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Numbers of Natural Teeth, Diet, and Nutritional Status in US Adults
1 Health Disparities Research Program, Center for Clinical Research, National Institute of Dental and Craniofacial Research, National Institutes of Health, NIH/DHHS, 45 Center Drive, Room 4AS-43F, Bethesda, MD 20892-6401, USA; and Correspondence: * corresponding author, Ruth.Nowjack-Raymer{at}nih.gov
Evidence that dental status affects diet is equivocal. The hypothesis of this study was that diet was affected by dental status. The objective was to assess the relationship between numbers of teeth and diet and nutritional status in US adult civilians without prostheses. We examined 6985 NHANES (1988–1994) participants. Data included socio-economics, demographics, dental status, and diet and nutritional status. Dietary data were obtained from food frequency questionnaires and 24-hour dietary recall. Serum levels of beta carotene, folate, and vitamin C were measured with isocratic high-performance liquid chromatography. The population was classified by numbers of teeth. Covariance and Satterthwaite F-adjusted statistical comparisons were made between tooth groupings and the fully dentate population. Multilinear regression models adjusted for covariates. People with fewer than 28 teeth had significantly lower intakes of carrots, tossed salads, and dietary fiber than did fully dentate people, and lower serum levels for beta carotene, folate, and vitamin C. Dental status significantly affects diet and nutrition.
Key Words: teeth • diet • nutrition • vitamins • health disparities
The consumption of adequate fruits and vegetables and foods high in dietary fiber is widely recommended. Public health programs attempt to increase fruit and vegetable consumption for all age groups. Healthy People 2010 and other expert nutritional bodies have recommended an increased intake of fruits, vegetables, and dietary fiber, because their consumption in the United States was below recommended levels (Alaimo et al., 1994; Steinmetz and Potter, 1996; US Department of Health and Human Services, 2000; Block, 2002; WHO, 2003). Numerous factors have been associated with lower intakes of healthy foods (Feldman et al., 1984; Patterson et al., 1990; Alaimo et al., 1994, 1998). One factor, seldom mentioned, is the numbers and condition of natural teeth. Natural teeth are associated with the ability to bite and chew foods, and therefore affect the quality of the diet. Laboratory and clinical dental studies have indicated that chewing capacity and bite force were affected by dental status (Feldman et al., 1984; Aukes et al., 1988). Furthermore, oral-health-related quality-of-life studies report that sizable subpopulations report that dental problems affect their ability to chew, the intake of specific types of foods, and the consumption of a full range of desired foods (Feldman et al., 1984; Leake, 1990; Locker and Slade, 1993; Slade et al., 1996; Sheiham et al., 1999). Full-denture wearers have a poorer diet compared with that of dentate people (Nowjack-Raymer and Sheiham, 2003). Nowjack-Raymer and Sheiham (2003) showed that in US civilian adults, intakes of dietary fiber and some nutrient-rich foods and serum levels of beta carotene, folate, and vitamin C were significantly lower in complete-denture wearers than in the fully dentate. Several studies have assessed whether the numbers of teeth present were associated with the intake of nutritious foods (Lee et al., 2004) and dietary fiber (Krall et al., 1998) among those who had no dental prostheses. One nationally representative survey, the National Diet and Nutrition Study (NDNS) of people aged 65 yrs and older in the United Kingdom, examined the relationship between diet and serum levels of biochemical analytes and numbers of teeth present, regardless of prosthesis status. They found a relationship between dental status and dietary intake and certain blood analytes (Steele et al., 1998; Sheiham et al., 2001). Their sample included dentate individuals who wore prostheses. The objective of the present study was to analyze the relationship between dental status, in terms of numbers of teeth present, and diet and nutritional status in a representative sample of US civilian, non-institutionalized adults, aged 25 yrs and older, who did not wear dental prostheses to replace missing teeth.
Human Participant Protection All participants provided written informed consent in compliance with clinical research guidelines of the authors’ institutions, and the study was approved by the Centers for Disease Control and Prevention/National Centers for Health Statistics Institutional Review.
Data Source
Study Population
Dependent Variables
Nutritional Status
Independent Variables—Dental Status
Statistical Analyses
Study Population Of the 6985 sample persons, 35% were fully dentate, 54% had from 21 to 27 teeth, one-tenth had from 1 to 20 teeth, and 1% had from 1 to 10 teeth (Table 1  ). The mean age of the fully dentate population was 37.4 yrs. Those with from 1 to 10 natural teeth remaining were, on average, 67.8 yrs old. Nearly half the population was female in all of the tooth groupings, with the exception of the 1–10 category, where 43.1% were female. The fully dentate, the reference category, consisted predominantly of white, non-Hispanics (83.3%) and those of higher socio-economic status (47.4%), whereas those with the greatest disparity in numbers of teeth (1–10 teeth present) were primarily minorities (98.6%) and those of lower socioeconomic status (51.7%). Tobacco and vitamin and mineral supplement use was lowest among the fully dentate (23.2% and 55%, respectively) (Table 1).
Intake of Foods and Dietary Fiber Numbers of teeth present were associated with the intake of specific foods and dietary fiber after adjustment for socio-demographic and behavioral factors (Table 2 ). Mean intake of carrots per month was statistically significantly lower for all categories of numbers of teeth fewer than 28 (p < 0.02) after adjustment for age, gender, socio-economic factors, race/ethnicity, smoking status, caloric intake, and whether people consumed vitamin or mineral supplements. There was a clear trend for mean number of intakes of carrots to decrease as numbers of teeth decreased. Those who had from 1 to 10 teeth ate carrots 2.5 times less often than the fully dentate: 2.3 times per month vs. 5.8. Likewise, after adjustment for the same confounders as for carrots, the mean intake of tossed salads per month was statistically significantly lower for those with missing teeth, compared with the fully dentate (p < 0.04). Those with from 11 to 20 teeth reported eating tossed salads 9.1 times a month, compared with 11.0 times in those with 28 teeth (Table 2).
