ROLE OF NUTRITION IN MAINTAINANCE OF ORAL HEALTH OF EDENTULOUS PATIENTS

Presented By
Dr. Kartik R. Morjaria
Post Graduate student Department Of Prosthodontics Karnavati School Of Dentistry

Guided By
Dr. Dipti S. Shah
Dean, Professor & HOD Department Of Prosthodontics Karnavati School of Dentistry

CONTENTS
1) 2) INTRODUCTION NUTRITION IN PREVENTION AND MANAGEMENT OF PERIODONTAL DISEASE 3) 4) 5) 6) 7) 8) 9) 10) 11) AGING FACTORS THAT AFFECT NUTRITIONAL STATUS THE IMPACT OF DENTAL STATUS ON FOOD INTAKE GASTRO INTESTINAL FUNCTIONING NUTRITIONAL NEEDS AND STATUS OF ELDERLY FOOD PYRAMID FOR 70+ ADULTS CALCIUM AND BONE HEALTH CLIMATERIC VITAMIN SUPPLEMENTATION DIETARY COUNSELLING OF PATIENTS UNDERGOING PROSTHODONTIC TREATMENT 12) 13) 14) 15) TRIPHASIC NUTRITIONAL ANALYSIS RISK FACTORS FOR MALNUTRITION IN DENTURE PATIENT NUTRITION GUIDE LINES FOR PROSTHODONTIC PATIENT CONCLUSION

INTRODUCTION

maintenance and metabolism. Enjoyment of food is an important determinant of an adult’s quality of life. edentulousness or ill fitting dentures may preclude eating favourite food as well as limit the intake of essential nutrients. Loose teeth. Decreased chewing ability. social isolation. a regular balanced intake of essential nutrients is required for the maintenance of oral epithelium. Because of rapid cell turn over (3-7 days) in the mouth. The nutritional status of a denture wearer is influenced by economic hardship. Medications Smoking UNHEALTHY Xerostomia ORAL TISSUES Soft Diet Diabetes Low Caloric Alcohol abuse Low nutrients Intake intake Inttake NUTRITION IN PREVENTION AND MANAGEMENT OF PERIODONTAL DISEASE . Clinical symptoms of malnutrition are often observed first in the oral cavity. development. and irritation of the oral mucosa when food particles get under dentures may influence food choices of the denture wearer. for growth.All people have some basic needs of nutritional intake. degenerative diseases medication regimens and dietary supplementation practices. well designed and constructed denture or an implantsupported prosthesis may prove to be unsatisfactory for a patient because of poor tolerance by the underlying tissues and bone. glossitis and slow tissue healing. fear of choking while eating. affects the health of the oral tissues and the patient’s adaptation to the new prosthesis. Hence denture failures can also be due to poorly nourished tissues. In fact. Conversely. Inadequate long term nutrition may result in angular cheilitis.

iron. zinc Nutrition and immune mechanisms  Antibody formation – Protein  Immune cell activity – Protein Nutrition and the repair process  Connective tissue formation – Protein and Vitamin C  Accelerate wound healing – Zinc  Promoting bone density – Calcium and phosphorus Effects of food textures on periodontal health  Chewing firm. B vitamins. protein  Maintain epithelial integrity – Vitamin A  Collagen in basement membrane – Vitamin C.Nutrition can affect periodontal disease at 3 levels • Contributing to microbial growth in the gingival crevice • Affecting the immunological response to bacterial antigens • Assisting in the repair of connective tissue at the local site after injury from plaque and calculus Nutrition and sulcular epithelium  New cell synthesis – Foliate. fibrous foods is beneficial to periodontal health – Increases salivary flow – Promotes a strong periodontal ligament AGING FACTORS THAT AFFECT NUTRITIONAL STATUS .

