JCTXXX10.

1177/23800844211026608JDR Clinical & Translational ResearchImpact of Wearing Dentures on Dietary Intake

research-article2021

Vol. XX • Issue X Impact of Wearing Dentures on Dietary Intake

Reviews

Impact of Wearing Dentures on Dietary

Intake, Nutritional Status, and Eating:
A Systematic Review
P. Moynihan1 and R. Varghese2

Abstract: Introduction: A key and 41 studies were included in the Knowledge Transfer Statement: The
purpose of denture provision is to synthesis (14 rated good quality, results of this systematic review can
enable eating, yet the body of evidence 20 fair, and 7 poor). The balance be used to advocate for health care
pertaining to the impact of dentures on of data supported a positive impact services to address prosthodontic need
wide-ranging nutritional outcomes has of wearing full (5/7 studies) or to benefit nutritional outcomes. The
not been systematically reviewed. partial (3/3 studies) dentures (vs. findings will be of use in educating
no dentures) on nutritional status, health care professionals on the
Objectives: To systematically
though no clear direction of effect impact of wearing dentures and not
review published evidence pertaining
was detected for the impact of addressing prosthodontic need on
to the effect of wearing removable
dentures on dietary intake. The nutritional outcomes.
dental prosthesis on dietary intake,
balance of data clearly showed that
nutritional status, eating function, and
objective measures of eating function Keywords: tooth loss, malnutrition,
eating related–quality of life (ERQoL). mastication, aged, denture complete,
were compromised in full (14/15
studies) and partial (6/7 studies) removable partial denture
Methods: Eight questions relating
to the impact of wearing dentures denture wearers as compared with
on nutritional outcomes were the dentate. Data showed that ERQoL Introduction
addressed. The target population was also compromised in denture
Tooth loss in adults remains prevalent
was healthy adults aged ≥18 y. Data wearers as compared with the dentate
in many countries, and a large proportion
sources included Medline, Embase, (3/3 studies). However, data showed
of older adults rely on full or partial
CINAHL, and PubMed. Included were a positive impact of wearing dentures
dentures for aesthetics, speaking, and
all human epidemiologic studies. on ERQoL (5/5 studies) as opposed to
eating. For example, in Australia 47% of
The Newcastle-Ottawa score was wearing no dentures.
adults aged ≥75 wear dentures (Do and
used for appraisal of study quality.
Conclusion: The balance of Luzzi 2019), and the most recent UK data
Harvest plots, vote counting, and
evidence shows that despite no clear show that approximately 45% of those
accompanying narrative provided the
pattern on impact of wearing dentures aged 75 to 84 y wear dentures (Public
basis for synthesis.
on measured dietary intake, in those Health England 2020). By contrast, some
Results: Of the 1,245 records with tooth loss, wearing dentures can low- and middle-income countries have
identified, 134 were retrieved and have a positive impact on nutritional a high prevalence of prosthodontic
eligibility assessed by 2 reviewers, status and enjoyment of eating. need, yet edentulism without prosthetic

DOI: 10.1177/23800844211026608. 1Adelaide Dental School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia; 2Glaxosmithkline
Consumer Healthcare, Weybridge, UK. Corresponding author: P. Moynihan, Adelaide Dental School, Faculty of Health and Medical Sciences, The University of Adelaide,
AHMS Building, Cnr North Tce and George St. Adelaide, AU-SA 5005, Australia. Email: paula.moynihan@adelaide.edu.au
A supplemental appendix to this article is available online.
Article reuse guidelines: sagepub.com/journals-permissions
© International & American Associations for Dental Research 2021
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 JDR Clinical & Translational Research
rehabilitation is common (de Oliveira
Ferreira et al. 2014).
Tooth loss directly causes reduced
chewing and eating function and
results in avoidance of some foods.
Observational studies report that tooth
loss is associated with a poor diet,
including lower intakes of fruits and
vegetables (Nakamura et al. 2019),
dietary fiber (Iwasaki et al. 2016), and
protein (Iwasaki et al. 2016; Mendonça
et al. 2018) and an increased risk of
undernutrition (Zelig et al. 2018).
However, a recent systematic review of
longitudinal studies concluded that limited
data were inconsistent (Gaewkhiew et al.
2019) and a causal relationship has not
been established. If observed differences
in nutritional outcomes by dental status
are directly due to loss of function, it
could be hypothesized that rehabilitation
with dental prosthesis would result in
improvement in nutritional indicators.
Indeed, a key aim of providing dentures
is to improve eating function and
promote nutritional well-being; yet,
despite the wealth of evidence pertaining
to the association between tooth loss
and nutritional outcomes, a systematic
appraisal has not been performed to date
of the evidence relating to the impact
of wearing dentures on nutritional well-
being. The aim of this research was to
explore the impact of wearing dentures
on eating and nutrition. The objective
was to conduct a systematic appraisal
of all available published literature
pertaining to the impact of wearing
dentures on dietary intake, measures of
nutritional status and eating function,
and eating-related quality of life (ERQoL;
i.e., enjoyment of eating and social and
emotional issues around eating). The
overall research question was as follows:
In adults, does wearing dentures, as
compared with not wearing dentures,
affect nutritional status and eating-related
well-being?
Methods
A systematic review was conducted
and reported according to the PRISMA
statement (http://www.prisma-statement
.org). The protocol was developed
2
a priori and is available on Figshare
(Moynihan and Varghese 2021). The
specific questions addressed in this
review were as follows.
In adults, does being edentulous and
wearing full dentures, as compared
with being edentulous and not wearing
dentures or being dentate (with ≥20
natural teeth), reduce or increase
1)  Risk of inadequate nutritional intake?
2)  Risk of undernutrition?
3)  Eating-related quality of life?
4) Eating function (mastication and
swallowing measured subjectively or
objectively)?
In adults, does being edentulous and
wearing partial dentures, as compared
with being partially dentate and not
wearing dentures or being dentate (with
≥20 natural teeth), reduce or increase
5)  Risk of inadequate nutritional intake?
6)  Risk of undernutrition?
7)  Eating-related quality of life?
8) Eating function (mastication and
swallowing measured subjectively or
objectively)?
Eligibility Criteria
The review included systematic
reviews, randomized controlled trials,
cohort studies, quasi-experimental
studies, and quantitative observational
studies (for the assessment of ERQoL,
semiquantitative studies).
The following hierarchy was applied
as a framework for narrative synthesis
of the best available evidence (Petticrew
and Roberts 2006): systematic reviews,
randomized controlled trials, quasi-
experimental studies, cohort studies,
case-control studies, and cross-sectional
studies. Only peer-reviewed studies
published between January 1, 1980, to
August 26, 2019, were considered for
inclusion. Articles written in non-English
language were included if they presented
an English-language abstract.
Participants were apparently healthy
adults aged ≥18 y from any country. The
exposure variable was wearing complete
or partial dentures, and the comparators
Month 2021
were being edentulous without wearing
full dentures (for edentulous), being
partially dentate without wearing partial
dentures (for partially dentate), and
being dentate (≥20 natural teeth; for
edentulous and partially dentate).
The outcome variables reported dietary
intake (intake of energy, protein, fiber,
saturated fat, and fruit/vegetables),
indices of nutritional status (low
body mass index, low Mini Nutrition
Assessment score, percentage weight
loss, low protein intake), measures of
eating function (objective measures
of chewing, biting, and swallowing
foods and perceived chewing function
scores), and ERQoL (e.g., self-reported
semiquantitative data on eating problems
including comfort, pleasure, flavor, and
food avoidance; excluding predefined list
or scores). Details of the exposure and
intervention, control and comparator,
and outcomes relating to each question
are presented in Appendix Table 1.
Search Strategy
Relevant information was identified and
retrieved by conducting searches of the
following reference databases: Medline,
Embase, and CINAHL. The search
strategy is presented in Appendix Tables
2 to 4.
Study Selection and Data Extraction
Titles and abstracts of all records
identified in the electronic search were
assessed, and records that were clearly
ineligible were eliminated by 1 reviewer.
A random 10% sample of all records
identified from searches were screened
by a second reviewer, and interrater
reliability was assessed. Any differences
between the reviewers’ decisions were
resolved by discussion, and if consensus
was not reached, a third reviewer (P.M.)
was consulted.
When the studies apparently met
the inclusion criteria or insufficient
information was in the abstract, 2
reviewers evaluated the full article.
Difference between the reviewers’
decisions was resolved by discussion,
and when consensus was not reached,
a third reviewer was consulted. The
 Vol. XX • Issue X Impact of Wearing Dentures on Dietary Intake

