Vitamin D: Bone Health and Implant Integration

Vitamin D has received a lot of press lately because it is being advised for the prevention and treatment of COVID-19. As with all things related to COVID, the urgency to find therapies has rushed studies and pressured physicians to use therapies before a full understanding of their effectiveness is obtained and the use of vitamin D for COVID is a case in point. However, we do have good research on vitamin D in many other areas. Since vitamin D is associated with bone health, bone science is a primary repository of all things vitamin D. This quick summary will cover some of the knowledge we have of vitamin D regarding various diseases and will end with a discussion of vitamin D, bone health, and dental implant integration.

Gene Regulation
The vitamin D receptor (VDR) is present in virtually all cells and tissues. It has been estimated that 3% to 10% of all genes are under the direct or indirect control of 1,25(OH)2D3, so the potential effect of vitamin D on the body is very large.

Cardiovascular Disease
Vitamin D supplementation has no effect on any individual’s cardiovascular event, such as myocardial ischemia, or in the composite cardiovascular end points.

Cancer
Vitamin D status has no influence on cancer incidence, but supplementation with vitamin D does reduce cancer mortality. This finding is most likely associated with the fact that vitamin D is antiproliferative. We will discuss the antiproliferative aspect of vitamin D when we discuss implant integration.

Diabetes
Vitamin D supplementation for those who are predisposed to diabetes showed no reduction on the incidence of diabetes mellitus (DM). However, when the treatment group was limited to those deficient in vitamin D with a baseline of 25OHD <12 ng/mL (or < 30 nmol/L), the results showed a 62% reduction in the development of DM in the vitamin D group. This is a common finding when studying vitamin D. Giving vitamin D to the general population shows no benefit, but when you locate those who are deficient in vitamin D, supplementation then shows a benefit. The key to this fact is that only 6% of the population in the US is deficient in vitamin D. We will discuss this more in relationship vitamin D status as related to bone health.

Relationship to COVID-19
he reason why vitamin D was tried in the first place was the knowledge that in patients with vitamin D deficiency, it has been found to reduce the risk of respiratory infection. In an individual participant data meta‐analysis of 15 RCTs (randomized clinical trials), daily or weekly supplementation in individuals with vitamin D deficiency, defined as a serum 25OHD level <10 ng/mL, reduced risk of acute respiratory infection by 30% (odds ratio, 0.30; 95% CI, 0.17–0.53). The key here, again, is in order for vitamin D to have any benefit, the patients needed to be deficient in vitamin D and very few healthy people in the US are.

Vitamin D is Produced by UVB Light from the Sun
UVB light (wavelength of approximately 280 to 310 nm) opens the B ring of 7‐dehydrocholesterol, the last step in the synthesis of cholesterol, and generates pre-vitamin D, which undergoes thermally-induced isomerization into vitamin D3 before being transferred into the circulation by binding to the serum vitamin D binding protein (DBP). From the following graph, you can see that vitamin D production from sun exposure is very efficient and only a small amount of exposure is required to maximize vitamin D production:

Am J Clin Nutr. 2008 Aug;88(2):570S-577S. doi: 10.1093/ajcn/88.2.570S.

Vitamin D and Bone Health
There is an ongoing debate regarding the definition of vitamin D deficiency as noted by different recommendations from various expert groups. However, there is consensus on two points:

25OHD levels below 12 ng/mL (30 nmol/L) are clearly deficient at all ages
25OHD levels above 30 ng/mL (75 nmol/L) are clearly sufficient

Many refer to those who are between 12 ng/ml and 30ng/ml as insufficient. Most studies do not find supplementing those who are insufficient with vitamin D to have to have any beneficial effect from supplementation with vitamin D.

Data from the National Health and Nutrition Examination Survey (NHANES) for 2007 through 2010 found that less than 6% of Americans had vitamin D levels less than 12 ng/mL (30 nmol/L). If supplementation is only beneficial for those who are deficient and only 6% of the population is deficient, widespread testing of individuals for vitamin D is of little value.

Dr. Finkelstein is a professor of endocrinology at Harvard Medical School and the associate director of the Bone Density Center at Massachusetts General Hospital, agrees with the authors of an NEJM article on vitamin D that states that we are currently over-screening for vitamin D deficiency and overtreating people who are getting enough vitamin D through diet and sun exposure. “Vitamin D has been hyped massively,” he states. “We do not need to be checking the vitamin D levels of most healthy individuals.”