Atrophic gastritis results in increased levels of bacteria in the stomach and small intestine that bind the vitamin B12 for their own use and make it unavailable. decline in the skin’s ability to synthesize vitamin D from sun. Lactase deficiency results when the villi of the small intestine secrete too little lactase enzyme to fully digest the milk sugar. lactose. The resulting pain. and may affect from 10% to 15% of persons over age 60 years. decreased lean body mass. A classic example is the increase in lactase deficiency found in older individuals. megaloblastic anemia. Impairment in the function of the intestinal track secondary to illness. bloating. is common. disease. can result in neuropathy. with a decline in lean body mass. or medications can also result in food maldigestion and malabsorption. and nausea lead sufferers to avoid dairy products. This hypochlorohydria results from atrophic gastritis and can cause malabsorption of food-bound vitamin B12.PHYSIOLOGIC FACTORS: Declines in physical and cognitive status often increase with age. and impaired kidney or liver function needed to activate vitamin D. and cognitive impairment. Muscle mass is a predictor of strength. For example. in turn. gastrointestinal symptoms. Thus. Vitamin B12 deficiency. excessive gas. Decrease in intestinal function may also be associated with increased constipation in older people. particularly muscle mass (sarcopenia). mobility. The adoption of low-fiber . Vitamin D synthesis at age 80 years is half that at age 20 years. Declines in gastric acidity also often occur with age. insulin sensitivity and basal metabolic rate. caloric needs decrease and risk of falling increases. Vitamin D deficiency is also common in the elderly for several reasons : insufficient sun exposure.

xerostomia. vitamin C and Vitamin E. and interference with nutrient absorption and utilization. Prescription drugs are the primary cause of anorexia. vomiting. Overt deficiency of several vitamins is associated with neurological and behavioural impairment B1 (thiamin). those with chronic disease and restrictive diets. Dehydration can be insidious and unrecognized until serious side effects occur. Drugs can affect the absorption and utilization of some foods and nutrients. Elders particularly at risk include those living alone. Panthothenic acid. Dehydration. the isolated. nausea. These drugs can interact with food and diet. B6 (pyridoxine).diets in response to chewing difficulties and dentures can exacerbate this condition. is a major concern in the older population. taste loss. and the oldest old. and vice versa. caused by declines in kidney function and total body water metabolism. PSYCHOSOCIAL FACTORS: Psychosocial factors may play even greater roles than physical. Declining physiologic function can keep drugs in the body for longer periods of time than is desirable. sometimes with serious side effects. Foliate. gastrointestinal disturbances. and dental issues in determining the health and well-being of elders. These . the physically handicapped with insufficient care. B2. niacin. Poverty is also a major contributor to malnutrition. B12. PHARMACOLOGIC FACTORS: MEDICATIONS AND ALCOHOL Most elders take several prescription and over-the-counter medications daily. medical.

Drugs that exert an effect on taste and appetite Reduce taste Baclofen. penicillamine. griseofulvin. estrogens. antineoplastic. tetracyclins. indomethacin. metronidiazole. phenylbutazone Captopril. carbonic anhydrase inhibitor. and ultimate malnutrition. digitalis. flurazepam. weight loss. lithium carbonate Ethambutol. lithium salts. lincomycin.conditions can lead to nutrient deficiencies. phenylbutazone Anticonvulsants. gold compounds Carbamazepine. carbamazepine. thiazides Alter taste perception Metallic taste Bitter taste Decreased appetite ORAL FACTORS THAT AFFECT THE DIET AND NUTRITIONAL STATUS .

Xerostomia: Xerostomia (dry mouth or hyposalivation) affects almost one in five older adults. so taste sensitivity may be reduced when an upper denture covers the hard palate. teeth become more susceptible to dental caries. burning or soreness of the oral mucosa. The hard palate contains taste buds. age-related changes in taste and smell may alter food choice and decrease diet quality in some people. and smoking. Saliva provides natural protection to the hard and soft tissues of the oral cavity. denture use. Factors contributing to this report decreased function may include health disorders. oral hygiene. It also becomes difficult to determine the location of food in the mouth when the upper palate is covered. swallowing can be poorly coordinated and dentures can become a major contributing factor to deaths from choking. Xerostomia can also impair complete denture retention and is associated with increased periodontal disease. The exposed root surfaces of teeth are particularly at risk. As a result. medications. When salivary levels decline. THE IMPACT OF DENTAL STATUS ON FOOD INTAKE . Effects of dentures on taste and swallowing: A full upper denture can have an impact on taste and swallowing ability. Oral infectious conditions: Periodontal disease also increases with age and maybe exacerbated with systemic disease Sense of taste and smell: Although the olfactory system is generally well preserved with age. and difficulties in chewing and swallowing – all of which can adversely affect food selection and contribute to poor nutritional status.