reasons for exclusion of studies in this Figure 1. PRISMA flow diagram.

phase were logged. Data extraction was

IDENTIFICATION
undertaken by 1 reviewer and checked
by a second (P.M.). Disagreements
Records identified through
between the reviewers was resolved by database searching
consensus, with involvement of a third (n = 1854)
reviewer (R.V.) where necessary.

Quality Assessment Duplicates removed

(n = 608)

SCREENING
Records screened
The quality of the studies was assessed (n = 1245)
Records excluded
by 2 reviewers using the Newcastle- (n = 1111)
Ottawa Quality Assessment Scale,
where stars are awarded by quality Full-text articles assessed for Full-text articles
excluded, with reasons
in terms of selection of participants, eligibility
(n = 92)
(n = 134)
comparability of groups, and assessment
Population (n = 0)
of exposure or outcome (Wells et al. ELIGIBILITY Intervention /
Exposure (n = 15)
2009). The quality of the studies was Comparator (n = 50)
classified as good, fair, or poor based Outcome (n = 25)
Study design (n = 2)
on the stars in each domain (selection, Studies eligible for inclusion Other (n = 0)
comparability, and exposure/outcome), (n = 41 (42 papers))

following the Newcastle-Ottawa scale

guidelines. A good quality score required
INCLUDED

3 or 4 stars in selection, 1 or 2 stars Studies included in evidence

in comparability, and 2 or 3 stars in
exposure and outcomes. A fair quality
score required 2 stars in selection, 1 or 2
stars in comparability, and 2 or 3 stars in
exposure and outcomes. A poor quality
score reflected 0 or 1 star in selection,
0 stars in comparability, or 0 or 1 star
in exposure and outcomes (Appendix
Table 5).
Synthesis
Evidence was grouped according to the
8 questions and each organized by study
type and design (Fig. 1, Appendix Table
6). For each research question, a vote-
counting approach based on direction
of effect was employed to weight
1) the evidence showing a positive
relationship between the exposure
and outcome with 2) the evidence
showing a negative relationship. This
was based not on statistical significance
but on direction of effect, with a 5%
cutoff difference between groups as an
arbitrary level of nutritional significance
(McKenzie and Brennan 2019). Data
were formulated into harvest plots to
summarize study characteristics and the
weight of evidence in relation to specific
questions (Ogilvie et al. 2008). Where
a study reported >1 outcome variable
synthesis
(n = 41 (42 papers))
Studies including full dentures
Q1a. n = 4 studies (1 quasi-experimental; 1 cohort; 2
cross-sectional)
Q1b. n = 6 studies (3 case-controlled; 3 cross-sectional)
Q2a. n = 7 studies (2 quasi-experimental; 1 cohort;
1 case-controlled; 3 cross-sectional)
Q2b. n = 1 study (1 case-controlled)
Q3a. n = 6 studies (2 quasi-experimental; 4 cross-
sectional)
Q3b. n = 3 studies (1 case-controlled; 2 cross-sectional)
Q4a. n = 1 study (1 quasi-experimental)
Q4b. n = 15 studies (10 case-controlled;
5 cross-sectional)
with respect to a research question
(i.e., showing contrasting effects),
separate data points were used to depict
the identified outcome variables in
the harvest plots. This approach was
supplemented with a narrative synthesis
of findings based on a “best available
evidence” approach (Petticrew and
Roberts 2006).
Results
Figure 1 shows the results of searching,
the process of screening, and study
exclusion to result in 41 studies in 42
articles. In total, 1,854 records were
returned, reducing to 1,245 following
removal of duplicates. The interrater
Studies including partial dentures
Q5a. n = 1 study (1 quasi-experimental)
Q5b. n = 2 studies (2 cross-sectional)
Q6a. n = 3 studies (1 quasi-experimental;
2 cross-sectional)
Q6b. n = 1 study (1 cross-sectional)
Q7a. n = 3 studies (3 cross-sectional)
Q7b. n = 1 study (1 cross sectional)
Q8a. n = 5 studies (2 quasi-experimental;
2 case-controlled; 1 cross-sectional)
Q8b. n = 7 studies (4 case-controlled;
3 cross-sectional)
reliability score indicated near perfect
agreement for the 10% of articles
screened in duplicate (kappa, 0.81).
The reasons for exclusions on full-
text screening are provided in Figure
1 and Appendix Table 7. The assigned
Newcastle-Ottawa scores are provided in
the Table, and details on components of
the final score are presented in Appendix
Table 5.
A breakdown of the number of studies
for each main research question, in total
and by study design, is provided in
Figure 1 and Appendix Table 6. A brief
description of the studies is provided
in Appendix Table 8. A summary of the
body of evidence pertaining to each
question is presented in the Table,

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 JDR Clinical & Translational Research Month 2021

Table.
Summary of Included Studies.

