***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: AIM This study was conducted to determine periodontal changes in postmenopausal breast cancer ( BCa ) survivors using aromatase inhibitors ( AI ) as compared to postmenopausal women without BCa . METHODS An 18-month prospect i ve examination of periodontal health in postmenopausal women ( 29 receiving AI therapy ; 29 women without BCa ) was conducted at University of Michigan . Comprehensive periodontal examinations including alveolar bone height ( ABH ) were conducted at baseline , 6 , 12 , and 18 months .  Bisphosphonate , vitamin D , and calcium supplementation  were collected via chart review . Linear mixed models were utilized to investigate the relationship between AI and periodontal measures . RESULTS Aromatase inhibitor users had significantly deeper probing depths , more dental plaque and clinical attachment loss as compared to controls at the 6 , 12 , and 18 month study visits ( p < 0.05 ) . ABH loss was seen over time within the AI group . The linear mixed model showed a significant effect of time as well as an interaction between aromatase inhibitor use and calcium supplement status . AI users taking calcium experienced less ABH loss over the study than AI users not taking calcium ( p = 0.005 ) . CONCLUSION Aromatase inhibitor therapy has a negative impact on the periodontal health of postmenopausal BCa patients .  Calcium supplementation appears to mitigate ABH loss in women on AI Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more There is mounting evidence that periodontal disease ( PD ) is linked to low serum 25-hydroxyvitamin D [ 25(OH)D ] concentrations in addition to recognized risk factors like diet and smoking . This paper review s this evidence using Hill 's criteria for causality in a biological system . Evidence for strength of association , consistency , cohesion and ' dose-effects ' [ biological ' gradients ' ] include strong inverse correlations between serum 25(OH ) and both PD cross-sectionally and that PD is consistently more prevalent in darker vs. lighter skinned people and increases at higher latitudes with analogy for gingivitis and for disorders associated with PD whose risks increase with hypovitaminosis D. Evidence for plausibility includes that vitamin D increases calcium absorption and protects bone strength ; induces formation of cathelicidin and other defensins that combat bacterial infection ; reduces tissue production of destructive matrix metalloproteinases actively associated with PD and that prevalence of PD varies with common vitamin D receptor polymorphisms . Experimental evidence from limited supplementation studies [ using calcium and vitamin D ] shows that supplementation reduces tooth loss . Thus , existing evidence for hypovitaminosis D as a risk factor for PD to date meets Hill 's criteria for causality in a biological system . Further experimental evidence for effectiveness and temporality , preferably from r and omized controlled trials of vitamin D supplementation [ adjusting for other PD risk factors including diet and smoking to reduce confounding ] are necessary to confirm causality . If confirmed , dentists and periodontists could perform a valuable service to their patients by discussing the importance of adequate vitamin D status and on how to avoid deficiency Osteoporosis and osteopenia may influence periodontal disease and tooth loss . Medications such as hormone replacement therapy and nutritional supplements that are used to prevent or treat osteoporosis have been evaluated for beneficial effects on oral health in a small number of human studies . Hormone replacement therapy ( HRT ) , which slows the rate of bone loss at skeletal sites such as the hip and spine , also appears to reduce the rate of alveolar bone loss in postmenopausal women .  HRT use is consistently associated with greater tooth retention and a reduced likelihood of edentulism in studies of elderly women . The number of studies on the effects of calcium or vitamin D intake on oral outcomes is limited , but suggest that higher intake levels are associated with reduced prevalence of clinical attachment loss and lower risk of tooth loss . Data from a prospect i ve study of oral health in men show a similar association between higher calcium intake and reduced alveolar bone loss . The number of teeth with progression of alveolar bone loss over a 7-year period was significantly lower among men whose calcium intake was at least 1,000 mg per day , compared to men with a calcium