journal of dentistry 42 (2014) 14281435

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Tooth loss and its association with dietary intake

and diet quality in American adults
Yong Zhu a,*, James H. Hollis b
a
b

Department of Epidemiology, The University of Iowa, Iowa City, IA 52242, United States
Department of Food Science and Human Nutrition, Iowa State University, Ames, IA 50011, United States

article info

abstract

Article history:

Objectives: To investigate associations between the number of natural teeth and energy

Received 12 July 2014

intake, nutrient intake, and diet quality in adults.

Received in revised form

Methods: Eligible adults who participated in the National Health and Nutrition Examination

6 August 2014

Survey during 20052008 were included in the present study (n = 9140). Participants were

Accepted 21 August 2014

classified into three groups depending on the total number of natural teeth (excluding third
molars): full dentition (28 teeth), moderate dentition (2127 teeth), and poor dentition (20
teeth or less). Dietary intake and diet quality were estimated from the first 24-h dietary recall

Keywords:

data.

Tooth loss

Results: Participants in the poor dentition group had significantly lower energy intake than

Epidemiology

those with moderate dentition (P < 0.05), however, both groups did not significantly differ

Nutrition

from those who had full dentition. Adjusting for sociodemographic characteristics, physical

Dietary intake

activity, smoking status, and energy intake, the intake of protein as well as most vitamins
and minerals were positively associated with the total number of natural teeth (P < 0.05); an
inverse association was observed for carbohydrate intake (P < 0.001). Diet quality, as
measured by the Healthy Eating Index 2005, was inversely associated with tooth loss
(P < 0.001).
Conclusions: Tooth loss in adults is associated with lower diet quality and reduced intake of
most nutrients; this may partly explain for the higher risk of chronic diseases in this
population.
Clinical significance: People with missing teeth are recommended to monitor their dietary
intake to avoid nutrient deficiency and to improve their diet quality for better health.
# 2014 Elsevier Ltd. All rights reserved.

1.

Introduction

Tooth loss in adults is a common condition resulting from

ageing, poor oral care, or injury. Recent data reported that
American adults aged 2064 years have an average of 25 teeth;

for adults over 65 years old, the number is 19.1 Several studies
have shown that tooth loss in adults is associated with an
increased risk of chronic diseases such as obesity,27 cardiovascular diseases,8,9 diabetes,913 and certain types of cancer.14,15 Similar results have been reported by studies that
examined the associations exclusively in older adults.1623

* Corresponding author at: The University of Iowa, W265 BioVentures Center, Iowa City, IA 52242, United States. Tel.: +1 319 335 4588.
E-mail address: yong-zhu-1@uiowa.edu (Y. Zhu).
http://dx.doi.org/10.1016/j.jdent.2014.08.012
0300-5712/# 2014 Elsevier Ltd. All rights reserved.

journal of dentistry 42 (2014) 14281435

The relationship between tooth loss and chronic diseases

may partly be explained by changes in dietary intake, as a
balanced diet contributes to reduced risk of chronic diseases.24
For people with missing teeth, their chewing ability is reduced
as the number of natural teeth decreases.25,26 As a result, there
may be changes in their dietary choices such as a reduction in
the intake of harder foods including certain fruits and
vegetables, leading to reduced intake of certain nutrients.2643
Among studies that have evaluated the impact of tooth loss
on dietary intake,2643 the majority have only focused on older
adults.2637 This is likely due to the fact that older adults are at
a higher risk of tooth loss than young adults;44 nonetheless,
studies that included young and middle-aged adults are
needed to support many studies that have shown significant
associations between tooth loss and chronic diseases in the
general adult population.215 A limited number of studies did
include young or middle-aged adults in their study sample;
however, they were usually conducted in a defined population
such as veterans,38 dentists,39 health professionals40 or
nurses.41 Two studies have sampled participants from the
general population; nevertheless, the investigation was limited to intake of certain foods such as carrots, tossed salads, and
dietary fibre,42,43 rather than a comprehensive examination of
dietary and nutrient intake. In addition, none of these studies
examined diet quality in relation to tooth loss.3843 Therefore,
studies to investigate associations between tooth loss and
overall dietary intake and diet quality in the general adult
population are needed to fill these gaps.
Using data from the National Health and Nutrition
Examination Survey (NHANES), the present study evaluated
the associations between the total number of natural teeth
and diet in a nationally representative adult population.
Energy intake, nutrient intake, and diet quality were examined. It was hypothesized that tooth loss in adults was
associated with lower diet quality and reduced energy and
nutrient intake.

