INTRODUCTION:

Nutrition is the process of providing proper food elements for

maintenance of health and growth. Nutrition includes digestion, absorption,
assimilation and the actual use of nutrients by the cells of the body. Diet is
related to the variety and amount of food that is eaten. A proper diet must be
followed for an individual to be well nourished.

The essential nutrients are proteins , fats, carbohydrates, vitamins,

minerals and water. Diet and nutrition refers to specific functions in the body
of proteins, carbohydrates, fats, vitamins, minerals and water and to the
individual dietary requirements for these factors. One aspect of nutrition is the
integration of physiologic and biochemical reactions within the body. These
are:
1. Digesting food to make nutrients available
2. Absorbing and delivering nutrients to the cells, where they are
utilized
3. Eliminating waste products

Psychological and social factors that enter into frequent decisions

concerning food choices are also important aspects of nutrition. Freedom of
choice and variety in consumption are important components of an
individual’s personal and social life, tastes budget, environment and cultural
attitude influence food choices. The systemic affects of nutrients, which are
determined by these food choices, in turn affect dental health.

Balanced diet:

It contains all the proximate principles of diet in

appropriate quantity. The ratio of carbohydrates proteins and fats
should be 4:1. The patients should be able to supply all the

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essential aminoacids. The diet should also contains adequate
amounts of vitamins, minerals and water.

AGING AND CHANGING PHYSIOLOGY:

1) Aging and the oral cavity:

The decreased functional capacity of aging cells in the

nervous and skeletal muscle systems and the volumetric loss of
upto one third of the lean muscle mass of the body by the age of
75 are reflected in impaired masticatory force and neuromuscular
incoordination. Generalized skeletal loss of 50% of cancellous
bone and 5% of cortical bone minerals by the age of 75 results in
a poor osseous basal seat already ravaged by osteoporosis.

At approximately 45 years of age, a person begins to

experience a decrease in the number of taste buds on the lingual
papillae and this loss is progressive and continuous as age
increases. A decrease in the number of taste buds does not
necessarily be indicative of loss of taste and there is an ability to
identify primary taste qualities remains, an individual becomes
progressively impaired in the discrimination of subtle blending
of taste qualities of food.

The problem is compounded by age related atrophy and

fibrous infiltration of the salivary glands. Because the sensory
stimulation of taste receptors is dependent on water solubility of
food as well as the taste buds, salivary flow may result in
diminished taste reception and decrease in pleasurable aspects of
eating. A compensatory change in dietary preferences is sought to
produce a more positive response to the sensory stimulation of
food. Simultaneously the loss of saliva under the denture,

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advancing alveolar resorption, osteoporosis, epithelial thinning,
loss of elastic attachment of epithelium and lack of
neuromuscular coordination introduce biomechanical obstacles to
the wearing of complete dentures. These obstacles also
contribute to an adverse compensatory change in dietary habits.
The diet is frequently changed to include large amounts of
commercially prepared convenience foods which are rich in
carbohydrates and calories and deficient in protein, iron, calcium
and ascorbic acid. Such a diet routinely contains salt and
saturated fats in quantities detrimental to persons with
cardiovascular disease. In addition, this type of diet is usually
deficient in vitamin k, inducing calcium loss in bone.

Commercially processed food products, contain a high

ratio of phosphorous to calcium and this excessive phosphorous
induces secondary hyperparathyroidism which causes withdrawal
of calcium from skeletal tissues to maintain serous
concentrations of calcium. In the aged, deficiency in calcium
intake and excessive phosphorus intake can cause osteoporosis.
Wical and Swoope concisely summarize an extensive literature
survey concerning osteoporosis as “Among the many recognized
systemic influences which affect the resistance and resorption of
bone, calcium deficiencies and calcium/ phosphorous imbalances
have been specifically implicated as contributing factors in the
pathogenesis of alveolar bone destruction and osteoporosis”.

