosis may be defined simply as a condition of
insufficient bone. This deficiency undermines skeletal
strength, resulting in fractures that occur with minimal
stress in the spine, distal radius and ulna, and in the
femoral neck.5,7 Of the 190,000 hip fractures occurring
annually, 80% are in postmenopausal women, attribut-
ing to 40,000 deaths each year. It is estimated that 90%
of all fractures sustained in persons past the ages of 60
years are due to osteoporosis. The medical costs of
osteoporosis in the United States have been estimated at
almost $4 billion annually. That is in addition to the
The views expressed in this article are those of the authors and do not
reflect the official policy or position of the Department of the Navy,
Department of Defense, or the U.S. Government.
*Lieutenant Commander, Dental Corps, United States Navy; Postdoc-
toral Fellow in Prosthodontics.
**Director, Lifestyle Medicine Institute.
***Captain, Dental Corps, United States Navy; Head, Department of
Prosthodontics; Director, Postdoctoral Fellowship Program in
Prosthodontics.
****Captain, Dental Corps, United States Navy; Assistant Head,
Department of Prosthodontics.
590
ridge
Table I. Accumulative effect of long-term
negative calcium balance on osteoporosis-bone
loss
Total body calcium 1300 gm
Skeletal calcium loss in 30 years if 540 gm
daily calcium balance is -50 mg
(50 mg X 365 days x 30 years)
Body calcium loss 42%
costs of suffering, physical disability, and mortality
associated with the disease.*s9
Research in primary osteoporosis is currently focused
on possible etiologic factors, such as diet, lifestyle,
physical activity, and hormone status.8z‘Of” Although
questions remain concerning the osteoporotic mechanism
and the exact nature of causative factors, it is clear that
osteoporosis is a result of excessive loss of bone calci-
um.
CALCIUM METABOLISM
Although most of the body’s calcium is insoluble,
soluble calcium is maintained in a dynamic state by
continuous absorption, exchange, deposition, resorption
of bone, and excretion. ” Dietary absorption is the only
means of obtaining calcium. There are nevertheless
several mechanisms whereby calcium is lost from the
body, including renal clearance, excretion of unabsorbed
talcum in the feces, and dermal losses. If the amount of
calcium absorbed is greater than the amount lost, excess
calcium is deposited in the skeleton. This is referred to as
a positive calcium balance. Conversely, if losses exceed
absorption, calcium is mobilized from the skeleton to
optimally maintain the narrow limits of extracellular
fluid calcium, and is thus termed negative calcium
balance. A negative calcium balance sustained over an
extended period of time will lead to osteoporosis (Table
I).’ Therefore, the primary goal of preventive and
therapeutic regimens is to maintain a positive calcium
balance.
TREATMENT MODALITIES
A complex array of etiologic factors in primary
osteoporosis has been identified. Those factors include
NOVEMBER 1987 VOLUME 58 NUMBER 5
CALCIUM METABOLISM: A PROTEIN CONNECTION

