Vitamin and Mineral Supplements
What Is the Dentist to Do?
Riva Touger-Decker, PhD, RD
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ABSTRACT
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Background. Vitamins and minerals are essential for systemic and oral health and the prevention of nutrient deficiencies. The author reviews recommendations for their use, consumer intake patterns and considerations for dental practice.
Conclusions. Vitamin and mineral supplements are designed to treat and prevent deficiency syndromes and promote health. Consumers frequently misuse them, as they are guided by the belief that these supplements will prevent diseases and cure symptoms. Scientific evidence demonstrates their limited usefulness in systemic disease prevention or treatment. The author reviews demonstrated benefits in select diseases.
Clinical Implications. Being familiar with the appropriate uses of vitamin and mineral supplements, as well as nutrient-supplement and drug-supplement interactions, will give dental professionals the knowledge to question and advise patients using evidence-based resources.
Key Words: Vitamin supplements; mineral supplements; dietary supplements; nutrients; nutritionAbbreviations: AHRQ: Agency for Healthcare Research and Quality • CVD: Cardiovascular disease • DRIs: Dietary reference intakes • FNB: Food and Nutrition Board • MVM: Multivitamin mineral supplements • RDA: Recommended dietary allowance
Vitamin and mineral supplements are the largest growing category of dietary supplements used. Despite their widespread use, their value in disease prevention is questionable. It is important that dentists be aware of the scientific evidence surrounding supplements, their use and misuse by consumers, and patient care considerations. This article focuses on one category of dietary supplements: vitamins and minerals.
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A HISTORICAL PERSPECTIVE
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The term "dietary supplements" is defined by the Dietary Supplement Health and Education Act of 19941 as products taken orally, "intended to supplement the diet" and includes vitamins and minerals. "Vitamins" are defined as "a group of substances essential for normal metabolism, growth and development, and regulation of cell function."2 They work with enzymes, coenzymes and other substances in the human body, each of which has a specific function. Minerals are essential inorganic elements that are provided by foods or supplements in small amounts.
Recommended intakes of vitamins and minerals are the purview of the Food and Nutrition Board (FNB) of the Institute of Medicine, National Academy of Sciences. In 1997, the FNB introduced the dietary reference intakes (DRIs), which are divided into four categories: recommended dietary allowances, estimated average requirement, adequate intake (AI) and tolerable upper intake level3 (Box 1
). This classification system addresses amounts of nutrients needed for disease prevention and health promotion.
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VITAMIN AND MINERAL SUPPLEMENT USE IN THE UNITED STATES
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Vitamin and mineral supplements are intended to provide nutrients to people who cannot adequately consume them from food sources owing to increased needs, decreased intake or altered metabolism. They are the most commonly used dietary supplements in the United States.4,5 In 2005, U.S. adults spent $20.3 billion on dietary supplements. Calcium, B vitamins and vitamins C and E were the top four vitamin or mineral supplements used.6 The primary reasons cited for their use were prophylaxis, disease prevention and disease management.
Multivitamin mineral (MVM) supplements are dietary supplements containing several vitamins and minerals—most commonly 10 vitamins and 10 minerals with 100 percent of the recommended intake.5 The most frequent users of MVM supplements are women, elderly people and people with higher incomes and education levels, as well as adults who are active, in good health and non-smokers and have a normal body mass index.4,5 In contrast, MVM use is lower among smokers, African-Americans, Hispanics and American Indians.
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VITAMINS, MINERALS AND ORAL AND SYSTEMIC DISEASES: STATE OF THE SCIENCE
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Despite widespread use, there is a lack of scientific evidence to support the use of MVM or single vitamin or mineral supplements beyond the DRI to prevent or treat oral diseases. Although vitamin C has been promoted as preventing and curing periodontal diseases, there is no scientific evidence for such outcomes. While increasing evidence supports a relationship between calcium and periodontal disease,7,8 a direct causative relationship has not been proven. Other than in the case of nutrient deficiency diseases such as pernicious anemia that include oral manifestations such as glossitis,9 there is no evidence that MVM can cure or prevent oral diseases.