2.

Materials and methods

2.1.

Data source and study population

The NHANES was conducted by the National Centre for Health

Statistics and involved interview, physical examination, 24-h
dietary recalls, and laboratory tests of sampled participants.45
The NHANES dietary interview component was What We Eat
in America, to assess the types and amount of foods and
beverages consumed during the 24-h period reported by
participants.45 In 20052008, the NHANES oral health examination included a tooth count for participants who were at
least 5 years old by trained health technologists. The
methodology, quality controls, and de-identified data sets of
the NHANES are publicly available.45 The NHANES were
conducted according to the guidelines laid down in the
Declaration of Helsinki and all procedures were approved by
National Centre for Health Statistics Research Ethics Review
Board. Written informed consent was obtained from all
participants.
The present study combined data from the NHANES 2005
2006 and the NHANES 20072008. Adults aged 19 years or older,

1429

who completed the oral health examination were initially

included (n = 9869). Among them, 14 participants had at least
one tooth not assessed, 433 were pregnant or lactating
women, 291 had an unreliable dietary recall as determined
by NHANES staff. Participants who were in at least one of the
above categories were excluded (n = 729), giving a final sample
size of 9140 participants in the present study.

2.2.

Exposure and outcome variables

For each tooth assessed, a status was recorded in the NHANES

oral health examination dataset (primary tooth present,
permanent tooth present, tooth not present, or permanent
dental root fragment present). Based on this information, a
binary variable was created in the present study for each tooth
to indicate if the natural tooth was present, with a value of 1
if primary or permanent tooth present, and 0 if tooth not
present or permanent dental root fragment present. The total
number of natural teeth, excluding third molars, was then
calculated. Participants were then categorized into three
groups: full dentition (28 teeth), moderate dentition (2127
teeth), and poor dentition (20 teeth or less). Participants with
20 teeth or less were considered as having poor dentition
because people with at least 21 teeth are able to chew most
foods without difficulty.46 The same number was used in
previous dental studies.29,30,43
Data from the first 24-h dietary recall was used to estimate
energy intake, nutrient intake and diet quality. The NHANES
processed 24-h dietary recall data using the United States
Department of Agricultures Food and Nutrient Database for
Dietary Studies, to calculate energy and nutrients from each
reported food item. Diet quality was measured using the
Healthy Eating Index 2005 (HEI-2005).47,48 The HEI-2005
contains 12 food groups that can be used to evaluate the
overall diet quality; it has 9 adequacy components and 3
moderation components; reported food items under each
component were standardized to percent of 4189 kJ
(1000 kcal), then compared to Dietary Guidelines for Americans 2005; a higher score indicates better compliance with
dietary guidelines, i.e., higher intake of foods from the
adequacy components and lower intake of foods from
moderation components.47,48 The HEI-2005 total and component scores were calculated using SAS programmes developed
by the Centre for Nutrition Policy and Promotion at the United
States Department of Agriculture.49

2.3.