decreased estrogen levels in postmenopausal women, Table II. Effect of low and high protein diets
inactivity, alcohol abuse, high phosphate diets, low on calcium balance
calcium diets, Vitamin D deficiency, corticosteroids,
Calcium balance
smoking, caffeine intake, dietary protein imbalance, and
stress.*,I3 Prevention and management of osteoporosis Calcium Low High
intake protein protein
include estrogen therapy, dietary Vitamin D, fluoride
Investigator (mg) (50 gm)’ (145 gm)*
supplementation, and increased calcium intake.
Estrogen therapy remains controversial because of Hegsted” 500 +24 -116
Anand and 500 +31 -120
uncertainty about long-term benefits.*,14Some authori-
Linkswile@
ties caution against routine use of estrogen in treating Walker and 800 +12 -85
osteoporosis because of associated risks, including uter- Linkswilef’*
ine cancer, thrombophlebitis, gall bladder disease,diabe- Linkswiler et aLso 1400 +20 -65
tes, and hypertension.‘, 15-‘* Johnson et a1.4’ 1400 +10 -84
Vitamin D is another widely used therapeutic adjunct Mean +19 -94
because of its important role in bone metabolism. The *+10?&
active metabolite of Vitamin D (1 alpha, 25-dihydroxy-
Vitamin D3) is actually a hormone synthesized by the
body through the action of sunlight on the skin. The tion between decreased bone density and low calcium
Vitamin D levels in a person’s body are a direct result of consumption in women over 45 years of age in the
the amount of sunlight received and are not dependent United States. Jowsey”, 3o and Lutwak3’ reported that
on dietary sources of the hormone.” Because of its calcium supplements were effective in reducing bone loss
questionable therapeutic role and potential toxicity, and showed that calcium/phosphorus ratios less than 1
some investigators conclude that Vitamin D supplemen- may lead to osteoporosis. These and other studies
tation should be approached with considerable cau- indicate protection against age-related bone loss in the
tion.932%z1 hand bones and alveolar and residual ridge bone with
Perhaps the most controversial experimental therapy increased calcium intake.1~31~32In contrast, several
for osteoporosis is the use of fluoride. Several groups studies reported no benefit to bone density from daily
have studied the effects of fluoride on the skeleton in calcium supplementation.22~“, 33,34
postmenopausal osteoporosis. A question to be answered This variance in reported data helps to explain the
is whether a fluoride-induced increase in bone mass will wide range in recommended dietary calcium intake from
also proportionally increase bone strength. Fluoridic various health organizations. The current recommended
bone displays increased crystallinity, which may actually dietary allowance (RDA) is 800 mg of calcium/day,
result in decreasedelasticity predisposing to fracture.*, 22 whereas the most recent National Institutes of Health
Although the fluoride therapy has been shown to (NIH) proposal calls for 1000 to 1500 mg of daily calci-
increase trabecular bone, studies to date suggest that it um.9B35 The World Health Organization (WHO) recom-
does not increase and may, indeed, decreasecortical bone mendation is only 400 to 500 mg of calcium/day inas-
density.9 Researchers suggest that one or more adverse much as calcium intake in most populations around the
side effects of fluoride therapy, including joint pains and world is 300 to 500 mg/day without any evidence of
gastric irritation, occur in 20% to 40% of treated osteoporosis.35,36That osteoporosis is epidemic in the
patients.*,9s23Fluoride therapy has not yet been approved United States, where consumption of dairy products and
by the Federal Drug Administration for treatment of calcium supplements is the highest in the world, is para-
osteoporosis and is considered an investigational doxical.9s37-39
Osteoporosis may not be simply a deficiency
drug.*, 9 disease, but a disease related to dietary excess.
Increasing calcium intake by means of dairy foods and
supplementation is the method most practiced in the THE PROTEIN CONNECTION
prevention and treatment of osteoporosis to optimize Nongeriatric American adults consume 105 to 120 gm
calcium balance. Reports on the relationship between of protein on average each day, far exceeding current
calcium intake and bone density are conflicting. Garn et RDA levels of 56 gm for men and 44 gm for women.35In
a1.,24Smith and Frame,25 and other researchers26*27 have addition to its association with kidney stones and pro-
failed to show a correlation between differences in gressive deterioration of renal function,40B4’ this excess
calcium intake and bone mass or rates of bone loss with protein may produce a calciuretic effect. As early as
age in adults. Matkovic et a1.28reported important 1920, Sherman42observed that adding meat to the diet
differences in bone mass in all ages between two caused an increase in urinary calcium excretion. The
ethnically similar Yugoslav groups who had calcium same observation was also noted between 1930 and 1952
intakes that differed by approximately a factor of two. in experiments in which meat or other high protein food
Similarly, Albanese et a1.29reported a statistical correla- was added to the diet.43-45

THE JOURNAL OF PROSTHETIC DENTISTRY 591

 BLANK ET AL

150 - LOW PROTEIN INTAKE (47 dm)

s 100 -
posititie
.E

p 50.. l .

E 38 l -.... -.......,.......*i...............i...e
20 20
i 0
HIGH PROTEIN INTAKE (142 gm)
3
3 -50 - negative

i3

-100 - lc:r
?70

1 1. I I I k I I 1 1
500 800 1400
CALCIUM INTAKE (mg)

Fig, 1. Calciuti retention levels (mg) at different intakes of protein and calcium.
(Adapted from Linkswiler et al?‘)