Study Design:
First Author Outcome Comment and NOS
(Year) Country Measure Exposure Group Comparator Group +, 0, – a No. Age, y b Rating

Question 1a: Inadequate intake of nutrients and full dentures as compared with no dentures

Quasi-experimental

Madhuri (2014) India Energy, protein Full denture Edentulous (before 0, 0 42 50 to 80 Energy intake based
wearers (after rehabilitation) on 1 × 24-h recall.
rehabilitation) NOS fair

Cohort

Sadamori Japan Energy Edentulous Edentulous 0, 0 55 86 to 88 Energy intake based

(2012) denture wearers: without dentures: on food ordered.
+dementia, +dementia, NOS fair
–dementia –dementia

Cross-sectional

Sareela (2016) Finland Energy, fiber, Edentulous with Edentulous without –, 0, 0 162 83 Nonvalidated 1-d
protein dentures dentures food record. NOS
poor

Han (2016) Korea Energy, protein Edentulous with Edentulous without 0, 0 1,168 ≥65 24-h recall.
dentures dentures Unadjusted data
presented. NOS fair

Question 1b: Inadequate intake of nutrients and full dentures as compared with dentate

Case-control

Greksa (1995) USA Energy, protein Full denture Dentate with ≥24 0, 0 72 51 to 83 Energy intake based
wearers teeth on 1 × 24-h recall.
NOS fair

Bradbury England Fruit and Full denture Dentate ≥21 teeth – 131 66.8, test; 3-d diet diary.
(2008) vegetables wearers 58.6, control Controlled for
confounders.
NOS good

Cousson France Energy, fiber Full denture Fully dentate –, – 97 70.1 3-d diet diary.
(2012) wearers Not controlled for
confounders.
NOS good

Cross-sectional

Marshall USA Energy, protein Full denture Dentate +, – 81 ≥79 3-d dietary diary.
(2002) wearers NOS fair

Nowjack- USA Fiber Full denture Dentate (≥28 teeth) – 3,794 ≥25 24-hour recall.
Raymer wearers Controlled for
(2003) confounders. NOS
fair

Jauhiainen Finland Energy, protein, Edentulous with Dentate (mean No. +/0, 0/–, –/0, 0 1,466 55 to 84 Female/male
(2017) fiber and dentures of teeth = 23) findings. Validated
saturated fat FFQ. NOS fair
intake

Question 2a: Poor nutritional status and full dentures as compared with no dentures

Quasi-experimental

Prakash (2012) India MNA score Edentulous with Edentulous before + 94 50 to 80 NOS poor
new dentures new dentures

(continued)

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Vol. XX • Issue X Impact of Wearing Dentures on Dietary Intake

Table.
(continued)

Study Design:
First Author Outcome Comment and NOS
(Year) Country Measure Exposure Group Comparator Group +, 0, – a No. Age, y b Rating

Madhuri (2014) India BMI Full denture Edentulous (before + 42 50 to 80 Mean values
wearers (after rehabilitation) reported graphically.
rehabilitation) NOS fair

Cohort

Sadamori Japan BMI Edentulous Edentulous +, 0 55 86 to 88 Potentially

(2012) denture wearers: without dentures: underpowered study.
+dementia, +dementia, NOS fair
–dementia –dementia

Case-control

Horn (1994) USA Weight loss Edentulous with Edentulous without 0 33 73.9 Study potentially
full denture denture underpowered. NOS
poor

Cross-sectional

Lamy (1999) Belgium MNA score Edentulous with Edentulous with no + 120 ≥65 Both groups fell into
full dentures or 1 denture at risk category.
NOS fair

Chai (2006) China (Hong BMI Edentulous with Edentulous without 0 50 ≥65 Potentially
Kong) full dentures denture underpowered.
NOS fair

Saarela (2016) Finland BMI, MNA Edentulous with Edentulous without +, + 162 83 Means higher in
dentures dentures denture wearers
but no statistics
for comparison
provided. NOS poor

Question 2b: Poor nutritional status and full dentures as compared with dentate

Case-control

Cousson France MNA score Full denture Fully dentate – 97 70.1 Not controlled for
(2012) wearers confounders.
NOS good

Question 3a: Eating-related quality of life and full dentures as compared with no dentures

Quasi-experimental

Shigli (2012) India Question on After full denture Before full denture + 35 67.7 Convenience
problems eating provision provision sample. NOS fair

Madhuri (2014) India Self-reported Full denture Edentulous (before + 42 50 to 80 NOS fair
eating problems wearers (after rehabilitation)
rehabilitation)

Cross-sectional

Lamy (1999) Belgium Self-reported Edentulous with Edentulous with no + 120 ≥65 NOS fair
pleasure on full dentures or 1 denture
eating and
difficulty eating
hard foods

Pallegedara Sri Lanka Self-reported Edentulous with Edentulous without + 110 68.9 – for taste, affected
(2008) question- denture denture more denture
naire: comfort wearers. NOS fair
eating and
taste

(continued)

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JDR Clinical & Translational Research Month 2021

Table.
(continued)

Study Design:
First Author Outcome Comment and NOS
(Year) Country Measure Exposure Group Comparator Group +, 0, – a No. Age, y b Rating

Saarela (2016) Finland Self-reported Edentulous with Edentulous without +, +, – 162 83 NOS poor
chewing dentures dentures
difficulty,
swallowing
difficulty, pain

Mac Giolla Ireland Self-rated Edentulous with Edentulous without + 185 57 NOS fair
Phadraig eating difficulty denture denture.
(2019)

Question 3b: Eating-related quality of life and full dentures as compared with dentate

Case-control

Greksa (1995) USA Self-reported Full denture Dentate with ≥24 – 72 51 to 83 NOS fair
problems with wearers teeth
chewing