Covariates

The covariates included in the analysis were age, gender, race/

ethnicity, ratio of family income to poverty, physical activity,
smoking status, and energy intake.30,5052 For race/ethnicity,
participants were recoded to one of the four groups: hispanic,
non-hispanic white, non-hispanic black, and other.53 For ratio
of family income to poverty, it was recoded to a three-level
categorical variable.54 Because previous studies found physical activity55 and smoking5658 were associated with tooth loss,
they were included as covariates in the present study. Physical
activity was coded using responses from questions does your
work involve vigorous-intensity activity that causes large
increases in breathing or heart rate and do you do any

1430

journal of dentistry 42 (2014) 14281435

moderate-intensity sports, fitness, or recreational activities

that cause a small increase in breathing or heart rate from the
physical activity questionnaire, then categorized into one of
the three groups: vigorously active, moderately active,
sedentary. Smoking status was defined as non-smoker (who
smoked less than 100 cigarettes in entire lifetime), former
smoker (who smoked at least 100 cigarettes in entire life and
do not smoke currently), and current smoker (who smoked at
least 100 cigarettes in entire life and currently smoke some
days or every day).30 Energy intake was obtained from the total
energy intake in the 24-h dietary recall.

2.4.

Statistical analyses

The data were analysed by SAS version 9.3 (SAS Institute, Inc.).
Four-year sample weight and specific survey procedures were
used in all statistical models to account for the complex multistage design in the NHANES. Survey Chi-square tests were
used to compare characteristics of participants among
different dentition groups. Survey linear regression was used
to compare covariate-adjusted least square means of total
energy intake, nutrient intake, and HEI-2005 scores. In
addition, a sensitivity analysis was conducted to compare
those with 120 teeth and edentate adults among the poor
dentition group. For categorical variables, data were presented
as a weighted percentage  standard error; for continuous
variables, data were presented as least square mean  stanstandard error. P < 0.05 was considered to be statistically
significant.

3.

Results

3.1.

Characteristics of participants

Excluding third molars, 3148 participants had 28 teeth, 3452

had 2127 teeth, and 2540 had 20 teeth or less; the weighted
percentages were 41.9  1.4%, 38.4  0.9%, and 19.7  1.4%,
respectively. The distributions of gender, race/ethnicity, ratio
of family income to poverty, physical activity, and smoking
status were significantly different among the three groups
(P < 0.001 for all, Table 1). The percentages of females, nonhispanic blacks, people with a lower ratio of family income to
poverty, sedentary people, and current smokers were higher
in people with a poor dentition status, compared to those who
had full dentition or had a moderate number of missing teeth.

3.2.

Energy intake and nutrient intake

The unadjusted energy intake was inversely associated with

the total number of natural teeth (P < 0.001). When age,
gender, race/ethnicity, ratio of family income to poverty,
physical activity, and smoking status were adjusted, participants who had 20 teeth or less had significantly lower energy
intake than those who had 2127 teeth (P < 0.05), however,
both groups did not significantly differ from those who had full
dentition (Table 2).
Adjusting for age, gender, race/ethnicity, ratio of family
income to poverty, physical activity, smoking status, and

Table 1 Characteristics of 9140 adults by the total number of natural teetha: National Health and Nutrition Examination
Survey 20052008.
Full dentition
(28 teeth)

Moderate dentition
(2127 teeth)

Poor dentition
(20 teeth)