Trends in the intake of carrots and tossed salads were clearly reflected in reported mean intake of grams of dietary fiber (Table 3 ). A difference in intake of dietary fiber between the fully dentate and those with fewer teeth decreased monotonically, and ranged in the adjusted model from a 1.5-gram difference (p = 0.03) for those with 21–27 teeth to a 4.7-gram difference (p = 0.007) for those with 1–10 teeth.
Biochemical Analytes Numbers of teeth present were associated with biochemical analyte levels after adjustment for sociodemographic and behavioral factors (Table 4 ). The level of serum beta carotene was statistically significantly different and lower among those with 20 or fewer teeth, when compared with that in fully dentate people (p = 0.04). No statistically significant difference was found between those with from 21 to 27 teeth and those with 28 teeth (p = 0.06). Similarly, serum folate differences were statistically significantly different among those with 20 or fewer teeth, compared with differences in the fully dentate. The serum folate level was 1.4 times lower for those with few teeth remaining (4.7 ng/dL vs. 6.4 ng/dL). Serum vitamin C levels were progressively lower as numbers of teeth decreased, and differences were statistically significant (p = 0.003). People with from 1 to 10 teeth had mean levels of serum vitamin C that were, on average, 1.5 times less than those in the fully dentate (0.5 mg/dL vs. 0.8 mg/dL).
The intake of nutrient-rich foods was associated with increased disparities in numbers of teeth present. These findings were corroborated when dietary fiber intake and biochemical analyte levels for nutrients found in these foods were also analyzed. After adjustment for a broad array of social and behavioral factors, a clear trend emerged across three nutrition epidemiologic measures used (food frequency questionnaire, a quantitative 24-hour dietary recall, and biochemical analyte levels). The intake of the nutritious food items and dietary fiber declined, and there were lower levels of the biochemical analytes serum beta carotene, folate, and vitamin C as numbers of teeth decreased. This is the first analysis of a nationally representative survey of United States adults to assess the relationship among diet, nutritional status, and disparities in dental status in terms of numbers of natural teeth present. The only other nationally representative survey to explore these relationships was the United Kingdom’s NDNS of people aged 65 yrs and older. The findings of this study were very similar to those of the NDNS (Steele et al., 1998; Sheiham et al., 2001), despite the fact that the NDNS dental typology did not distinguish between those who did and did not have dental prostheses. They also reported that the percentage of people aged 65 and over in the UK who reported difficulty in eating, or who totally avoided raw carrots and lettuce, was statistically significantly higher among those with more impaired dentitions, and those people had lower intakes of non-starch polysaccharide (Steele et al., 1998; Sheiham et al., 2001). Other studies of subpopulation groups (Lee et al., 2004) used dental typologies that focused on people who had no prostheses and assessed the intake of nutritious foods. Ranta et al.(1988) also found that people with fewer teeth reported lower intake of root and other vegetables. A longitudinal study of US male health professionals (Joshipura et al., 1996) reported that the intake of carrots and other vegetables was lower among those with fewer teeth. In addition, they found that those men who had lost 5 or more teeth, in the 4 years since baseline, decreased their intake of vegetables, apples, and pears. We found considerable differences in the intake of dietary fiber between the fully dentate and those with from 1 to 10 teeth, and an over-3-gram-per-day difference for those with 20 or fewer teeth—a finding similar to that in the national United Kingdom study (Steele et al., 1998; Sheiham et al., 2001). Likewise, Krall et al.(1998) found, in US male veterans, that there was a 2-gram mean difference in the intake between those who were fully dentate and those who had fewer than 14 teeth on one or both sides of the mouth. Joshipura et al.(1996) reported that there was a trend for greater dietary and crude fiber intake among those with more teeth, regardless of whether teeth had been replaced. The biochemical analyte levels of several bioactive nutrients (serum beta carotene, serum folate, and serum vitamin C) found in fruits and vegetables were, for the most part, higher among the fully dentate than in those with the most impaired dentitions in the US civilian non-institutionalized population, even after adjustment for potential confounders. Results of the UK NDNS (Steele et al., 1998; Sheiham et al., 2001) found no difference in the level of alpha tocopherol, but statistically significant differences and lower levels of vitamin C as numbers of teeth declined. The importance of a full complement of teeth vs. a dentition of 20 teeth has been a topic of discussion and research during the past decades (Witter et al., 1999). In the 1970s, Ramfjord (1974) stated that "the diet of modern man does not require an intact dentition to satisfy the functional demands". In the quarter-century since Ramfjord’s writings, studies by nutrition epidemiologists have led to a better understanding that the "diet of the modern man" referred to by Ramfjord consisted of highly processed foods and refined carbohydrates, as opposed to the more healthful diet rich in fresh fruits and vegetables called for today. Currently, with evolving but incomplete knowledge of the specific levels of nutrients needed to maintain health, it is impossible to conclude that the mean differences, even among those with the greatest disparities in dental status, may have health or functional consequences.
This work was supported by the National Institute of Dental and Craniofacial Research, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD 20892, USA. We thank Drs. Wagner Marcenes and Thomas Drury for suggestions and Mr. Richard Oldakowski for programming assistance. Received for publication December 20, 2006. Revision received June 28, 2007. Accepted for publication August 31, 2007.
Journal of Dental Research, Vol. 86, No. 12,
1171-1175 (2007) This article has been cited by other articles:
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