Altered taste sensation may be complicated by medications

common in aging. Alkaloids and halogens transported back to
oral cavity by the circulatory, digestive or respiratory system can
result in a bizarre taste sensation.

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 Similar taste alterations are produced by saccharin and
other sulfur compounds, tetracycline, chloramphenicol, salts of
heavy metals and even therapeutic doses of thiamine
hydrochloride. Salt deficient diets and certain medications such
as d-penicillamine produce temporary loss of taste, while psychic
energizers and depressors commonly produce xerostomia.

It is generally accepted that the microbial population of

the oral cavity undergoes significant challenge during a life span,
with a tendency for lactobacillus acidophilus in children,
streptococcus mutans predominate in middle years and the
actinomyces group of organisms to predominate in old age.

Actinomyces organism is found in heavy concentrations in

the aged who have retained natural teeth with exposed root
surfaces and heavy plaque formation. A more serious concern
relating to oral bacterial flora now relates to the growing number
of aged who are diabetic, bedridden or victims of oral cancer. In
these people, significant populations of highly pathogenic
organisms are recoverable from the saliva and dentures
indicating the potential for generalized infection due to minor
instrumentation or injury within the oral cavity.

Significant psychologic change also accompanies the aging

process.

2) Aging within the Gastrointestinal tract:

As food is passed to the digestive tract, it enters an

environment increasingly impaired in the elderly.Decreased
intestinal mobility in itself unimportant, permits bacterial
residents to the tract to proliferate.

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 The selective ingestion of critical nutrients by intestinal
flora is compounded by the fact that the microorganisms are
afforded priority of access to the alimentary nutrients.
Nutritional deficiency of the host becomes accentuated if the
dietary intake is inadequate in quantity or quality.

As food passes through the alimentary canal, most

absorption occurs in the upper 20% of the small intestine and
80% of the absorptive process results from passive transport, a
simple perfusion or osmosis of nutrients through the intestinal
walls. The remaining 20% of a process dependent on the
intestinal Villi’s seeking out and absorbing nutrients. It has been
demonstrated that in aged human subjects there is a significant
decrease in absorptive capacity of the small intestine. Among the
reasons advanced for this altered functions capacity is a
decreased rate of cell renewal in the intestinal wall, resulting in
a preponderance of epithelial cells with a life span exceeding the
3-day renewal rate in younger people. These older cells appear to
be relatively inactive to nutrient selection, especially, if
nutrients are present in small amounts. In using malabsorptive
processes result primarily in impaired adsorption of fats, which
in turn produces a deficient calcium absorption with a negative
calcium balance.

Absorption of essential nutrients may be further impaired

as ingested medications exact an additional nutrient toll in the
elderly.

Alcoholism is conservatively estimated as affecting upto

10% of the population beyond the age of 60. The well
documented nutritional problems associated with alcoholism are

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compounded in the elderly by a reduced or marginal dietary
intake and by an absorptive capacity impaired by factors other
than alcohol.

NUTRITIONAL CONSIDERATIONS FOR GERIATRIC

PERSONS

1) Role of nutrition in conditioning edentulous patients:

It is our responsibility as dentists to provide appliances

which produce minimum stress upon oral structures. It is also our
responsibility to assure a maximum vitality and adaptive capacity
of these oral structures. Since tissue vitality is in such large
measure dependent upon the availability and use of nutrients, it
is advisable to inquire into and when necessary, adjust the
nutritional status of our complete denture patients.

Nutritional therapy adjunctive to preparation of the

recently edentulous patient or to preparation of the patient
evidencing oral tissue damage due to existing dentures need to be
time-consuming, complex procedure for dentist or patient. In the
absence of clinical evidence indicating severe or specific dietary
deficiency, our procedures must be concise, clearcut and simple
and they must require minimal alteration in existing habits of
denture age patients.

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Nutritional objectives:

1) To establish a balanced diet which is consistent with the

physical, social, psychological and economic background
of the patient.

2) To provide temporary dietary supportive treatment directed

toward specific goals such as caries control, postoperative
healing or soft tissue conditioning.