intake below this level . Future studies should confirm these findings and evaluate the oral effects of new medications for osteoporosis . If confirmed , the implication s for dental professionals may include an exp and ed array of medications for the treatment of periodontal disease and a greater emphasis on nutrition education for patients The anthropological record indicates that we are exposed to considerably less ultraviolet radiation ( required for the synthesis of vitamin D ) and consume considerably less calcium than did our early ancestors . Most U.S. citizens have calcium intakes and serum levels of vitamin D far below recommended values . This is despite there having been extensive evidence that optimal calcium and vitamin D intakes not only benefit our postcranial bone health but also have many other health benefits . Numerous articles indicate that vitamin D and calcium deficiencies result in bone loss and increased inflammation , which are well recognized symptoms of periodontal disease . For more than 40 years , investigators have suggested that calcium intake may be associated with alveolar bone resorption , and more recently there have been a number of studies in which investigators have suggested that calcium and vitamin D may benefit periodontal health , and it has been suggested that calcium deficiency may be a risk factor for periodontal disease . There has not , however , been a vitamin-D-calcium-periodontitis clinical trial in which r and omization and masking were carefully controlled , the periodontal disease status of patients known , periodontal disease measures were the primary outcomes , and levels of intake optimized to produce maximal effects . Such research might demonstrate that calcium and vitamin D are important adjuncts to st and ard treatments for preventing and treating periodontal disease INTRODUCTION It has long been recognized that vitamin D is a hormone and were many studies reporting that patients in periodontal maintenance programs taking vitamin D and calcium supplementation had a trend for better periodontal health compared to patients not taking supplementation . AIM To evaluate the effect of vitamin D and calcium supplementation in reducing gingival inflammation , using clinical parameters like gingival index ( GI ) , oral hygiene index-simplified ( OHIS ) , probing pocket depth ( PPD ) , clinical attachment level ( CAL ) and bone density ( BD ) . Also , to assess whether calcium and vitamin D oral supplementation influences alveolar Bone Density ( BD ) . DESIGN AND SETTING S A nonr and omised clinical trial done in Amrita School of dentistry , Kochi , India . MATERIAL S AND METHODS Group A taking vitamin D ( 250IU/day ) and calcium ( 500 mg/day ) supplementation  , and Group B were not taking oral supplementation . All subjects had at least one or more teeth with chronic moderate periodontitis . Digital Orthopantomogram images were taken to assess bone density . Data were collected at baseline and three months . STATISTICAL ANALYSIS USED OHI-S , GI , PPD , CAL , and Bone Densities ( BD ) were calculated per group . Karl Pearson Coefficient of correlation was used to test correlation of bone density with GI and OHI -S. Intergroup comparison of parameters were done using Independent two Sample t-test . Intragroup comparison of parameters at recall interval was done using Paired sample t-test . The results were considered statistically significant when p-value was < 0.05 . RESULTS Both Groups showed significant change in the periodontal parameters and bone density after three months and intragroup comparison showed highly significant results for vitamin D group in relation to GI , OHI S and bone density . CONCLUSION Calcium and vitamin D supplementation has got a positive effect on periodontal health and it can be used as an adjunct to non surgical periodontal therapy BACKGROUND A previous study reported by this group found that patients in periodontal maintenance programs taking vitamin D and calcium supplementation  had a trend for better periodontal health compared to patients not taking supplementation . The objective of the present study is to determine , for the same cohort of subjects , whether such differences persist over a 1-year period . METHODS Fifty-one patients enrolled in maintenance programs from two dental clinics were recruited . Of these , 23 were taking vitamin D ( ≥400 IU/day ) and calcium ( ≥1,000 mg/day ) supplementation , and 28 were not . All subjects had at least two interproximal sites with ≥3 