Table III. Osteoporosis, dairy food, and Table IV. Calcium in selected foods
protein intake by countries9,37,38,39
Food Seiving mg
Dairy food Protein
Yoghurt, low fat 1 cup 415
Hip fractures intake intake
Greens,collard 1 cup 400
(rate/ (gmldayl (gxhldayl
Milk, low fat 1 cup 300
Country 100,000 :ivamen) person) person)
Greens,turnip 1 cup 250
United States 162 462 106 Chinesecabbage 1 cup 250
New Zealand 97 480 112 Greens,mustard tops 1 cu@ 200
Israel 70 315 105 Cottagecheese,low fat 1 cup 160
United Kingdom 63 455 90 Broccoli 1 cup 150
Hong Kong 31 95 82 Grains and pasta 1 cup 100-150
Singapore 15 113 82 Bread 2 slices 100
South African 5 10 55 Beans 1 cup 100
Bantu

In recent studies, only one group of investigators failed
to demonstrate this calciuretic effect.46 Most studies
consistently demonstrated a marked positive correlation
between the aniount of dietary protein intake and the
level of calcium excretion (Table II).47-57Although not
linear, varying protein intakes from less than 6 to 600
gm/day resulted in an increase of approximately 800%
in urinary calcium excretion.52 Among the minei-als
studied (calcium, magnesium, sodium, potassium, and
phosphorus) that relationship was unique for urinary
calcium.52Studies have shown that men consuming diets
containing more than 95 gm of protein daily developed a
negative calcium balance even with high calcium intakes
(Fig. 1).4*,49In one long-term study, investigators mea-
suring calcium in adults found a negative calcium
balance even when subjects consumed only 75 gm of
protein, despite daily calcium intake ad high as 1400 mg.
The investigators concluded that the consumption of
high calcium diets is unlikely to prevent a negative
calcidm balance and associated bone loss induced by the
consumption of high protein diets.56
DISCUSSIdN
Observations of various world populations show a
direct correlation between high protein intake and the
incidence of ostedporosis (Table III).9a 37-39,
‘* Bantu tribes
living in Africa consume a daily average of 47 gm of
predominately plant source protein and only 400 mg of
calcium. They are essentially free of osteoporosis. Even
women who bear 5 to 10 children demonstrate that same
finding.59-6’Genetic relatives of the Bantus in the United
States consume a typically high protein diet and experi-