nb

Weighted%c

nb

Weighted%c

nb

Weighted%c

Gender
Male
Female

1705
1443

53.1  0.8
46.9  0.8

1725
1727

47.7  1.0
52.3  1.0

1274
1266

46.4  1.9
53.6  1.9

Race
Hispanic
Non-hispanic White
Non-hispanic black
Other

892
1570
550
136

12.2  1.2
74.2  2.1
8.2  1.0
5.3  0.7

970
1618
721
143

13.5  1.4
69.5  2.4
11.2  1.4
5.7  0.7

487
1285
703
65

8.4  1.4
72.2  3.3
15.5  2.3
3.9  0.7

Ratio of family income to poverty

1.85
1.863.49
3.50

1060
705
1205

22.8  1.6
23.6  1.4
53.6  2.3

1227
839
1155

26.7  1.3
25.9  1.2
47.4  1.6

1298
624
428

45.7  1.7
29.4  1.2
25.0  1.9

Physical activity
Vigorously active
Moderately active
Sedentary

1137
966
1045

37.5  1.5
33.8  1.7
28.7  1.2

899
1064
1489

27.8  1.1
33.8  1.3
38.3  1.3

347
604
1589

15.3  0.9
26.2  1.9
58.5  1.7

Smoking status
Non-smoker
Former smoker
Current smoker

1757
571
531

60.3  1.3
21.2  0.9
18.5  1.0

1777
847
766

50.8  1.4
24.9  1.0
24.3  1.3

975
872
690

34.5  1.3
33.2  1.7
32.2  1.7

a
b
c
d

P valued

<0.001

<0.001

<0.001

<0.001

<0.001

Excluded the third molars.

The total n by each specific characteristic may be less than the total number of participants (9140) due to missing values.
Data were expressed as weighted percentage  standard error.
P value was obtained from bivariate analysis of the association between the dentition status and the specific characteristic.

1431

journal of dentistry 42 (2014) 14281435

Table 2 Energy intake and nutrient intake of 9140 adults by the total number of natural teetha: National Health and
Nutrition Examination Survey 20052008.
Full dentition
(28 teeth)
Energy intake (kJ)
Unadjusted
Adjustedb
Nutrient intakec
Protein (g)
Total fat (g)
Saturated fatty acids (g)
Monounsaturated fatty acids (g)
Polyunsaturated fatty acids (g)
Cholesterol (mg)
Carbohydrate (g)
Total dietary fibre (g)
Alcohol (g)
Vitamin A as retinol activity equivalents (mg)
Vitamin E as alpha-tocopherol (mg)
Vitamin C (mg)
Vitamin K (mg)
Thiamin (mg)
Riboflavin (mg)
Niacin (mg)
Vitamin B6 (mg)
Total folate (mg)
Vitamin B12 (mg)
Choline (mg)
Calcium (mg)
Phosphorus (mg)
Magnesium (mg)
Iron (mg)
Zinc (mg)
Copper (mg)
Sodium (mg)
Potassium (mg)
Selenium (mg)

9684  117*
8694  112*z

83.3  1.0*
80.9  0.9*
26.1  0.3*
30.1  0.4*
17.7  0.4*
308.3  7.6*
248.1  2.3*
16.6  0.3*
11.6  0.7*
602.5  14.0*
7.5  0.2*
96.7  3.3*
119.2  5.8*
1.62  0.02*
2.13  0.03*
24.8  0.3*
1.98  0.03*
411.3  6.2*
5.4  0.2*
340.3  4.9*
886.0  14.6*
1304.4  9.1*
306.7  3.0*
15.5  0.2*
12.4  0.4*z
1.39  0.03*
3481  52*
2697  30*
112.0  1.6*

Moderate dentition
(2127 teeth)

Poor dentition
(20 teeth)

P value

9046  83z
8736  91*

7942  169y
8346  165z

<0.001
0.043

82.5  0.9*
80.2  0.8*
26.2  0.3*
29.6  0.3*
17.5  0.2*
305.6  6.4*
250.2  2.1*
15.6  0.2z
11.7  0.8*
587.1  13.2*
7.2  0.1*
90.3  2.8*z
106.4  6.3z
1.56  0.03z
2.13  0.03*
24.6  0.3*z
1.95  0.02*
387.7  6.8z
5.3  0.1*
339.9  4.1*
861.9  15.3*
1290.6  10.1*
297.5  3.8z
14.8  0.2z
12.0  0.3*
1.36  0.03*
3374  48z
2686  25*
110.5  1.4*z