Cross-sectional

Jones (2003) USA Self-reported Edentulous with Dentate with ≥25 – 375 66.3, test; Analysis controlled
oral health- denture teeth 60.6, control for confounders.
imposed food NOS poor
avoidance

Mac Giolla Ireland Self-rated Edentulous with Dentate – 185 57 NOS fair
Phadraig eating difficulty denture
(2019)

Question 4a: Eating function and full dentures as compared with no dentures

Quasi-experimental

Madhuri (2014) India Perceived Full denture Edentulous (before + 42 50 to 80 NOS fair
chewing ability wearers (12 mo rehabilitation)
after rehabilitation)

Question 4b: Eating function and full dentures as compared with dentate

Case-control

Jemt (1981) Sweden Measured Edentulous with Dentate – 21 49, test; 28, Groups not age
chewing full dentures control matched. NOS poor
function with
test foods

Kapur (1984) USA Masticatory Edentulous with Dentate – 26 56.7, test Groups not age
performance full dentures 38.1, control matched. NOS fair
score

Laurell (1985) Sweden Swallowing Edentulous with Dentate – 28 53, test; 54, Age match.
threshold and full dentures control Multivariate analysis.
particle size of NOS good
test food

Shi (1990) China Chewing Complete denture Dentate – 22 56, test; 21, Analysis did not
strokes and wearers control control for age. NOS
particle size good
with test food

Shi (1991) China Chewed gum, Complete denture Dentate 0 26 55, test; 25, Analysis did not
velocity cycle, wearers control control for age.
and muscular NOS fair
mean potential
(EMG)

(continued)

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 Vol. XX • Issue X Impact of Wearing Dentures on Dietary Intake

Table.
(continued)

Study Design:
First Author Outcome Comment and NOS
(Year) Country Measure Exposure Group Comparator Group +, 0, – a No. Age, y b Rating

Jacobs (1993) Belgium Masticatory Complete denture Dentate – 24 50, test; 45, NOS fair
muscle fatigue wearers control
(EMG)

Koshino (1997) Japan Test food Edentulous full Dentate – 30 66.5, test; NOS good
particle size denture wearers 63.6, control.
following
20 chewing
strokes

Mishellany- France Chewing Complete denture Aged dentate – 28 68.1, test; NOS fair
Dutour threshold, wearers 68.8, control
(2008) particle size,
chewing
duration, and
EMG

Uram- USA EMG, Maxillary full Dentate (≥10 teeth – 25 62.5, test; Wide variance and
Tuculescu chewing cycle denture wearers in both arches) 62.4, control study may have
(2015) frequency, and been underpowered.
duration with NOS good
test food

Torres- Spain Test food Edentulous full Dentate – 34 61.4, test; Unclear if analysis
Sanchez particle size denture wearers 52.6, control was controlled
(2017) following for age difference.
20 chewing NOS good
strokes

Cross-sectional

Wayler (1983) USA Swallowing Complete denture Dentate – 408 25 to 75 Analysis was done
threshold testc wearers for each age band.
NOS fair

Sheiham UK Difficulty/ Edentulous with Dentate – 753 ≥65 Multiple logistic

(1999) inability to eat full dentures regression controlled
defined foods for confounders.
NOS poor

Fontijn- China No. of chewing Complete denture Dentate – 51 59, test; Descriptive data,
Tekamp strokes to halve wearers 54.1, control no statistical
(2000) original particle comparison between
size of test food groups. NOS fair

Miyaura (2000) Japan Bite force Complete denture Dentate – 394 74.6, test; Age difference not
wearers 31.7, control controlled for. NOS
good

Jauhiainen Finland Ability to chew/ Edentulous with Dentate (mean No. – 1,466 55 to 84 Descriptive data
(2017) eat defined dentures of teeth = 23) only. NOS fair
hard foods

Question 5a: Inadequate nutritional intake and partial dentures as compared with no dentures

Quasi-experimental

Moynihan England Energy, protein, Partially dentate Partially dentate +, +, +, 0 19 64.7 2 × 3-d food
(2000) fiber, fruit with partial before denture diaries. Number of
and vegetable dentures provision participants was
intake small. NOS good

(continued)

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 JDR Clinical & Translational Research Month 2021

Table.
(continued)
Study Design:
First Author Outcome Comment and NOS
(Year) Country Measure Exposure Group Comparator Group +, 0, – a No. Age, y b Rating

Question 5b: Inadequate nutritional intake and partial dentures as compared with dentate

Cross-sectional

Marshall USA Energy, protein Partial denture Dentate 0, 0 220 ≥79 3-d dietary diary.
(2002) wearers NOS fair

Jauhiainen Finland Energy, protein, Partially dentate Dentate (mean No. 0 1,466 55 to 84 Validated FFQ.
(2017) fiber and with dentures of teeth = 23) NOS fair
saturated fat
intake

Question 6a: Poor nutritional status and partial dentures as compared with no dentures

Quasi-experimental

McKenna UK MNA Partially dentate Partially dentate + 21 67 NOS good

(2012) after denture before dentures
provision

Cross-sectional

Griep (2000) Belgium MNA Partial dentures Partially dentate + 36 61 to 98 NOS fair
with mean 10.8
teeth, no dentures

Furuta (2013) Japan MNA (short Partially dentate Partially dentate + 48 84.5 Multivariate analysis
form) with denture without denture showed no impact of
dentures. NOS fair

Question 6b: Poor nutritional status and partial dentures as compared with dentate

Cross-sectional

Furuta (2013) Japan MNA (short Partially dentate Dentate – 79 84.5 Multivariate analysis
form) with denture showed no impact of
dentures. NOS fair

Question 7a: Eating-related quality of life and partial dentures as compared with no dentures

Cross-sectional

Jones (2003) USA Self-reported Partially dentate Partially dentate + 172 66.1, test; Analysis controlled
oral health– with 11 to 24 with 11 to 24 teeth, 65.3, control for confounders.
imposed food teeth, with denture without denture NOS poor
avoidance

Pallegedara Sri Lanka Self-reported Partially dentate Partially dentate +, – 509 68.9 – for taste, affected
(2008) question- with denture without denture more denture
naire: comfort wearers. NOS fair
eating taste
perception

Mac Giolla Ireland Self-rated Partially dentate Partially dentate + 379 57 NOS fair
Phadraig eating difficulty with denture without denture.
(2019)

Question 7b: Eating-related quality of life and partial dentures as compared with dentate