soft foods are often lower in nutrient density and fiber. department of agriculture human nutrition research center – Boston – the nutrition intake of those who had one (or) two complete dentures was about 20% lower than that of the dentate subjects. chewing is difficult. The use of osseointegrated implants also increased the chewing ability and varieties of foods were eaten. Denture wearer must complete a greater number of chewing strokes to prepare food for swallowing. improved the quality of their diet. Salivary flow facilitates – mastication. oral motor function. 4) There is general agreement that the masticatory function of denture wearer is greatly inferior to person with intact dentition. denture retention is compromised and mucosal soreness (or) ulcerations develop. formation of food bolus and swallowing. 6) Studies in Finland showed that the wearing of dentures for several years. 5) In a study of the united states. 2) The loss of teeth often leads adults to select soft diet. 7) The condition of an individual’s denture also may influence food selection. If the oral mucosa is dry. 9) Xerostomia may contribute to geriatric malnutrition. When old complete dentures with poor retention were replaced with new dentures the masticatory performance of the patients improved. 8) The comfort of wearing dentures is dependent on the lubricating ability of saliva in the mouth.1) The food choices of older adults are closely linked to dental status and masticatory efficiency. Xerostomia – (dry mouth) is a clinical manifestation of salivary . adequate saliva and the number of occluding pairs of teeth in the mouth. 3) An individual’s masticatory ability is mainly determined by age.

vit A or vit B complex deficiency. When a denture covers the upper palate. Individuals with poor masticatory ability often swallow large pieces of food. milk not only aids in lubricating the tissues. alcoholism. the use of milk serves as saliva substitute and also an excellent source of nutrients. but also has a buffering capacity. which may cause death. depression. 10) Milk has been proposed as saliva substitute. menopause. therapeutic radiation to the head and neck. pernicious anemia. The purpose of mastication is to reduce food particles in size. so that they can be swallowed and to increase the surface area of food exposed to digestive juices and enzymes. it is difficult to detect the location of food in the mouth. NUTRITIONAL NEEDS OF ELDERLY . Causes of xerostomia may be use of medication. diabetes. As dry mouth may result in inadequate nutritional intake.gland dysfunction. Adults with such dentures are at a greater risk of having a large piece of food (or) a bone lodged in the air or food passage. GASTRO INTESTINAL FUNCTIONING Little research exists on the effect of tooth loss on gastrointestinal functioning.

vit C. With aging lean body mass is replaced by fat. Women – 1300 k cal. This is lower than RDA for adults – 51 – 65 yrs Men 2300 k cal Women 1900 k cal 5) Complex carbohydrate should be the mainstay of elderly diet. obesity. 4) Cross sectional surveys showed that the average energy consumption of 65 – 74 yrs old men – 1800 k cal. but is often adequate. 2) Depending on body metabolism an individual may need more (or) less of nutrients than proposed in the required daily allowances. 6) Fats contribute about 33% of total calories in an adult diet Fats – Cause heart diseases. So it is difficult to generalize about energy. iron and protein. 8) Oral symptoms of malnutrition are usually due to lack of vitamin B-complex. Important component of complex carbohydrate is fibre which promotes normal bowel function. Nutrient lacking 1) Protein Oral symptoms • Decreased salivary flow. . this leads to a decrease in metabolic rate.1) The nutrient needs of older persons vary depending on health status and level of physical activity. vitamin and mineral requirements appropriate for all older adults. certain cancers. 7) The protein intake of denture wearers is lower than that of dentate adults. 3) Energy needs decline with age because of decrease in basal metabolism and decreased physical activity. so adults are advised to maintain their dietary fat intake at 20% to 35% of total calories. may reduce serum cholesterol and is thought to prevent diverticular disease. and haemorrhoids.