3) To interpret factors peculiar to the denture age group of

patients which may relate for complicate nutritional
therapy.

Treatment:

A five fold plan of treatment may be used in nutritionally

oriented tissue conditioning consists of:

1. Examination by the physician.

2. Use of physical tissue conditioning agents.

3. Dietary advice.

4. Motivation.

5. Dietary supplementation.

1. Examination by physician:

An examination by the patient’s physician is advisable and

is always indicated if an extensive dietary change is anticipated
or if frank systemic or nutritional disease is apparent. Such an
examination may benefit the dentist in two ways.

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i) It may reveal concurrent medical problems which
interfere with dental and general health or utilization of
nutrients.

ii) It may reveal specific medical problems such as

diabetes or anemia which may be masked by any dietary
treatment other than massive, concerted nutritional therapy.

2. Physical tissue conditioning agents:

When existing dentures are retained during a program of

tissue conditioning the dentures should be restored to an
acceptable occlusal vertical dimension and occlusal relation. The
basal seat area of the dentures should be generously reduced and
an ethyl methacrylate lining material applied periodically,
relieving areas of tissue impingement as they occur.

The use of soft liners is a substitute for the more effective

procedure of leaving dentures out of the mouth during a period of
tissue recovery. Massage of oral tissues, including the tongue,
with an antifungal agent and lavage and massage with a mouth
wash that has antifungal properties are also helpful in correcting
monilial infection in the oral cavity.

3. Dietary advice and motivation:

Advice and motivation must be considered concurrently

since one reinforces the other. Because we are primarily
concerned with the mouth, our discussion of nutrition should be
oriented toward oral tissue preservation and healing, with
emphasis being placed upon the abnormal stress imposed upon a
denture foundation by appliances, the necessity of maintaining

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maximum tissue health; the relation of tissue health to nutrient
supply and the consequences of tissue abuse.

Dietary advice to complete denture patients, unlike that

designed for dietary control of caries need not involve an
extensive survey of existing eating habits. Indeed such a survey
tends to create patient resistance. A far better approach, in the
absence of specific health problems, is a discussion of
shortcomings in the average diet of the denture age patient,
emphasizing the common problems of carbohydrate excess with
deficiency of animal protein, calcium, thiamin, vitamin A, and
ascorbic acid. It should be emphasized that regulation of these
and other nutritional elements requires neither specialized fat
diets nor drastic change in a daily routine. Rather, it should be
pointed out that all nutritional elements are readily available
from normal foods and that these nutritional elements of the diet
are interrelated and often interdependent in their function.
Ascorbic acid (vit.C) furnishes an interesting example for the
patient. Although the primary function of this vitamin is the
regulation of collagen formation, it is indirectly responsible for
prevention of iron deficiency anemias by enhancing the intestinal
absorption of iron and also is indirectly responsible for
preventing macrocytic anemias because of its involvement in the
transformation of folic acid into the biologically active folinic
acid.

Nutritional education of the patient may be considered

successful if the patient is made to realize that all essential
nutritional elements are available in virtually any diet which
observes basic rules of food distribution and quantity.

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4. Dietary supplementation:

Except in severe deficiency states, nutritional therapy does

not produce sudden, dramatic changes in oral or general health.
When conditioning of abused oral tissue is undertaken, temporary
dietary supplementation should be considered. This
supplementation may serve several purposes:

1. Create a sense of well-being and a feeling of immediate

progress in the patient.

2. Stimulate appetite, thus making more acceptable any

required dietary changes.

3. Provide a controllable and balanced source of required

nutrients during the period of dietary transition.

4. Provide individual, specific nutritional elements.

Dietary supplementation may take many forms. The

following programs has been found particularly useful in
satisfying these purposes. For psychologic reasons, this program
should be instituted several days after the patient has begun
adjustment of his daily diet. The immediate physical and
psychologic responses of the patient to dietary supplements may
be interpreted by the patient as benefits derived from his dietary
regulation; thus he is encouraged to continue his dietary regimen.