Cross-sectional

Mac Giolla Ireland Self-rated Partially dentate Dentate – 379 57 NOS fair
Phadraig eating difficulty with denture
(2019)

(continued)

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Table.
(continued)
Study Design:
First Author Outcome Comment and NOS
(Year) Country Measure Exposure Group Comparator Group +, 0, – a No. Age, y b Rating

Question 8a: Eating function and partial dentures as compared with no dentures

Quasi-experimental

Omo (2017) Nigeria Masticatory Partially dentate Partially dentate + 36 52.2 Not paired analysis.
score based with dentures before dentures NOS good
on particle size (3 mo)
on 20 chewing
strokes of test
food

Wallace (2018) Ireland Bolus kneading Partially dentate Partially dentate + 65 79.7 NOS good
test (bicolored with partial before dentures
gum) dentures

Case-control

Arce-Tumbay Peru Particle size Shortened dental Shortened dental + 20 42 NOS good
(2011) following and arch when wearing without dentures
time to 20 partial dentures
chewing cycles.
Perceived
ability

Kamiya (2016) Japan Occlusal force, Partially dentate Partially dentate not + 24 63.1 NOS poor
masticatory wearing dentures wearing dentures
muscle activity,
and self-rated
chewing score

Cross-sectional

Furuta (2013) Japan Swallowing 10 to 19 teeth with 10 to 19 teeth + 48 84.5 NOS fair
function denture without denture
cervical
auscultation

Question 8b: Eating function and partial dentures as compared with dentate

Case-control

Laurell (1985) Sweden Swallowing Unilateral/bilateral Dentate –/0 40 51, unilateral; Age match.
threshold and partial dentures 54, bilateral; Multivariate analysis.
particle size of 56, control NOS good
test food

Arce-Tumbay Peru Particle size Shortened dental Dentate – 20 42 NOS good

(2011) following and arch when wearing
time to 20 partial dentures
chewing cycles.
Perceived
ability

Al-Zarea Saudi Arabia Maximum bite Unilateral implant Dentate opposing 0 85 43 Between-side
(2015), Al- force supported side difference only 3%.
Omiri (2014) prosthesis NOS good

Kamiya (2016) Japan Occlusal force, Partially dentate Dentate – 24 63.1, test; NOS poor
masticatory wearing dentures 22.1, dentate
muscle activity, control
and self-rated
chewing score

(continued)

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 JDR Clinical & Translational Research Month 2021

Table.
(continued)

Study Design:
First Author Outcome Comment and NOS
(Year) Country Measure Exposure Group Comparator Group +, 0, – a No. Age, y b Rating

Cross-sectional

Miyaura (2000) Japan Bite force Removable partial Dentate – 394 74.6, test; Age difference not
denture wearers, 31.7, control controlled for. NOS
fixed partial good
dentures

Furuta (2013) Japan Swallowing 10 to 19 teeth with Dentate with ≥20 – 48 84.5 NOS fair
function denture teeth
cervical
auscultation

Jauhiainen Finland Ability to chew/ Dentate with Dentate – 1,466 55 to 84 Descriptive data
(2017) eat defined partial denture only. NOS fair
hard foods

Full references to the articles cited in this table are presented in the Appendix.
BMI, body mass index; EMG, electromyography; FFQ, food frequency questionnaire; MNA, Mini Nutrition Assessment; NOS, Newcastle Ottawa Scale (quality
assessment: 0 to 9, low to high quality; Wells et al. 2009).
a
+, a positive and significant relationship between denture wearing and nutritional outcome. 0, no significant relationship. –, a negative and significant relationship
between denture wearing and the nutritional outcome. Significance based on direction of effect with a 5% cutoff for a nutritionally meaningful difference.
b
Mean or range.
c
Swallowing threshold test: percentage expectorated food passing through sieve.

and the evidence synthesis is depicted
in harvest plots in Figures 2 to 4. The
results are considered in turn by research
question.
Question 1: Does being edentulous
and wearing full dentures reduce or
increase risk of inadequate nutritional
intake as compared with (Q1a) being
edentulous and not wearing den-
tures and (Q1b) being dentate with
≥20 teeth?
Ten studies conducted in Asia, Europe,
and the United States had data pertaining
to the impact of wearing full dentures on
nutritional intake (Table). In 4 studies,
the comparator was being edentulous
and not wearing dentures: all showed no
association except 1 cross-sectional study
(rated poor quality), which cited a lower
intake of energy in denture wearing as
compared with being edentulous and
not wearing dentures (Sareela et al.
2016). Based on study type, the best
available evidence came from the quasi-
experimental study (Madhuri et al.
2014), which was rated fair quality and
found no significant changes in intake
of energy or macronutrients (obtained
by one 24-h diet recall) in older Indian
adults before versus following provision
of complete dentures. Overall, to
answer question 1a, these data suggest
that being edentulous and wearing full
dentures does not reduce or increase
the risk of inadequate nutritional intake
when compared with being edentulous
and not wearing dentures.
Six studies compared wearing full
dentures with being dentate. Of these,
4 studies, all of fair quality, reported
on energy intake: 2 cited at least 1
positive association (1 for females only)
indicating that denture wearers had a
higher intake of energy as compared
with the dentate (Marshall et al. 2002;
Jauhianen et al. 2017); 2 indicated no
association (1 for males only; Greksa
et al. 1995; Jauhianen et al. 2017); and 1
reported a negative association (Cousson
et al. 2012). Three studies, all rated fair
quality, reported on protein intake: 2
cross-sectional studies cited a negative
association (with denture wearers having
a lower protein intake [Marshall et al.
2002]; 1 for men only [Jauhiainen et al.
2017]), and 2 showed no association
(Greksa et al. 1995; 1 in women only
[Jauhiainen et al. 2017]). Three studies (1
rated good quality and 2 fair) measured
fiber intake, with all showing at least 1
negative association (Nowjack-Raymer
and Sheiham 2003; Cousson et al. 2012)
and 1 for females only (Jauhiainen
et al. 2017). One study, rated fair quality,
measured saturated fat intake and found
no association (Jauhiainen et al. 2017).
Based on study design, the best
available evidence was from 3 case-
control studies: 2 studies, 1 rated good
quality and the other fair, measured fruit
and vegetable intake, and both revealed
a negative association (Greksa et al.
1995; Bradbury et al. 2008). The other
study, which was rated good quality,
indicated a lower intake of energy and
fiber in denture wearers as compared
with dentate controls (Cousson et al.
2012). Overall, based on the available
data, being edentulous and wearing
full dentures does not increase the risk
of inadequate nutritional intake when
compared with being dentate, with
the exception of fruit and vegetable
intake and fiber intake. Overall, there
was much heterogeneity among studies