In May 2006, the Agency for Healthcare Research and Quality (AHRQ) released an evidence report on MVM5; the National Institutes of Health concurrently published a state-of-the-science statement on MVM supplements and chronic disease prevention.10 The AHRQ report indicated that the "strength of the evidence on the efficacy of multivitamin mineral supplementation was rated as very low for primary prevention of cancer and cardiovascular disease (CVD)" and low for vitamin E and cancer and CVD. No efficacy data were found regarding use of vitamin C or B12, niacin, iron, magnesium or calcium/magnesium supplements in chronic disease prevention. Beta carotene use, however, was associated with increased risk of developing lung cancer and of experiencing mortality among heavy smokers.5 The "overall strength of the evidence is low for folic acid with or without vitamin B12 and moderate for vitamin B6" in the prevention of cognitive decline.5 Evidence was found for the combined use of calcium and vitamin D to prevent bone mineral loss and hip or nonvertebral fracture.5 Neither report provided evidence that MVM prevents or cures any oral disease.
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THE USE AND MISUSE OF VITAMIN AND MINERAL SUPPLEMENTS
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According to the American Dietetic Association,11 "Diets rich in a variety of foods ... support nutritional balance and supply nutrients that cannot be added to foods or nutrient supplements at optimal levels." Despite widespread use of MVM,4–6,12 there are several important tenets relating to the use of MVM supplements. Use of MVM in place of a varied diet consistent with the United States Department of Agriculture’s Food Guide Pyramid represents misuse, whereas adjunctive use of MVM to improve the nutritional quality of a diet when intake is compromised owing to masticatory difficulties, soft-tissue disorders or prolonged periods of edentulism or during adjustment to new dentures is appropriate. No single supplement, however, can replace the unique combination of nutrients that exist in a varied diet.
Safety is paramount when selecting supplement quantities, types and forms. While synergistic reactions can occur, antagonistic responses also can take place (Table 1).11,13–18 An imbalance in consumption of one nutrient can cause altered absorption, utilization and excretion of another13; for example, the use of supplemental folate can mask a vitamin B12 deficiency. Drug-supplement interactions are another concern. For example, drugs such as warfarin may vary in effect when changes in supplemental vitamin E or K intake occur. Different forms of nutrients are not equal. For example, although natural d-alpha tocopherol (vitamin E) is more expensive that the synthetic form, it is twice as active. In addition, chewable vitamin C can affect oral integrity by increasing risk of tooth erosion owing to its high acidity, while the pill form of vitamin C for swallowing does not.
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TABLE 1 Oral and systemic manifestations of vitamin and mineral supplement intake beyond the tolerable upper intake level.*
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Paracelsus, a 15th century physician, wrote, "Poison is in everything, and no thing is without poison. The dosage makes it either a poison or a remedy."19 Overall, MVM supplements are considered safe; however, when individual vitamins and minerals are taken in doses that exceed AI, they may lead to toxicity and increase the risk of patients’ experiencing nutrient-nutrient and drug-supplement interactions (Tables 1
and 2).13–18,20
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TABLE 2 Potential interactions between medications and vitamin and mineral supplements taken at doses greater than the tolerable upper limit.*
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FACTORS TO CONSIDER IN PATIENT CARE
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The need for dental professionals to be familiar with their patients’ MVM use is underscored by the issues described in this article, along with the systemic and oral health sequelae of supplements and potential nutrient-nutrient and drug-supplement interactions (Tables 1 and 2). Dentists should ask patients about supplement use, including frequency, dose and form, and advise them to use evidence-based resources for avoiding risks. Box 2 provides a suggested supplement use/risk screening tool, and Box 3 is a list of online resources regarding nutrition and vitamin and mineral supplement use for dental professionals to use. Registered dietitians are a professional resource for questions, guidance and patient referral.
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FOOTNOTES
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Dr. Touger-Decker is a professor and the program director, Graduate Programs in Clinical Nutrition, School of Health-related Professions, and a professor and the director, Division of Nutrition, New Jersey Dental School, University of Medicine and Dentistry of New Jersey, 65 Bergen St., Room 157, Newark, N.J. 07107-3001, e-mail "decker{at}umdnj.edu". Address reprint requests to Dr. Touger-Decker.
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REFERENCES
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- U.S. Food and Drug Administration. Dietary Supplement Health and Education Act of 1994: Public law 103-417—103rd Congress. Available at: "www.fda.gov/opacom/laws/dshea.html". Accessed Aug. 7, 2006.