mm clinical attachment loss . For m and ibular-posterior teeth , gingival index , plaque index , probing depth , attachment loss , bleeding on probing , calculus index , and furcation involvement were evaluated . Photostimulable-phosphor , posterior bitewing radiographs were taken to assess alveolar bone . Daily vitamin D and calcium intakes were estimated by nutritional analysis . Data were collected at baseline , 6 months , and 12 months . RESULTS Total daily calcium and vitamin D intakes were 1,769 mg ( 95 % confidence interval , 1,606 to 1,933 ) and 1,049 IU ( 781 to 1,317 ) in the taker group , and 642 mg ( 505 to 779 ) and 156 IU ( 117 to 195 ) in the non-taker group , respectively ( P < 0.001 for both ) . Clinical parameters of periodontal health improved with time in both groups ( P < 0.001 ) . When clinical measures were considered collectively , the differences between supplement takers and non-takers had the following P values : baseline ( P = 0.061 ) ; 6 months ( P = 0.049 ) ; and 12 months ( P = 0.114 ) . After adjusting for covariates , the P values for the effect of supplementation were as follows : baseline ( P = 0.028 ) ; 6 months ( P = 0.034 ) ; and 12 months ( P = 0.058 ) . CONCLUSIONS Calcium and vitamin D supplementation ( ≤1,000 IU/day ) had a modest positive effect on periodontal health , and consistent dental care improved clinical parameters of periodontal disease regardless of such supplements . Our findings support the possibility that vitamin D may positively impact periodontal health and confirm the need for r and omized clinical trials on the effects of vitamin D on periodontitis Vitamin  D deficiency and oral diseases ( periodontitis , caries , and tooth loss ) are highly prevalent in Germany . Previous studies suggested that vitamin D might be a modifiable and protective factor for periodontitis , caries , and tooth loss . However , prospect i ve studies investigating such associations are limited . We explored the association between the concentration of  serum 25-hydroxy vitamin D ( 25OHD ) and incidence of tooth loss , progression of clinical attachment loss ( CAL ) ≥ 3 mm , and progression of restorative and caries status in a population -based longitudinal study . We analyzed data from 1,904 participants from the Study of Health in Pomerania with a five-year follow-up . Generalized estimating equation models were applied to evaluate tooth-specific associations between serum 25OHD and incidence of tooth loss , progression of CAL ≥ 3 mm , and progression of restorative and caries status . Age , sex , education , smoking status , alcohol drinking , waist circumference , dental visit frequency , reasons of dental visit , vitamin D or calcium supplements , and season of blood draw were considered as confounders . Serum 25OHD was inversely associated with incidence of tooth loss . A significant dose-response relationship ( p = .0022 ) was observed across the quintiles of serum 25OHD . After adjusting for multiple confounders , each 10-µg/L increase of serum 25OHD was associated with a 13 % decreased risk of tooth loss ( risk ratio : 0.87 ; 95 % confidence interval : 0.79 , 0.96 ) . The association was attenuated for changes of CAL ≥ 3 mm when adjusting for multiple confounders . No significant association was found between serum 25OHD and caries progression  . Vitamin D might be a protective factor for tooth loss . The effect might partially be mediated by its effect on periodontitis PURPOSE To assess the anti-inflammatory effect of vitamin D on gingivitis at various doses . MATERIAL S AND METHODS In this r and omized controlled trial , daily oral vitamin D supplementation was given in doses of 2000 IU for group A , 1000 IU for group B , 500 IU for group C and a placebo for group D over a 3-month period . The changes in gingival scores were measured after the 1st , 2nd and 3rd months . RESULTS The gingivitis score changed in direct proportion to the dose of vitamin D supplementation . In group A , the mean gingival scores were 2.4 ( baseline ) , 1.7 after the first month , 0.8 after the second month and 0.3 after the third month . The group B mean baseline gingival score of 2.3 decreased to 2.0 in the first month , 1.1 after the second month and 0.5 after the third month . In group C , the baseline gingival scores were 2.2 and 1.9 after one month , 1.4 after two months and 0.8 by the 
    Output:
    
None of the observational longitudinal studies found that periodontal disease progression could be attributed to lower vitamin D levels .