10
 Vol. XX • Issue X Impact of Wearing Dentures on Dietary Intake

Figure 2. Harvest plot to illustrate weight of evidence for positive or negative effect of wearing full and partial dentures as compared with
(a) not wearing dentures and (b) being dentate, on risk of undernutrition. Based on direction of effect (and not statistical significance) with
a 5% cutoff for a nutritionally meaningful difference. Height of bar represents study quality: 3 blocks, good; 2 blocks, fair; 1 block, poor.
Based on Newcastle-Ottawa scale (for details of studies, see Appendix Table 8).

with respect to nutritional outcomes
measured, and a harvest plot depicting
these data is presented in Appendix
Figure 1.
Question 2: Does being edentulous
and wearing full dentures reduce
or increase risk of undernutrition as
compared with (Q2a) being edentu-
lous and not wearing dentures and
(Q2b) being dentate with ≥20 teeth?
Eight studies had data pertaining
to question 2: 2 quasi-experimental
studies, 1 cohort study, 2 case-control
studies, and 3 cross-sectional studies.
No study was rated good quality. In 7
studies, the comparator was edentulous
without dentures: 5 showed a positive
association between wearing dentures
and nutritional status as compared with
wearing no dentures (1 study for people
with dementia only; Sadamori et al.
2012), and 3 showed no association
(1 for those without dementia only;
Sadamori et al. 2012; Fig. 2). Based on
study design, the best available evidence

11
 JDR Clinical & Translational Research Month 2021

Figure 3. Harvest plot to illustrate weight of evidence for positive or negative effect of was provided by 2 quasi-experimental
wearing full and partial dentures as compared with (a) not wearing dentures and (b) being studies, both of which revealed a
dentate, on eating-related quality of life (ERQoL). Based on direction of effect (and not positive effect of wearing dentures on
statistical significance), with a 5% cutoff for a nutritionally meaningful difference. Height nutritional status as assessed by Mini
of bar represents study quality: 3 blocks, good; 2 blocks, fair; 1 block, poor. Based on Nutrition Assessment score (Prakash
Newcastle-Ottawa scale (for details of studies, see Appendix Table 8). et al. 2012) and body mass index
(Madhuri et al. 2014). However, the
quality rating of these studies was
poor and fair, respectively. Overall, to
answer question 2a, the balance of the
best available data suggests that being
edentulous and wearing full dentures
does reduce the risk of undernutrition as
compared with being edentulous and not
wearing dentures.
In 1 good-quality study, the comparator
was being dentate. This study showed
a negative association between wearing
dentures and nutritional status; however,
confounders were not accounted for
(Cousson et al. 2012). Therefore, there are
insufficient data to answer question 2b.

Question 3: Does being edentulous

and wearing full dentures reduce or
increase eating-related quality of life
as compared with (Q3a) being eden-
tulous and not wearing dentures and
(Q3b) being dentate with ≥20 teeth?

Eight identified studies had data

pertaining to question 3: 2 quasi-
experimental studies, 1 case-control
study, and 5 cross-sectional studies (Fig.
3). In 6 studies (5 rated fair quality and
1 poor), the comparator was edentulous
without dentures: all showed at least 1
positive association between wearing
dentures and ERQoL as compared with
not wearing dentures. Two studies, both
cross-sectional (1 rated poor quality
and 1 fair), found at least 1 negative
association: Saarela et al. (2016) for
data pertaining to pain on eating only
and Pallegedara and Ekanayake (2008)
for data pertaining to perception of
taste only. Overall, to answer question
3a, being edentulous and wearing full
dentures does increase ERQoL when
compared with being edentulous and not
wearing dentures.
In 3 studies, the comparator was
being dentate: all indicated a negative

12
 Vol. XX • Issue X Impact of Wearing Dentures on Dietary Intake

Figure 4. Harvest plot to illustrate weight of evidence for positive or negative effect of wearing full and partial dentures as compared with
(a) not wearing dentures and (b) being dentate on eating function. Based on direction of effect (and not statistical significance), with a 5%
cutoff for a nutritionally meaningful difference. Height of bar represents study quality: 3 blocks, good; 2 blocks, fair; 1 block, poor. Based
on Newcastle-Ottawa scale (for details of studies, see Appendix Table 8).

association between wearing dentures
and ERQoL. Overall, to answer question
3b, being edentulous and wearing
full dentures does reduce ERQoL as
compared with being dentate.
Question 4: Does being edentulous
and wearing full dentures reduce or
increase eating function (mastica-
tion and swallowing) as compared
with (Q4a) being edentulous and not
wearing dentures and (Q4b) being
dentate with ≥20 teeth?
Sixteen studies were identified with
data pertaining to question 4: 1 quasi-
experimental study, 11 case-control
studies, and 4 cross-sectional studies.
Data were from studies conducted in
Asia, Europe, and United States (Table,
Fig. 4). In 1 quasi-experimental study of
fair quality, the comparator was being
edentulous without dentures, and there
was a positive association between
provision of full dentures and chewing
ability (Madhuri et al. 2014). However,
there are insufficient data to answer