Crude liver extract in 5cc doses is administered

intramuscularly on alternate days, providing a total dosage of

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20cc. Appetite and a sense of well being are restored usually
within 48 hours. The intermuscular use of crude liver produces
much faster response than does oral administration. After a series
of injections of crude liver extract, the patient is maintained for
approximately two months on oral doses of a fractionalized liver
product until a stabilized diet is assured.

Many denture patients undergoing tissue conditioning

treatment are limited in masticatory efficiency by inflamed
mucosa. Since protein is essential for tissue rebuilding and since
meat, the best source of protein, may be avoided by the patient
during this period, it is often wise to augment the daily food
intake with two helpings of a prepared food supplement. These
products insure a basic protein supply and may also provide a
controlled, balanced supply of other nutrients during the period
of dietary transition.

Vitamins:

Although dietary supplementation with single or multiple

vitamin preparations has been employed, these preparations serve
little purpose in a conscientiously applied program designed to
provide balanced and adequate nutrition.

FACTORS AFFECTING NUTRITIONAL STATUS:

1. Quality and quantity of food.

2. Ingestion of food obtained (mastication and swallowing).

3. Absorption and digestion (malabsorption).

4. Requirement of body tissues (metabolism).

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1) Quality and quantity of food:

The quality and quantity of food consumed will vary

between individuals for a variety of reasons, including habits,
preference, addiction (e.g. alcoholism), appetite, knowledge or
ignorance, money, as well as ability to obtain food and the skill
to prepare it for consumption. Lack of interest in food and its
preparation can easily alter both quantity and quality of diet and
a habit can form which will lead to overt deficiency with clinical
signs and symptoms. Elderly widowers living alone may be
particularly prone to deficiency status. Ignorance of food values
probably plays an important part in this deficiency, since a good
quality diet is not necessarily more expensive.

2) Ingestion of food:

Mastication and swallowing are both important components

of the ingestion process. The production of saliva diminishes
with age, as the salivary glands become less efficient. As a
result, mastication becomes less efficient and swallowing more
difficult and food may often be chewed for long periods and then
spatout. It has long been known that the proportion of solid foods
ingested is closely associated with presence or absence of teeth.
Although inadequacy of the dentition alone as a primary factor
causing poor nutrition is open to question, there is no doubt that
it contributes to poor nutritional status. Drugs may also reduce
saliva. Diuretics and substances with anticholinergic affect are
particularly liable to do this.

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 Disorders of neuromuscular coordination may also make
swallowing difficult. These may be associated with paralysis or
dysfunction of the facial and masticatory muscles as well as
those involved with the control of the tongue and pharynx.

Sufferers from Parkinson’s disease often appear to suffer

from excess salivation and dribbling is obvious. This symptom is
the mainly due to the inability of these patients to swallow their
saliva against gravity since their head, neck and upper trunk tend
to be bend forward.

Many other disease processes may also interfere with

ingestion of food. Rheumatoid arthritis may affect the
temperomandibular joints, thus interfering with mastication.
Breathlessness due to respiratory disease or associated with heart
failure may make swallowing difficult.

3) Taste and smell:

It is often stated that the senses of the taste and smell

decline with age. Abnormal taste patterns, can certainly lead to
reduction in food intake but it is doubtful whether loss of taste
and smell significantly reduces intake and leads to subnutrition.

4) Absorption and digestion:

Some changes occur in gastrointestinal function with aging

because of mild generalized atrophy. Gastric hydrochloric acid
secretion diminishes, and the finding of achlodhydria is common.
Pancreatic lipase also diminishes but these changes probably
have little effect on absorption. However, when illness occurs or
heart failure exists, digestion may well be impaired. In any case,

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elderly should be advised to avoid large meals and to eat smaller
meals reasonably distributed during the course of the day.