or persons with high aspirin intake have a higher daily requirement of vit – C. may be due to chronic alcohol intake. bald • Edematous oral mucosa • Tender gingiva • Spontaneous bleeding of gingival • Haemorrhages in interdental papillae 3) Vit – C 9) Heavy smokers. iron. Vit c – Ascorbic acid – plays a role in collagen synthesis (essential for wound healing) 10) Deficiency of thiamine. pyridoxine. . niacin. folate (vit-B) and ascorbic acid are commonly seen in alcoholic’s. protein Lips : • Chelosis • Angular stomatitis • Angular scars • Inflammation Tongue : • Edema • Magenta tongue • Atrophy of filiform papillae • Burning sensation • Soreness • Pale. 11) Osteopenia in males. alcohol abusers.complex.• enlarged parotid glands 2) Vit B.

The bread. alcohol and drinks containing caffeine can cause the body to lose fluids and become dehydrated. as well as water. The emphasis on fluids is due to older adults reduced sense of thirst that can lead to drinking less fluid. GERODONTIC NUTRITION AND DIETARY COUNSELING FOR PROSTHODONTIC PATIENTS. 47:355-71) In general. However. milk and non-caffeinated soft drinks and beverages. Dehydration can make kidney function and constipation worse. recognizing that seniors usually need less energy and therefore usually eat less. This two-quart daily fluid intake can include juice. rice and pasta group forms the base of the original food guide pyramid. But the pyramid for older adults is based on at least eight-ounce glasses of water each day. the food guide pyramid for healthy older adults is narrower than the original pyramid.(PALMER CA. . DENT CLIN N AM 2003. cereal.

Another key difference from the original food guide pyramid is the flag at the top to indicate a recommendation for the dietary supplements calcium. thereby requiring a supplement if their milk intake is less than the three glasses. These supplements are sometimes recommended because older adults eat less and do not absorb and process nutrients as efficiently as younger people. Fiber is very important because it helps prevent constipation. which is the equivalent of three servings of calcium-rich dairy products (such as milk. Taking a multivitamin for seniors will ensure an adequate intake of both vitamin D and B-12. Eating the recommended number of servings of foods that contain fiber will usually provide that intake. A total of 2. Fiber comes from many sources. including whole fruits and vegetables. and a reduced risk of heart disease and cancer. It is also associated with lower cholesterol levels.4 micrograms is recommended each day. Sunlight provides vitamin D. . such as calcium citrate and calcium carbonate are available to make up the difference. Total calcium intake each day should be 1200-1400 milligrams. too. Seniors do not easily absorb vitamin B-12. whole grains and legumes. vitamin D and vitamin B-12. Supplements. Another difference for the pyramid for seniors is the addition of a fiber icon – (f+). Fortified breakfast cereal can help as it contains vitamin B-12 in a form that the body will absorb. A total of 20-30 grams of fiber is recommended each day for optimal health. hemorrhoids and diverticulosis (inflammation of small pockets lining the intestines). hard cheese or yogurt). but many seniors often have limited exposure to it. which is equivalent to three 8-ounce glasses of milk. Daily vitamin D intake should be 600 international units (IUs).

as well as the spine and long bones skeletal sites where trabecular bone is more prominent than cortical bone. wrist. and neck of femur) Several factors are thought to contribute to age related bone loss that leads to osteoporosis:• • • • • • • Genetic back ground Hormonal status Bone density at maturity Disturbance in bone remodeling process Low exercise level Inadequate nutrition Low calcium intake throughout life is a contributor to osteoporosis. are affected first (alveolar bone.CALCIUM AND BONE HEALTH Bone loss is a normal part of aging that affects the maxilla and mandible. . vertebrae.