- Medline Plus. Medical encyclopedia: Vitamins. Available at: "www.nlm.nih.gov/medlineplus/ency/article/002399.htm". Accessed Aug. 27, 2006.
- Institute of Medicine of the National Academies, Food and Nutrition Board. Dietary reference intakes. Available at: "www.iom.edu/project.asp?id=4574". Accessed Aug. 7, 2006.
- Radimer K, Bindewald B, Hughes J, Ervin B, Swanson C, Picciano MF. Dietary supplement use by US adults: data from the National Health and Nutrition Examination Survey, 1999–2000. Am J Epidemiol 2004;160(4):339–49.[Abstract/Free Full Text]
- Huang HY, Caballero B, Chang S, et al. Evidence report/technology assessment: No. 139—Multivitamin/mineral supplements and prevention of chronic disease. Agency for Healthcare Research and Quality: Rockville, Md.; 2006. AHRQ publication no. 06-E012.
- Nutrition Business Journal. Supplement business report 2005. San Diego: New Hope Natural Media, Pentron Media; 2005.
- Yoshihara A, Seida Y, Hanada N, Miyazaki H. A longitudinal study of the relationship between periodontal disease and bone mineral density in community-dwelling older adults. J Clin Periodontol 2004; 31(8):680–4.[Medline]
- White SC. Oral radiographic predictors of osteoporosis. Dentomaxillofac Radiol 2002;31(2);84–92.[Abstract]
- Touger-Decker R. Oral manifestations of nutrient deficiencies. Mt Sinai J Med 1998;65(5–6):355–61.[Medline]
- National Institute of Health. NIH state-of-the-science conference statement on multivitamin/mineral supplements and chronic disease prevention. Available at: "http://consensus.nih.gov/2006/MVMFINAL080106.pdf". Accessed Aug. 7, 2006.
- American Dietetic Association. Position of the American Dietetic Association: fortification and nutritional supplements. J Am Diet Assoc 2005;105(8):1300–11.[Medline]
- Balluz LS, Kieczak SM, Philen RM, Mulinare J. Vitamin and mineral supplement use in the United States: results from the Third National Health and Nutrition Examination Survey. Arch Fam Med 2000;9(3):258–62.[Abstract/Free Full Text]
- Institute of Medicine, Food and Nutrition Board. Dietary reference intakes: A risk assessment model for establishing upper intake levels for nutrients. Available at: "www.nap.edu/catalog/6432.html#toc". Accessed June 15, 2007.
- Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine. Dietary reference intakes for vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium and zinc. Washington: National Academy Press; 2001: 126–9, 357–60, 481–3.
- Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine. Dietary reference intakes for calcium, phosphorus, magnesium, vitamin D and fluoride. Washington: National Academy Press; 1997: 134–43, 180–6, 306–8.
- Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine. Dietary reference intakes for vitamin C, vitamin E, selenium and carotenoids: A report of the Panel on Dietary Antioxidants and Related Compounds Subcommittees on Upper Reference Intakes, and the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine. Washington: National Academy Press; 2000: 155–61, 253–4, 311–13.
- Institute of Medicine Standing Committee on the Scientific Evaluation of Dietary Reference Intakes; Institute of Medicine Panel on Folate, Other B Vitamins, and Choline; Institute of Medicine Subcommittee on Upper Reference Levels of Nutrients. Dietary reference intakes for thiamin, riboflavin, niacin, vitamin B6, folate, vitamin B12, pantothenic acid, biotin, and choline. Washington: National Academy Press; 1998: 138–42, 182–3, 273–7.
- National Library of Medicine, National Institutes of Health. Med-line Plus. Vitamins. Available at: "www.nlm.nih.gov/medlineplus/vitamins.html". Accessed Dec. 5, 2006.
- BrainyQuote. Paracelsus quotes. Available at: "www.brainyquote.com/quotes/authors/p/paracelsus.html". Accessed July 18, 2007.
- Slain D, Amsden JR, Khakoo RA, Fisher MA, Lalka D, Hobbs GR. Effect of high-dose vitamin C on the steady-state pharmacokinetics of the protease inhibitor Indinavir in healthy volunteers. Pharmacotherapy 2005;25(2):165–70.[Medline]
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ABSTRACT
A HISTORICAL PERSPECTIVE