It must also be remembered that disorders of the

gastrointestinal tract may give rise to nutritional or nutrient
deficiency because of the loss of nutrient. Loss of iron as a result
of bleeding is the commonest cause of iron deficiency anemia in
the elderly while this may occur from ulcerative lesions,
neoplasms or haemorrhoids, the place of drugs particularly
gastric irritants must not be forgotten. Many elderly patients
have their arthritis treated with aspirin or other non-steroidal
anti-inflammatory drugs, and all these may cause blood-loss from
the gut.

Finally, it should be remembered that gut mobility

impaired by age may have affects on nutritional intake.

5) Requirements of body tissues:

The nutritional requirement of individual body tissue in

old age is not known, but it probably declines. Certainly it seems
likely that total body requirements are reduced. Both muscle and
bone mass gradually reduce with age. Maximal physical
performance occurs at about 30 years and after this a steady
decline occurs, more rapidly in those who are inactive.

As a result of the loss of tissue, Body Cell Mass (BCM) or

Lean Body Mass (LBM) is reduced and Body Fat (BF) increases.
BCM declines more rapidly in men than in women. Because of
these changes the Basal Metabolic Rate (BMR) will also fall.

It is also likely that some changes take place within tissue

cells. Some enzymal patterns, alters, either because protein

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replication is defective or because enzyme adaptability and
induction is depressed or delayed.

3) NUTRITIONALLY RELATED ORAL PROBLEMS IN

ELDERLY PATIENTS:

One of the major functions of nutritional fitness is to

prevent or slow down the onset of those degenerative and disease
conditions associated with aging that occur in the mouth, such as
loss of taste, xerostomia, burning and sore tongue, oral mucous
membrane disease, temperomandibular joint discomfort,
periodontal disease and osteoporosis of the alveolar bone.

1) Alterations in gustation and olfaction

Gustation (taste perception) is mediated through the

papillae, taste buds and free nerve endings found primarily in the
tongue but also over the hard and soft palates and in the pharynx.
In general, number of these structures appears to decrease with
age.

Four modalities of taste are perceived by the tongue – salt,

sweet, sour and bitter.

Olfaction is the act of perceiving odors, the odors of food

contribute to its palatability. This olfactory sense is situated in
the upper part of the nasal cavity.

In the process of aging, the taste perception diminishes –

the perception for salt at any early age and for sweet a little later
- in part as result of hyperkeratinization of the epithelium that
may occlude the taste bud ducts.Vitamin A inadequacy may be
associated with such epithelial hyperkeratinization. On the other

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hand the receptors of bitter taste in the circumvallate papillae
seem to survive the aging process.

2) Xerostomia (dry mouth)

It is a condition commonly found in the elderly. It is not a

direct consequence of aging process but may result from one or
more factors affecting salivary secretion. Emotions, neuroses,
organic brain disorders and drug therapy all can cause
xerostomia. Many drugs are known to produce dry mouth as a
side effect. In addition salivary gland function may be
diminished by obstruction of the duct, infection such as mumps,
Sjogrens syndrome, lupus erythematosis, autoimmune haemolytic
anemia.

Since saliva lubricates the oral mucosa, lack of saliva

creates a dry and often painful mucosa. Without significant flow
of saliva, food debris will remain in the mouth, where it is
fermented by the bacteria.

In addition the lack of saliva can affect the nutritional

status in a number of ways.

1. It hinders chewing of food because it prevents formation of

bolus.

2. It makes mouth sore and chewing painful.

3. It makes swallowing difficult due to loss of saliva’s

lubricating effect.

4. It can cause changes in taste perception that decrease

adequate food intake.

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3. Painful and burning tongue:

A painful, burning tongue is often encountered in

nutritional anemias associated with deficiencies of vitamin B12,
folic acid or iron.

Vitamin B12 deficiency (pernicious anemia) seem with

increased frequency in older people, particularly women, is
characterized by a triad of symptoms. Generalized weakness, a
sore painful tongue, and numbness or tingling of the extremities.
The tongue is generally described as dark red. Characteristically
there is a gradual atrophy of the papillae that result in a smooth
or bald tongue. Not commonly in anemic patients, the oral
mucosa becomes sensitive and intolerant to dentures.