All that said, most experts, including Dr. Finkelstein, agree we should be checking vitamin D levels in high-risk people — those most at risk for a true deficiency. These include people with anorexia nervosa, people who have had gastric bypass surgeries, who suffer from other malabsorption syndromes like celiac sprue, or who have dark skin with little sun exposure, or wear total skin covering (and thus absorb less sunlight).

So what do we know about vitamin D supplementation and bone?

A study looking at supplemental vitamin D3 versus placebo for 2 years in general healthy adults not selected for vitamin D deficiency did not show improvement in bone mineral density (BMD) or bone structure.

Among participants with baseline free 25(OH)D (FVD) levels below the median (<14.2 pmol/L), there was a slight increase in spine aBMD (0.75% versus 0%; p = 0.043) and attenuation in loss of total hip aBMD (-0.42% versus -0.98%; p = 0.044) with vitamin D3.

So, the effect of these studies on vitamin D supplementation and bone health is that even in the 6% of the population that is deficient in vitamin D, supplementation with vitamin D had little effect on bone density.

However, it has been found that combined vitamin D and calcium supplements can reduce the risks of hip and nonvertebral fractures in the elderly.

The reason for these findings is that osteoporosis is not a disease caused by vitamin deficiency. The primary purpose for vitamin D is the regulation of calcium blood concentration. Vitamin D facilitates the absorption of calcium in the gut, Vitamin D promotes calcium reuptake in the kidney and is responsible for moving calcium in and out of the bone to maintain closely regulated calcium concentrations in the blood to make calcium available throughout the body. To date, we are unaware that vitamin D has been found to have any direct effect on the process of bone mineralization.

One fact about vitamin D supplementation that is well established is that over-supplementation of vitamin D will induce bone resorption. Among healthy adults, treatment with vitamin D for 3 years at a dose of 400 IU per day, 4,000 IU per day, or 10,000 IU per day, resulted in statistically significant lower radial BMD with the 4,000 IU and 10,000 IU per day dose when compared to the 400 IU group. Again, we find that only modest levels of vitamin D are adequate for bone health and higher levels of supplementation resulted in bone loss.

So what can we do to ensure we have the proper level of vitamin D without doing harm to our skin or our bones?

We can take a supplement of 400 IU per day, or we can get our vitamin D from the sun. Approximately 15–30 minutes of sun exposure, particularly between 10 a.m. and 4 p.m., either daily or at least twice a week to the face, arms, hands, and legs without sunscreen usually leads to sufficient vitamin D synthesis.

As you recall, vitamin D does not prevent cancer development, but reduces mortality from cancer. Also, we found the levels of vitamin D between 4,000 IU and 10,000 IU can lead to bone loss. The underlying mechanism for these findings is that vitamin D is antiproliferative. Vitamin D reduces cancer cell proliferation and reduces osteoblast and marrow stromal cell proliferation.

We have discussed how osteoporosis is not caused by vitamin D deficiency; however, osteomalacia is caused by lack of vitamin D. Now let us discuss the differences in these two diseases.

Definition of Osteoporosis:
Osteoporosis is a bone disease which is characterized by low bone mass as result of the body losing too much bone and making too little bone. This leads to increased bone fragility and increased susceptibility to fracture, especially in the hip, spine, wrist, and shoulder. Osteoporosis means “porous bone.” Healthy bone looks like a honeycomb. Once osteoporosis happens, the holes and spaces in the honeycomb are much larger than in healthy bone.

Definition of Osteomalacia:
It is the softening of the bones due to impaired bone metabolism as result of insufficient levels of phosphate, calcium, and vitamin D. All of this leads to inadequate bone mineralization. Osteomalacia in children is known as rickets.

We know that vitamin D deficiency can cause the bone disease called osteomalacia, but has anyone ever seen a patient who has osteomalacia? Probably not. We know that vitamin D deficiency is rarely found in the U.S., and even when it is found, we can easily identify those patients who would benefit from screening for vitamin D deficiency as listed above. But we now have some in dentistry who are claiming that all implant patients should be screened for vitamin D deficiency prior to dental implant placement.