13
 JDR Clinical & Translational Research
question 4a. In 15 studies, the comparator
was being dentate, and 14 showed a
negative association between wearing
dentures and eating function. Only 1 study
(of fair quality) showed no association,
and it did not account for age difference
between denture wearers and dentate
comparators (Shi et al. 1991). The best
available evidence came from case-control
studies, with 9 of 10 studies finding a
negative association. Overall, with respect
to question 4b, being edentulous and
wearing full dentures reduces eating
function (mastication and swallowing)
when compared with being dentate.
Question 5: Does being partially dentate
and wearing partial dentures reduce
or increase the risk of inadequate
nutritional intake as compared with
(Q5a) being partially dentate and not
wearing dentures and (Q5b) being
dentate with ≥20 teeth?
Three studies conducted in Europe and
the United States had data pertaining
to question 5, including 1 randomized
controlled trial with within-group data
relevant to this review (i.e., quasi-
experimental data) and 2 cross-
sectional studies (Table). In 1 study
of good quality, the comparator was
being partially dentate before dentures,
which showed a positive association
between wearing partial dentures and
intake of energy, protein, and fiber
and no association for intake of fruits
and vegetables (Moynihan et al. 2000).
However, there are insufficient data to
answer question 5a. In 2 studies, both
cross-sectional and rated fair quality,
the comparator was being dentate: both
found no association between nutrient
intake and wearing partial dentures as
compared with being dentate. Overall,
there are insufficient data to answer
question 5b. Overall, there was much
heterogeneity among studies with respect
to nutritional outcomes measured, and
a harvest plot depicting these data is
presented in Appendix Figure 1.
Question 6: Does being partially dentate
and wearing partial dentures reduce
14
Month 2021
or increase risk of undernutrition and not wearing dentures. In only 1
as compared with (Q6a) being par- study, a comparator was being dentate,
tially dentate and not wearing den- and this cross-sectional study, rated fair
tures and (Q6b) being dentate with quality, indicated a negative association
≥20 teeth? between wearing partial dentures and
ERQoL (Mac Giolla Phadraig 2019).
Three studies had data to address However, there are insufficient data to
question 6: 1 quasi-experimental study answer question 7b.
(rated good quality) and 2 cross-sectional
studies (both rated fair quality). Data Question 8: Does being partially dentate
were from studies conducted in Asia and and wearing partial dentures reduce
Europe (Table, Fig. 2). All studies had or increase eating function (mastica-
a comparator group of being partially tion and swallowing) as compared
dentate without dentures, and all showed with (Q8a) being partially dentate
a positive association between wearing and not wearing dentures and (Q8b)
partial dentures and nutritional status. being dentate with ≥20 teeth?
Overall, with respect to question 6a,
being partially dentate and wearing partial
Nine studies, reported in ten papers,
dentures reduces risk of undernutrition
had data that addressed question 8:
as compared with being partially dentate
2 quasi-experimental studies, 4 case-
and not wearing dentures.
control studies, and 3 cross-sectional
One cross-sectional study of fair quality
studies. Data came from studies
had a dentate comparator and found a
conducted in Africa, Asia, Europe,
negative association between wearing
and the Middle East (Table, Fig. 4).
partial dentures and nutritional status as
In 5 studies (3 rated good quality, 1
compared with the dentate (Furuta et al.
fair, and 1 poor), the comparator was
2013). However, there were insufficient
a partially dentate group that did not
data to answer question 6b.
wear dentures, and all 5 studies cited
a positive association between denture
Question 7: Does being partially dentate
wearing and eating function. Overall,
and wearing partial dentures reduce
with respect to question 8a, being
or increase eating-related quality of
partially dentate and wearing partial
life as compared with (Q7a) being
dentures does increase eating function
partially dentate and not wearing
(mastication and swallowing) when
dentures and (Q7b) being dentate
compared with being partially dentate
with ≥20 teeth?
and not wearing dentures.
Seven studies reported data with a
Three studies with data pertaining to
dentate comparator group: 6 studies (3
question 7 were identified, and all were
rated good quality, 2 fair, and 1 poor)
cross-sectional. Two were rated fair
cited at least 1 negative association
quality and 1 poor. Data were from
(1 for unilateral denture only; Laurell
studies conducted in Asia, Europe, and
and Lundren 1985), and 2 (both good
the United States (Table, Fig. 3). All
quality) found no association (1 for
3 studies noted a positive association
bilateral denture only; Laurell and
between wearing partial dentures (vs.
Lundren 1985). Overall, with respect to
not wearing dentures) and ERQoL. One
question 8b, being partially dentate and
study (rated fair quality) revealed 1
wearing partial dentures reduces eating
negative association for data pertaining
function (mastication and swallowing)
to impact on perception of taste only
when compared with being dentate.
(Pallegedara and Ekanayake (2008).
Overall, with respect to question 7a,
Discussion
being partially dentate and wearing
partial dentures increases ERQoL when To our knowledge, this is the first
compared with being partially dentate systematic review to investigate the
 Vol. XX • Issue X
impact of wearing dentures on a number
of nutrition-related outcomes, including
dietary intake, nutritional status, ERQoL,
and eating function. Data came primarily
from Asia, Europe, and the United States;
the only data from South America, Africa,
and the Middle East related to question
8. There were no data from Australia
or New Zealand. With the exception
of studies pertaining to eating function
(for which the majority came from
case-control studies), data identified in
this review primarily came from cross-
sectional studies. There were few data
from cohort and quasi-experimental
studies and none from randomized
controlled trials. However, the lack of
randomized controlled trials to address
the questions of this review is likely
due to ethical reasons (i.e., randomly
assigning prosthetic treatment to 1 group
while withholding from the control
group would be unethical).
Impact of Dentures on Risk of
Inadequate Nutritional Intake
The data did not suggest an impact
of wearing dentures on the intake of
macronutrients (question 1). Although
denture wearers consistently showed
a lower intake of fiber and fruits/
vegetables as compared with the dentate,
data pertaining to this impact were
few (question 1). Moreover, studies
were diverse in the nutrient outcomes
explored, and many studies failed to use
robust and validated nutrition assessment
methods, were underpowered, and/or
did not control for potential confounding
(for details of these limitations, see
Appendix Table 8). Assessment of the
impact of dental function on diet and
nutritional outcomes requires robust
methodologies and a standardized
approach to increase accuracy of results
and facilitate cross-study comparisons
(Moynihan et al. 2000).
Previous research has shown the
edentulous to consume a less healthy
diet than the dentate with respect to
intake of fruits/vegetables and fiber (e.g.,
Chari and Sabbah 2019). However, a
causal relationship between tooth loss
and a poor diet has not been proven. If
Impact of Wearing Dentures on Dietary Intake
the effect was causal, some improvement
in dietary intake on prosthetic
rehabilitation would be expected, despite
the inability of rehabilitation to totally
mitigate the impacts of tooth loss, as
rehabilitation does improve perceived