Achlorhydria, sensory disturbances, difficulty in walking,

incoordination and loss of vibrating sensations are characteristics
features of pernicious anemia. The major treatment consists of
intramuscular administration of vitamin B12.

Folic acid deficiency causes megaloblastic anemia. It

occurs in poorly nourished people, especially those with
malabsorption disorders is characterized by glossodynia,
glossitis, stomatitis, diarrhea and general weakness. Treatment is
to supplement the diet with 5 to 15mg of folacin tablets daily.
The best food source of folic acid are yeast, liver, fresh green
vegetables.

3) Oral mucous membrane problems

Oral mucous membrane of the lips, the buccal and palatal

tissues and the floor of the mouth change with age. The patients

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other chief complaints are a burning sensation, pain and dryness
of the mouth as well as cracks in the lips. Chewing and
swallowing becomes difficult and taste is altered.

Aging produces changing in the blood vessels, particularly

atheroscelerotic changes.

The palatal mucosa is often hyperkeratotic and thickened

in the elderly patient. The glandular tissue is apparently replaced
by connective tissue and the epithelial mass increases.

Cheilosis, inflammation of the lips caused by vitamin B

complex deficiency, is manifested by vertical fissuring of the
lips. Lesions at the angle of the mouth start out pale in color,
then become macerated . Therapeutic doses of vitamin B complex
and vitamin C as well as a balanced varied, adequate diet are the
nutritional means for managing these problems.

4) Temperomandibular joint pain:

As a result of masticating very firm foods over many years

or as a result of bruxism attrition of the incisal and occlusal
surfaces takes place. The resulting teeth have shortened
anatomical crowns, exposed dentin and wide, flattened chewing
surfaces. This type of tooth wear can produce overclosure of
jaws and affect the relations of the mandibular condyle to the
glenoid fossa. With age, the glenoid fossa can become shallower
and the head of the condyle, flatter. Thus it is possible for the
meniscus or articular disc between the condyle and fossa, to be
perforated or damaged by this change in temperomandibular
relationships, causing pain and limitation of range of movement
of the jaws.

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 Another common cause of overclosure, or loss of vertical
dimension, is partial or complete edentulism without prosthetic
replacement. This can produce a narrow and depressed lip line
because of loss of adequate support and muscle tone. The
circumoral skin becomes wrinkled, producing a “purse string”
appearance so characteristic of the elderly.

It is also possible that degenerative changes such as

osteoarthritis can affect the temperomandibular joint and can
also produce the articular disc changes that create the clicking of
the jaw and discomfort in the ear. There may even be limitation
to opening of the mouth, which may permit only a small-sized
bolus of food.

For temporary prevention of overclosure an acrylic night

guard can be used. The patient should be advised to select foods
of medium to soft consistency in order to prevent excessive
occlusal wear of the intact dentition.

5) Alveolar osteoporosis

The physiological liability of alveolar bone is maintained

by a sensitive balance between bone formation and bone
resorption, which is regulated by local and systemic influences.
The alveolar bone participates in the maintenance of body
calcium balance. Calcium is constantly being deposited and
withdrawn from the alveolar bone to provide for the needs of
other tissues and to maintain the calcium level of the blood. The
calcium in the cancellous trabeculae is more readily available
than that from compact bone.

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 Because alveolar bone acts as a reservoir of mineral ions
to maintain more vital functions, it is susceptible to osteoporosis.
With aging bone becomes less dense. Because of this alveolar
susceptibility to osteoporosis, the internal resorption may result
from dietary calcium deficiency or phosphorous excess, or a
combination of both. In fact, increased alveolar bone density has
been noted in patient who have been given daily supplements of
1g/day for a year.