Let us review the claims being made by Dr. Richard Miron and see how his claims match up to the facts:

Dr. Miron states that 70% of the US population is deficient in Vitamin D.

This is clearly false because the facts are that only 6% of the population is deficient in vitamin D.

Dr. Miron cites a study and claims that vitamin D deficiency resulted in a 66% reduction in implant pull out forces.

This was an animal study. Additionally, it was a vitamin D absence study, not a vitamin D deficiency study. Animals were fed a vitamin D free diet and housed in the dark with no light. Obviously, the animals developed osteomalacia and had reduced pull out forces, but the only relevance of the study was that the animal survived. This study has no clinical relevance to the real world.

The main study that Dr. Miron uses to support his claim that vitamin D is related to implant integration failure is the following study:

Low serum vitamin D and early dental implant failure: Is there a connection? A retrospective clinical study on 1740 implants placed in 885 patients.

Dr. Miron refers to a chart of the results and claims that vitamin D deficiency was found to cause a high level of early implant failure. Here are the statistics from the study:

3 early implant failures (11%) in the group that was vitamin D deficient with a level of <10ng/ml
20 early implant failures (4.4%) in the group with levels between 10 and 30 ng/ml
12 early implant failures (2.9%) in the group with levels >30 ng/ml

Dr. Miron claims that this study proves that vitamin D deficiency causes early implant failure. However, the authors of the study did not agree with Dr. Miron’s assessment because they explicitly stated in the abstract that there was no statistically significant relationship between vitamin D and early implant failure.

Does Dr. Miron tell you that there was no statistical relationship between vitamin D and early implant failure? Of course not. He tells you the exact opposite.

In one presentation, Dr. Miron claims that the early implant failure in his practice is 100% caused by vitamin D deficiency. He then goes on to tell you how much money you can make by requiring your patients to take his DentaMedica supplements. He also claims that you could be subject to malpractice if you do not test and prescribe vitamin D for all your implant patients.

Here we have Dr. Miron telling you the only cause of early implant failure is vitamin D deficiency. Therefore, you only need to prescribe his supplements and you will never have an early implant failure. It is not surprising that Dr. Miron would be capable of making such a foolish statement because many in the profession bought into his foolish statements about PRF regenerating bone. What is remarkable is that he thinks someone is dumb enough to believe him.

Dr. Miron’s vitamin D supplement program calls for 6,000 IU of vitamin D per day. It does not make much sense to prescribe this level of vitamin D when it has been shown to induce bone loss. It makes much less sense to prescribe this level of vitamin D when we know that vitamin D inhibits osteoblast proliferation at a time when you need osteoblast proliferation to produce implant integration.

The first part of this email was designed not to just provide you with information about vitamin D, but to provide you with an understand of where the science is regarding vitamin D so you can evaluate claims made by others who want to sell you something. At SteinerBio, we take no pleasure in being the bone police, but when there is another hoax being promoted by someone who does not have a deep understanding of bone, we feel we are obligated to inform the profession.

Dr. Miron and Dr. Choukroun were principal players in the PRF for bone regeneration hoax. Both individuals promoted this useless therapy until the science was so overwhelming that no one would take their courses. Unfortunately, this hoax resulted in thousands of patients receiving worthless treatment. However, the PRF for bone regeneration hoax did have one positive effect because for anyone who promoted PRF for bone regeneration, you now know that they know nothing about bone regeneration. Orthopedic surgeons know bone regeneration and we have never heard of a single orthopedic surgeon in the world ever using PRF for bone regeneration and we have never seen a single publication in the orthopedic literature about PRF for bone regeneration. The PRF hoax did not work on orthopedic surgeons because they have a genuine understanding of bone regeneration. You should not listen to anyone who promoted PRF for bone regeneration because they have a proven their lack of knowledge about the subject.

Now, the same players who pulled off the PRF hoax are pushing the vitamin D hoax, and at some point we need to stop listening to these promoters.

Like all good hoaxes, they have an element of truth. Our healthy patients do not need to be screened for vitamin D and do not need vitamin D supplements. Even though the literature states vitamin D has no relationship to implant failure, for those patients that are at high risk for vitamin D deficiency–the 6%–it is reasonable to screen and supplement, but it is probably best left up to their physician.

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Vitamin D: Bone Health and Implant Integration

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