79.1  0.9z
79.3  0.6*
26.2  0.3*
29.6  0.3*
16.6  0.2z
307.9  8.0*
258.4  2.1z
14.0  0.2y
9.5  0.7z
528.4  19.9z
6.5  0.1z
82.5  3.1z
89.8  6.0y
1.55  0.02z
2.08  0.03*
24.0  0.3z
1.82  0.03z
372.6  7.1z
4.8  0.2z
324.5  5.0z
817.3  17.6z
1225.0  14.9z
271.8  3.4y
14.5  0.1z
11.3  0.3z
1.26  0.03z
3361  31z
2510  26z
107.6  1.3z

<0.001
0.185
0.904
0.428
0.001
0.908
<0.001
<0.001
0.041
0.018
<0.001
0.010
<0.001
0.004
0.404
0.059
0.001
<0.001
0.030
0.031
0.003
<0.001
<0.001
0.001
0.116
0.009
0.033
<0.001
0.039

Note: Groups with different symbols (*, z, y) in the same row were significantly different (P < 0.05).
Excluded the third molars; data were expressed as the least square mean  standard error.
b
Adjusting for age, gender, race/ethnicity, ratio of family income to poverty, physical activity, and smoking status.
c
Adjusting for age, gender, race/ethnicity, ratio of family income to poverty, physical activity, smoking status, and energy intake.
a

energy intake, the intake of protein, polyunsaturated fatty

acids, total dietary fibre, alcohol, vitamin A, vitamin E, vitamin
C, vitamin K, thiamin, niacin, vitamin B6, total folate, vitamin
B12, choline, calcium, phosphorus, magnesium, iron, zinc,
copper, sodium, potassium, and selenium were significantly
lower in those with poor dentition compared to participants
with full dentition (P < 0.05 for all, Table 2), although the intake
of most nutrients did not differ between the full dentition group
and the moderate dentition group. There was no difference in
the intake of total fat, saturated fatty acids, monounsaturated
fatty acids, cholesterol, and riboflavin among the three groups
(P > 0.05). However, those in the poor dentition group had
significantly higher intake of carbohydrate than participants
from both full and moderate dentition groups (P < 0.001).

3.3.

Diet quality

The total number of natural teeth was positively associated

with diet quality, as those with more remaining teeth had a
higher HEI-2005 total score (P < 0.001, Table 3) when adjusting
for age, gender, race/ethnicity, ratio of family income to

poverty, physical activity, smoking status, and energy intake.

Similarly, most HEI-2005 component scores were significantly
different among the three groups, except meat and beans from
the adequacy component, and saturated fat from the
moderation component (Table 3). Specifically, scores of total
fruit, whole fruit, total vegetables, whole grains, and milk in
the adequacy component, as well as solid fat, alcohol, and
added sugar (SoFAAS) energy in the moderation component
were positively associated with the total number of natural
teeth, indicating higher intake of corresponding food items in
the adequacy components, as well as less intake of energy
from SoFAAS (P < 0.05 for all). In agreement to the sodium
intake data, the HEI-2005 sodium component score was lower
in those with full dentition (P < 0.05), indicating higher intake
of sodium in this group, compared to those who had missing
teeth.

3.4.

Sensitivity analysis

Results from the sensitivity analysis showed no significant

differences between those with 120 teeth and edentate adults

1432

journal of dentistry 42 (2014) 14281435

Table 3 Adjusted HEI-2005 total and component scores of 9140 adults by the total number of natural teetha: National
Health and Nutrition Examination Survey 20052008.
HEI-2005 component
scoreb (maximum)
Total HEI-2005 (100)
Adequacy component
Total fruit (5)
Whole fruit (5)
Total vegetables (5)
Dark green/orange
vegetables/legumes (5)
Total grains (5)
Whole grains (5)
Milk (10)
Meat and beans (10)
Oils (10)
Moderation component
Saturated fat (10)
Sodium (10)
Solid fat, alcohol, and
added sugar calories (20)

Full dentition
(28 teeth)

Moderate dentition
(2127 teeth)

Poor dentition
(20 teeth)