592 NOVEMBER 1987 VOLUME 58 NUMBER 5

CALCIUM METABOLISM: A PROTEIN CONNECTION
ence a rate of osteoporosis comparable with the rest of
the U.S. population. 62An example of the effects of excess
protein is seen in the native Eskimos, who consume a
diet high in both protein (250 to 400 gm/day) and
calcium (2000 mg/day). Despite high physical activity,
the Eskimos have one of the highest rates of osteoporosis
in the world.63
Atwood64 described the reduction of residual ridges as
a major oral disease entity dependent on several factors,
including anatomic, biologic, and mechanical factors.
Wical and Swoope’ suggested that this “oral disease”
type of resorption is a manifestation of osteoporosis.
Baxter2 and Rowe6’ stated that when patients exhibit
rapid continuing bone resorption under well-fitting
dental prostheses, osteoporotic bone loss must be consid-
ered as contributing to the etiology and pathogenesis of
the disease process. This can lead to frustration for both
dentist and patient as the otherwise inexplicable bone
loss progresses. Patients often return with complaints of
discomfort and inability to tolerate their prostheses.’
Early loss of teeth and the need for more frequent reline
procedures for denture-wearing patients may also result.
Efforts to treat or prevent the dental manifestations of
osteoporosis may concomitantly help the patient to avoid
the more grave effects of this disease.
RECOMMENDATIONS
By the time osteoporosis is generally diagnosed, 50%
to 75% of the original bone material has been lost from
the skeleton.*,” For this reason alone, prevention
becomesimperative. Although the etiologic puzzle is still
incomplete, the effect of protein on calcium metabolism
strongly suggests measurable benefits from a lifestyle
that avoids excessiveprotein in the diet. The adoption of
a dietary lifestyle that reduces the protein intake to levels
more in harmony with the RDA can dramatically
improve renal function40.4’ and serve as an effective
means of restoring and maintaining a positive calcium
balance. A positive calcium balance is necessary for
maximizing peak skeletal mass achieved during growth
and early adulthood and minimizing age-related bone
loss that begins in the third or fourth decade of life.66
Therapeutic and preventive measures, such as
increasing calcium supplementation without regard for
excessiveprotein intake, appear ineffectual in attaining a
positive calcium balance necessary in the prevention of
osteoporosis. The level of dietary protein must be
considered when making recommendations for calcium
requirements or allowances. For example, an individual
on a borderline high protein diet may not benefit from
recommendations of increasing the consumption of calci-
um by eating more dairy products, as is the present
clinical custom, because dairy products are also high in
protein.
Educating patients about the importance of a properly
THE JOURNAL OF PROSTHETIC DENTISTRY
balanced diet is advocated by Wical and Swoope,’
Baxter,2 and others6b2’Recommendations relevant to the
prevention and management of osteoporosis are as
follows.
1. Avoid a high protein diet and maintain daily protein
intake levels of 50 to 60 grams to promote a positive
calcium balance.
2. Maintain the RDA of 800 mg of calcium for men and
nonpregnant women.
3. Participate in regular exercise programs appropriate
to age and health status.
4. Avoid risk factors related to osteoporosis such as
smoking, excessive alcohol, and the generous use of
caffeine-containing beverages.
On a practical basis, this would include the following
recommendations.
Lower the consumption of animal products. This
would not only decrease protein intake but would
have the added benefit of reducing cholesterol and fat
consumption.
Increase consumption of complex carbohydrate foods,
such as unrefined grains (rice, barley, breads, pasta,
whole-grain cereals), potatoes, yams, squash, and
legumes (such as beans, peas, lentils).
Increase consumption of vegetables, especially those
rich in calcium, such as broccoli, collard greens,
turnips, kale, and Chinese cabbage (Table IV).
Use moderate amounts of low fat or skim milk
products as a source of calcium.
SUMMARY AND CONCLUSIONS
The unique interrelationship between excess dietary
protein, calcium metabolism, and osteoporosis with its
associated ridge resorption has been reviewed. Recom-
mendations for the prevention and management of
osteoporosis have been discussed with concern for the
calciuretic effect of a high protein diet customarily
consumed in American society. Positive calcium balance
promoted by the suggestedtreatment regimen may help
to preserve ridge integrity and at the same time prevent
the serious debilitating effects of generalized osteoporo-
sis. Further research to evaluate for retardation and
possible reversal of osteoporotic ridge resorption as
affected by dietary protein intake is warranted.
We thank Commander A. W. Fehling, DC, U.S. Navy, for his
helpful suggestions in editing this article prior to its submission for
publication.
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Reprint requests to:
LCDR R. P. BLANK, DC, USN
NAVAL DENTAL CLINIC
PLJCET SOUND NAVAL SHIPYARD
BREMERTON, WA 98314

Objective testing of the efficiency of

denture-cleansing agents
Shogo Minagi, D.D.S., Ph.D.,* Tatsuhiko Tsunoda, D.D.S.,**
Koichiro Yoshida, D.D.S., Ph.D.,* and Hiromichi Tsuru, D.D.S., Ph.D.***
Hiroshima University, School of Dentistry, Hiroshima, Japan

li aque on the tissue surface of a denture is an

important factor in the pathogenesis of denture stomati-
tis and many studies have been conducted to evaluate the
efficacy of denture-cleansing methods.lW7Nevertheless,
variations in denture plaque have made it difficult to
evaluate the clinical efficacy of the many available
denture-cleansing agents. This study reports a method of
objective evaluation of denture-cleansing agents.
UPPER (25 areas 1 LOWER (15 areas)
MATERIAL AND METHODS
Fig. 1. Area segmentation for upper and lower den-
Two upper and one lower complete dentures worn for tures.
more than 2 years by patients (three donors, A, B, and
C) 58 to 71 years of age were used in the study. After
new dentures were made for the patients, each old upper denture and 15 zones for the lower denture (Fig.
denture was cut into test pieces in the following man- 1). Each zone was further cut into four test pieces
ner. approximately 5 X 5 mm. The four test pieces from each
The test dentures were divided into 25 zones for the zone were randomly distributed to four groups consisting
of a control group and three cleansing-agent groups
according to the statistical method of randomized block
*Instructor, Department of Removable Prosthodontics.
**Research Fellow, Department of Removable Prosthodontics. design. This format resulted in each group having either
***Professor and Chairman, Department of Removable Prosthodon- 25 upper-denture or 15 lower-denture test pieces of
tics. 5 X 5 mm. Three immersion denture-cleansing agents

THE JOURNAL OF PROSTHETIC DENTISTRY 595