Alveolar bone undergoes constant modelling in response to

occlusal forces. Osteoclasts and osteoblasts redistribute bone
substance to meet new functional demands most efficiently. Bone
is removed where it is no longer needed and added where new
needs arise. When occlusal forces are reduced, bone is resorbed,
bone height is diminished and the number and thickness of the
trabeculae are reduced. This is termed as bone disuse or
nonfunctional atrophy.

In the elderly, there tends to be a relative increase in bone

disease and resorption compared with deposition. With the loss
of teeth, the alveolar process no longer serves its primary
function of tooth support and therefore is resorbed. So much
bone is lost in this way that the mandibular and maxillary ridges
sometimes approach flatness. This loss in vertical height of bone
and the changing the angle of the mandible is manifested as a
loss in face height in older people.

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4) NUTRITION FOR THE DENTURE PATIENT:

Perfect health is a prize that has been the goal of mankind

throughout all ages. It must be understood that there can be no
separation between good bodily health and good dental health. A
diseased body often produces a diseased mouth, in turn a
diseased mouth may lead to diseased body.

The process of “feeding” the body is not simple. Involved

are chemical, physical and even mental reactions, many of which
are still a mystery to scientists.

A good diet is a basic necessity. The tisues cannot live on

food that is fundamentally wrong. A person may starve his body
even though he puts what he considers good food in sufficient
quantity into his stomach. There also must be present the proper
vitamins and minerals and then the body must be capable of
using these materials and foods properly.

Nutritional authorities agree that food substances may be

classified into the following components:

1) Proteins.

2) Carbohydrates.

3) Fats.

4) Vitamins.

5) Minerals.

6) Water.

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 1) Proteins:

Proteins are necessary for building, repairing and

maintaining body tissue as well as supplying energy. Proteins
are of two types Class I and Class II. Meat, fish, poultry,
dairy products and eggs are the best sources of animal
protein, especially when not overcooked. Peas and beans are
among the best sources of vegetable proteins. Among the
meats, steaks and chops are hard to chew, but liver and sweet
breads are easier to chew. Ground and chopped meat and many
kinds of fish are easy to eat.

Milk, cheese are good protein foods. Cream cheese and

well aged cheddar are preferable.

Protein is a must for denture wearers. The average patient

will have more comfortable gums and the dentures will continue
to fit longer if the amount of carbohydrate in the diet is reduced
and proteins are increased. Complex proteins breakdown to form
proteases. These proteases when fried coagulate the protein
makes it difficult to eat therefore boiled food is preferred.

In the elderly, protein depletion of body stores is seen

mainly as decrease in skeletal mass. The elderly lack endurance
and agility and are easily fatigued. Therefore patients above 50
years of age should suggest 0.8mg/kg of wt or 12 to 14% of
calories 56gm for males and 46gms for females.

2) Carbohydrates:

These include mainly sugars and starches which are

obtained from plants. They are primarily a source of energy.
In our diet many of the carbohydrates are in refined form as in

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sugar, white bread, flour. These carbohydrates are the empty
calories and contain little or none of the essentials required
for building and maintaining a healthy body and mouth.

Most of the carbohydrates, especially the cooked cereals

are among the easiest to eat. That is why there is a real danger
that too much will be eaten.

3) Fats:

The primary function of fats is to produce heat and energy.

Only secondarily do they build and repair tissue. Chief
sources of fats are fat meats, vegetable oils, butter, egg yolk
and nuts. Fats are essential part of the diet. They contain
vitamins and other nutrient but should be used sparingly.

4) Vitamins:

These are chemical substances which promote growth and

assist in the maintenance of healthy body tissues. There are
times when the body may be unable to provide a sufficient
amount of vitamins.

One who eats the proper variety of food is relatively sure

of getting the required assortment of vitamins needed.
Denture patient however, frequently are on a deficiency diet
and may need additional vitamins.

Vitamin A:

It is essential for normal vision. A marked deficiency may

produce what is often called as night blindness. It also helps

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 to keep the skin and the linings of the mouth, nose and inner
organs in healthy condition.

Good sources of vitamin A are egg yolk, butter, whole

milk, fish liver oils. The body can produce vitamin A from
yellow, leafy green vegetables.