The glandular functional changes have varying effects Generalized osteoporosis – reduction in bone mass with pain. Resorption of alveolar ridge is a wide spread problem. Calcium intake by older adults will not restore the bone. In females this period is termed menopause and in males it is called andropause. when an important change in bodily function occurs. Dietary calcium is critical to maintaining the body skeleton. adults must drink 3 or 4 glasses of low –fat milk / day.CLIMACTERIC Climacteric is a period in both males and females. 2) Burning palate. Denture patients with excessive ridge resorption report lower calcium intake. burning tongue etc. Bone loss is accelerated in the first 6 months after tooth extraction and resorption is greater in the mandible than maxilla. 1) A greater degree of residual ridge resorption is seen in women than in men. deformity (or) pathologic fracture. . but will improve calcium balance and slow the rate of bone loss. Recommended daily allowance RDA (1997) Age (yr) 31 – 50 51 – 70 > 70 Calcium (µ g) 1000 1200 1200 Vitamin – D (µ g) 5 10 15 To receive 1000 to 1200 µ g of calcium.

VITAMIN SUPPLEMENTATION Based on nutrient deficiency in denture patients. can disturb calcium metabolism leading to calcification of soft tissues. headache. For nutrients to be present in proper ratio. it no longer functions as a vitamin but becomes a chemical with pharmacological activity. 2) High doses of retinol. 4) High intake of Niacin – flushing. 1) Mega doses of vit-D. accelerates bone resorption increasing the risk of hip fracture. to one another a multivitamin – mineral supplement is preferable to single –nutrient tablets. The use of megadose vitamin in elderly is of great concern because with a high dose of a vitamin. itching skin 5) High intake of Vit B6 – peripheral neuropathies .dose multivitamin diet. it may be reasonable to prescribe a low. 3) Mega doses of Vit-C can induce copper deficiency anaemia.

rapid cell turnover in the mouth.DIETARY COUNSELLING OF PATIENTS UNDERGOING PROSTHODONTIC TREATMENT The main objective of diet counseling for patients undergoing prosthodontic care is to correct imbalances in nutrient intake that interfere with body and oral health. 4) Maintenance of oral epithelium. 3) Elderly population over 70 years of age is more likely to have poor diets. assess nutritional risk 3) Teach about the components of a diet that will support the oral mucosa. 2) Evaluate the diet. Dietary evaluation and counseling should be included in prosthodontic treatment. 4) Guidance in the establishment of goals to improve the diet 5) Follow – up. requires a regular balanced intake of essential nutrients. 5) To lower the rate of alveolar ridge resorption. . and nutrition risk increases with advancing age. 2) The quality of a denture wearing patient’s diet can be improved with nutrition counseling. if patient has any of the following physical or social conditions. increased intake of calcium and vitamins is required. 1) Medical Conditions Greater than 75 yrs of age Low income Little social contact Involuntary weight loss Daily use of multiple drugs • Need for assistance with daily – self-care Providing nutrition care for the denture – wearing patient entails the following steps :• • • • • • 1) Obtain a nutrition history and an accurate record of food intake over a 3-5 day period. bone health and total body health.

ARAS M. Qualitative dietary assessment The purpose of the dietary assessment is to determine what an individual is eating now. the nutritional assessment should be terminated and approximate dietary counseling instituted.A. If potential nutritional problems are detected. 6.. screening for clinical signs of deficiency. conducting selected anthropological measurements and assessing the adequacy of dietary intake. based on any of these parameters. enough information is available to ensure a rational basis for therapy. what he or she has eaten in the past and recent changes in the diet. A questionnaire has been developed to identify older individuals with nutritional problems. 1:22-28) PHASE 1 The first phase must be used to screen all patients and consists of obtaining information from a medical-social history. However.ASSESSING THE NUTRITIONAL STATUS TRIPHASIC NUTRITIONAL ANALYSIS (BANDODKAR K. . the nutritional evaluation should progress to phase II. NUTRITION FOR GERIATRIC DENTURE PATIENTS. if at the conclusion of phase I. JIPS 2006. This questionnaire may be administered by health care professionals and applied in both inpatient and outpatient settings.