P value

53.67  0.51*

52.07  0.45z

48.92  0.50y

<0.001

2.46  0.07*
2.27  0.09*
3.13  0.06*
1.46  0.07*

2.29  0.07*
2.13  0.08*
2.95  0.05z
1.24  0.06z

2.10  0.07z
1.91  0.08z
2.79  0.06y
1.06  0.06y

0.011
0.008
<0.001
<0.001

4.16  0.04*
1.15  0.05*
4.36  0.10*
8.49  0.11*
5.40  0.15*

4.03  0.04z
1.04  0.05z
4.18  0.11*
8.37  0.09*
5.38  0.12*

4.18  0.04*
0.84  0.05y
3.81  0.13z
8.34  0.10*
4.89  0.13z

0.002
<0.001
<0.001
0.504
0.006

5.98  0.15*
3.66  0.12*
11.03  0.26*

5.97  0.12*
4.01  0.12z
10.47  0.26z

5.96  0.13*
3.97  0.11z
9.07  0.30y

0.994
0.011
<0.001

Note: Groups with different symbols (*, z, y) in the same row were significantly different (P < 0.05).
Excluded the third molars.
b
Data were expressed as the least square mean  standard error, adjusting for age, gender, race/ethnicity, ratio of family income to poverty,
physical activity, smoking status, and energy intake.
a

on all outcomes examined in this study, except lower intake of

total fibre and vitamin K in edentate adults was found
(P < 0.05).

4.

Discussion

In this study, data from a nationally representative sample

revealed that tooth loss in adults was significantly associated
with diet quality and nutrient intake. Specifically, a poor
dentition status (less than 21 teeth) was associated with
reduced intake of protein and most micronutrients, as well as
increased intake of carbohydrate; meanwhile, the full dentition status was associated with better diet quality and better
compliance to dietary guidelines for most food groups.
In the present study, participants with 20 teeth or less had
lower intake of energy intake than those with 2127 teeth,
although both groups did not differ significantly from the full
dentition group when confounding factors were adjusted for.
Ervin and Dye30 found that, among older adults without
replaced teeth, there were no differences in energy intake
between those with 20 natural teeth or less and those with 21
natural teeth or more; however, among those with replaced
teeth, significantly lower energy intake was found in older
males with 21 natural or replaced teeth or more, although such
significant differences were not found in older females. By
contrast, Krall et al.38 reported males with full dentition had
higher energy intake than males with less than 14 teeth on
only one side of mouth and no removable dentures, although
no differences were found in other groups except lower energy
intake in those who used complete dentures. While results
from these studies30,38 may not be directly comparable due to
inconsistent classification of dentition status, both data
suggest that use of dentures may have influenced the
associations between tooth loss and energy intake. As

information about denture use was not available in the

present study, additional studies are needed to address this
limitation and examine possible biological explanations for
relationships between energy intake and tooth loss.
Results from the present study are in agreement with some
previous studies, which reported tooth loss is associated with
lower intake of protein,26,32 higher intake of carbohydrate,39
but not with fat intake.26,32,39 Several other studies also
examined macronutrient intake but failed to observe significant associations between any macronutrient intake and the
number of natural teeth.28,29,37,38 These inconsistent results
may be explained, in part, by different study populations
ranging from a defined subpopulation to a nationwide
population in different countries such as Great Britain,26,32
Italy,28 Japan,37,39 and United States,29,38 where different
dietary patterns would be expected; as well as whether total
energy intake was adjusted when estimating nutrient intake.37,38 In addition, a smaller sample size may have
contributed to some non-significant results.37
Unlike the equivocal results on macronutrients, consistent
results on the positive associations between intake of many
micronutrients and the total number of natural teeth have
been reported by previous studies in older adults2630,32,34,35 as
well as studies that included young or middle-aged adults.3841
The associations with intake of micronutrients are likely due
to changes in dietary choices because of tooth loss. For
example, fruits and vegetables are good sources for many
micronutrients; nonetheless, the impaired chewing ability due
to tooth loss may result in reduced intake of fruits and
vegetables. This is supported by lower scores in participants
with missing teeth for the HEI-2005 components including
total fruit, whole fruit, total vegetables, dark green/orange
vegetables/legumes observed in the present study. In addition,
previous studies also reported intake of fruits and vegetables
were inversely related to missing teeth.26,31,33,3537,4042 Tsakos