chewing function. Still, the current
review was unable to demonstrate
this. Moreover, previous research on
the impact of optimizing or replacing
conventional full dentures has failed
showed an impact on dietary intake
in the absence of dietary intervention
(Bradbury et al. 2006). Nevertheless,
optimizing dentures and concurrent
dietary intervention has shown a positive
impact on diet (Bradbury et al. 2006:
Suzuki et al. 2018).
The nutritional methods applied to
studies that compared nutrient intake in
partial denture wearers were adequate
(see Appendix Table 8). However, the
amount of data was too sparse to draw
any conclusion, with only 1 quasi-
experimental study comparing partial
dentures with no dentures and 2 cross-
sectional studies comparing partial
denture wearers with the dentate. With
respect to full and partial dentures,
there is a need for well-designed
prospective studies that use appropriate
and validated nutrition and statistical
methods to elucidate any impact of
prosthetic rehabilitation on the intake of
energy, macronutrients, fiber, and fruits/
vegetables (i.e., nutrients associated with
risk of noncommunicable diseases).
Impact of Wearing Dentures
on Risk of Undernutrition
Despite the balance of evidence
supporting a positive impact of wearing
dentures (full and partial) on nutritional
status as compared with not wearing
dentures, there was much diversity in the
nutritional outcome measures used (body
mass index, Mini Nutrition Assessment,
weight loss, and other nutrition screening
tools) and limitations in data reporting;
none of the data were rated good quality.
There were insufficient data comparing
risk of undernutrition between full or
partial denture wearers and dentate
persons to draw any conclusion, and
more well-designed studies are required
to determine if provision of dentures
fully mitigates the impact of tooth loss
on risk of undernutrition. Undernutrition
in older people is a global problem with
far-reaching consequences for morbidity
and mortality (Favaro-Moreira et al.
2016). The current findings, though
not based on good-quality studies,
suggest that for those with loss of teeth,
provision of dentures may help mitigate
undernutrition; the results also indicate
that closer attention to oral health status
be considered in strategies for prevention
on undernutrition in older persons.
Impact of Wearing Dentures on ERQoL
The balance of data pertaining
to ERQoL demonstrated that in the
edentulous and partially dentate, wearing
dentures was associated with a better
ERQoL; however, the ERQoL of denture
wearers was inferior to that of fully
dentate persons. Data pertaining to
the impact of wearing partial dentures
(question 6) were fewer and solely
based on cross-sectional studies, thus
specifying a need for prospective studies
on the impact of provision of partial
dentures on ERQoL as well as on diet
and nutritional status.
Impact of Wearing Dentures
on Eating Function
The balance of data clearly showed
that full and partial denture wearers
have reduced eating function when
compared with the dentate despite
the heterogeneity in measures used to
assess eating function. Data unanimously
demonstrated better eating function in
the partially dentate with dentures than
in those without. However, the review
identified a lack of evidence pertaining
to the impact on eating function of full
versus no dentures, with the 1 identified
study reporting data on perceived
chewing scores only but nonetheless
indicating a positive effect. These data
demonstrate a need for clinicians to
manage patient expectations around
level of restoration of eating function
with dentures and provide practical
advice on coping strategies around
15
 JDR Clinical & Translational Research
eating to mitigate reduced eating
functionality (Roessler 2003). Despite the
lack of data from objective measures,
the data on ERQoL clearly show an
advantage to the edentulous of wearing
dentures.
Limitations of the Review
Several limitations to the current study
need to be acknowledged. First, it did
not explore the impact of replacement
or optimization of full or partial
dentures in existing denture wearers
on the nutritional outcomes, and this
warrants exploration. The questions
pertaining to intake of nutrients did
not include the impact of wearing
dentures on the micronutrient intake.
However, this review focused on the
intake of macronutrients known to be
associated with risk of noncommunicable
diseases (obesity, type 2 diabetes
mellitus, and cardiovascular disease)
and undernutrition (energy and protein
intake). The search did, though, identify
the studies that reported on the impact
of wearing dentures on intake of
micronutrients: most found negative
and null findings (Greksa et al. 1995;
Cousson et al. 2012; Han and Kim 2016;
Saarela et al. 2016; Jauhiainen et al.
2017); yet, none appropriately adjusted
micronutrient intakes for energy intake.
The review also excluded studies for
which there was not an English-language
abstract, which may in part explain
the lack of data from Latin American,
Middle Eastern, and African countries.
Finally, studies pertaining to ERQoL were
limited to those providing quantitative
and semiquantitative data, and studies
employing purely qualitative data were
excluded. Qualitative data may provide
a more in-depth assessment of the
nuanced impact of wearing dentures
on eating. Future studies exploring the
impact of wearing dentures on ERQoL
should consider qualitative as well as
quantitative evidence synthesis.
Conclusion
Although there are insufficient data
to compare the nutritional status of
denture wearers with the dentate, the
16
best available evidence suggests that
wearing dentures (full or partial) over
not wearing dentures may reduce risk
of undernutrition. Moreover, despite full
denture wearers having poorer ERQoL
when compared with the dentate,
wearing full dentures may improve
ERQoL. The balance of evidence
shows that denture wearers (full and
partial) have reduced eating function as
compared with the dentate. Sufficient
data show that wearing partial dentures
improves eating function in those with
tooth loss. There is a need for more
well-designed prospective studies—
with regard to nutritional methodology
and sample size while controlling for
confounders—to determine any impact
of prosthetic rehabilitation with dentures
on the intake of energy and nutrients.
Author Contributions
P. Moynihan, contributed to the
conception, design, and interpretation
of the data, drafted and critically revised
the manuscript; R. Varghese, instigated
the project and contributed to the
conception and interpretation of the
data, critically revised the manuscript.
Both authors gave final approval and
agree to be accountable for all aspects of
the work.
Acknowledgments
We thank Lisa Lovelidge, PhD, and
Clare Gurton, BSc (hons), from Lucid
for providing editorial and medical
writing support, including searching,
screening, and interrater reliability
assessments, which were funded by
GSK. We gratefully acknowledge the
contribution of Dr. Edoardo Aromataris
from the Joanna Briggs Institute at The
University of Adelaide for guidance on
the evidence synthesis and for feedback
on the manuscript. The views expressed
are our own.
Declaration of Conflicting Interests
The authors declared the following
potential conflicts of interest with respect
to the research, authorship, and/or
publication of this article: P. Moynihan’s
institution received a consultancy fee with
Month 2021
respect to some of the work on which
this article is based. R. Varghese is an
employee of GSK Consumer Healthcare.
Funding
The authors disclosed receipt of the
following financial support for the
research, authorship, and/or publication
of this article: The work was funded in
part by GSK.
ORCID iDs
P. Moynihan https://orcid.org/0000
-0002-5015-5620
R. Varghese https://orcid.org/0000
-0003-4749-0361
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