1 2 3 4 5 6 7 8 9 10 QUESTION I have an illness or condition that made me change the kind and/or amount of food I eat. liquor or wine per day I have tooth or mouth problems that make it difficult for me to eat I don’t always have enough money to buy the food I need I eat alone most of the times I take three or more different prescribed or overthe-counter drugs a day Without wanting to. I have lost or gained 10 pounds in the last six months I am not always able to shop.QUESTIONNAIRE Q. vegetables or milk products I have three or more glasses of beer. NO. cook and/or feed myself SCORE 2 3 2 2 2 4 1 1 2 2 SCORES TOTAL SCORE 0-2 3-5 >6 PHASE II NUTRITIONAL RISK Good nutritional health Moderate nutritional risk High nutritional risk . I eat fewer than 2 meals a day I eat few fruits.

. as well as the effects of drugs and chronic disease. Semi-quantitative dietary analysis At this level of evaluation. The analysis in this phase includes comprehensive nutritional biochemical assays of blood. dietary intake is assessed using more quantitative means. serving as a consultant. PHASE III The final phase of the analysis is reserved for more complex nutritional problems and should be accomplished under the direction of a physician. However.When the parameters described here indicate the existence of a nutritional problem. as well as tests of metabolic and endocrine function. Nutrients in all foods and beverages consumed during a 3 to 5 day period are calculated using Food Composition Tables or computer-assisted nutrient analysis programs. most indices fall within standard ranges for young adults and many of the parameters are affected by an age related decline in renal function and body water. Biochemical assessment Common automated blood tests are also useful in providing more definitive information regarding the nutritional status of patients. A semi-quantitative dietary analysis and routine blood chemistry should be undertaken. urine and tissues. Average caloric and nutrient intakes can be quantitated and compared with norms. are invaluable at this level of assessment. more information should be accumulated. The services of a registered dietician.

fruits. in the last 6 months. juice or milk daily. 7) Limit intake of prepared and processed foods high in sodium and fat 8) Consume 8 glasses of water daily. 3) Eat atleast 5 servings of fruit and vegetables daily. vegetables whole grams and cereals. meat (or) dried peas and beans every day 5) Consume 4 servings of calcium –rich – foods daily. Undergoing chemotherapy or radiation therapy Poor dentition or ill fitting prosthesis Oral lesions – glossitis. 6) Limit intake of bakery products high in fat and simple sugars. 4) Select fish. .RISK FACTORS FOR MALNUTRITION IN DENTURE PATIENT Unplanned weight gain or loss of > 10 lb. chelosis or burning tongue 5) Severely resorbed mandibular ridge 6) Alcohol or drug abuse 7) Eating less than 2 meals / day 1) 2) 3) 4) NUTRITION GUIDE LINES FOR PROSTHODONTIC PATIENT 1) Eat a variety of diet 2) Build diet around complex carbohydrate. poultry.

So the patient has to be well nourished and consume a well balanced diet. 6.A.SHELDON WINKLER  BANDODKAR K. GERODONTIC NUTRITION AND DIETARY COUNSELING FOR PROSTHODONTIC PATIENTS. NUTRITION FOR GERIATRIC DENTURE PATIENTS. ARAS M. JIPS 2006. Good health and nutrition of older patients are necessary for the successful wearing of dentures. 47:355-71 .. Dietary guidance based on assessment of the edentulous patient nutrition history and diet should be an integral part of comprehensive prosthodontic treatment. Many denture failures are the result of nutritional deficiencies. DENT CLIN N AM 2003.CONCLUSION The success of complete denture prosthesis is mainly influenced by the mucosal condition of the denture bearing areas. REFERENCES  PROSTHODONTIC TREATMENT OF EDENTULOUS PATIENTS – BOUCHER’S – 12TH EDITION  ESSENTIALS OF COMPLETE DENTURE PROSTHODONTIC’S . 1:22-28  PALMER CA.

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