journal of dentistry 42 (2014) 14281435

et al.36 examined intake of certain types of fruits and

vegetables; it was found intake of raw carrots and apples,
but not lettuce, was significantly different by dentition status.
Sheiham and Steele26 also reported that participants with
missing teeth had a greater difficulty in eating raw carrots and
apples but not lettuce and oranges. These data suggested that
food hardness potentially has an important role in dietary
choices.
Whole fruits and vegetables as well as whole grains are
good sources for dietary fibre.59 Many previous studies
reported that the intake of dietary fibre was higher in people
with fewer missing teeth.30,35,3743 Data from the present study
further support the positive relationship between dietary fibre
intake and the total number of natural teeth; meanwhile, the
component scores for the whole fruit, total vegetables, and
whole grains in the HEI-2005 were also higher in the full
dentition group. Taken together, the beneficial effects of fruits
and vegetables consumption, higher intake of whole grains
and dietary fibres, as well as improved micronutrient
intake,5962 could provide explanations, in part, for the
previous studies that observed significant associations between tooth loss and risk of chronic diseases.223
Previous studies in older adults reported that tooth loss is
associated with lower diet quality.29,34,35 Nonetheless, such
conclusion may not be directly transferable to the general
adult population since a previous study reported older adults
had better diet quality than young or middle-aged adults.63
Results from the current study indicated that the HEI-2005 in
adults was positively related to the total number of natural
teeth, with most HEI-2005 components being significantly
different. Improved diet quality plays an important role for
prevention and management of chronic diseases.64 This
further supports previous studies that reported relationships
between tooth loss and chronic diseases in adults.223
Nonetheless, the sodium component score of the HEI-2005
was significantly lower in the full dentition group. The data
emphasizes that American adults should be aware of their
high sodium intake and choose low sodium products for a
better diet.
The strength of the present study included use of a
nationally representative sample from the general adult
population, objective assessment of teeth number rather than
self-reported teeth number, and investigation of diet quality.
Nonetheless, the study also had several limitations. First, the
observed associations do not indicate any causal relationships. For example, higher intake of carbohydrate may not
necessarily have resulted from tooth loss; it is also possible
that intake of high-carbohydrate food contributed to the
development of dental decay and tooth loss.39 Second,
because validated statistical methods for estimation of HEI2005 based on multiple dietary recalls are still under
development; like previous studies,29,35,63 only data from a
single 24-h dietary recall were used to estimate diet quality;
this might not necessarily represent the habitual dietary
pattern. Third, the oral health examination in the NHANES
20052008 did not count implanted teeth nor included a
complete assessment of denture use; as a result, analyses
were only available for the total number of natural teeth in the
present study, without estimating how the associations may
be modified by dental restoration or denture use. Previous

1433

studies have shown that the chewing ability was still lower in
denture wearers compared to dentate participants,65 and
denture wearers had a lower intake of certain types of foods
and nutrients compared to fully dentate people.38,42 In
addition, the quality of remaining teeth and functional
occlusion pairs have not been examined and warrant
investigations by future studies.

5.

Conclusions

Results from the present study suggested the total number of

natural teeth is significantly associated with dietary intake
and diet quality in American adults. The inverse relationship
between tooth loss and nutrition observed in this study may
provide explanations for previous studies that have shown
significant associations between tooth loss and chronic
diseases in adults. Prevention of tooth loss may have a critical
role for a balanced diet and for prevention of chronic diseases.

Acknowledgements
The authors thank the investigators and participants of the
NHANES. The study received no financial support.

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