Vitamin D:

It is essential because it works with minerals (calcium in

particular) to form straight, strong bones and sound teeth.

Foods such as egg yolk, butter and irradiated whole milk,

contain vitamin D. Fish liver oils are the richest source of
vitamin D.

Vitamin B Complex:

Thiamine or B1, Riboflavin (B2) and niacin are the best

known members of Vitamin B family. Folic acid and vitamin B12
are also very important. They are necessary for healthy state of
the blood.

When thiamine B1 and Riboflavin B2 and niacin are

deficient in the diet, malnutrition or diseases such as beriberi and
pellagra occur. Much more common are partially deficient cases
in which burning of the tongue or cracking at the corners of the
mouth. Good sources of thiamine, riboflavin and niacin are the
whole grain cereals and whole grain breads. Leafy green
vegetables also contain some of the group. Milk is a good source
of vitamin B. Meats especially, liver is rich in vitamin B12.
Recommended doses of riboflavin is 1.2gm/day.

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Vitamin C:

A profound deficiency of vitamin C causes scurvey.

Vitamin C is essential for the synthesis of collagen. In the

elderly slow healing of wounds and hypermobility of teeth might
be related to an increased need for vitamin C.

Significant losses of vitamin C occurs in food during

storage and cooking. Most common oral manifestations occur in
the interdental and marginal gingiva. The tissue is edematous,
ulcerated and bleed on probing.

Good sources of vitamin C are tomatoes, fresh

strawberries, cantaloupe, raw green foods like cabbage, green
pepper.

5) Minerals:

Like vitamins, minerals in small amounts are essential to

tissue health. Of these adequate calcium and phosphorous in the
diet is absolute necessity. Calcium is essential for nerve
transmission, muscle tone and blood clotting.

Sources of calcium are milk and milk products. Iron is

essential for oxygen carrying capacity of the blood. Sources of
iron are liver, meat products, fish and green leafy vegetables.
Only minute quantities of minerals are required in the diet.

Application:

The essential requirement of the daily diet having been

described the simplest and most practical. Nutritional system to
follow is the basic seven which was given by leading

25
nutritionists. The basic seven provides excellent scheme for a
daily plan of eating. The following foods are recommended:

Water:

Water is the most important and essential nutrient in the

diet of humans. The body can survive for weeks without proteins,
carbohydrates, fats or minerals and without vitamins for months
and year, but lack of water for 2 weeks will result in death. Water
is essential to all body functions including cell activity, all
secretions, absorption of foods and elimination of catabolites.

Water lost by kidneys, intestines, lungs and skin must be

balanced every day by an adequate intake of water from drinking
water, beverages, soups and other foods, especially vegetables. If
the balance is not maintained it results in dehydration.

26
5) CLINICAL SIGNS IN DEFICIENCY OF NUTRITION:

Nutrient Clinical signs of deficiency

Vitamin A Night blindness, neutropenia

Vitamin B complex (thiamine, Peripheral neuropathy, cardiac

riboflavine, pyridoxine, niacin) failure angular stomatitis,
cheilosis, glossitis. Irritability,
memory loss, headache,
dermatitis, diarrhoea

Vitamin B12 Megaloblastic anemia, subacute

combined degeneration of the
spinal cord.

Vitamin C Scurvey, anemia, weakness,

delay in wound healing.

Vitamin D Osteomalacia, weakness, delay

in wound healing.

Vitamin K Subcutaneous haemorrhage.

Iron Atrophic glossitis, angular

stomatitis, koilonychias.

Potassium Muscle weakness, apathy

confusion.

Magnesium Confusion, tremor, ataxia

Sodium Weakness, portal hypertension

odema.

27
Calcium Tetany

Trace elements (zinc copper, Delayed wound healing, anemia

chromium, cadmium)

6) NUTRITION FOR NEW DENTURE WEARER:

The ability to manage the physical consistency of food can

be made easier for a new denture wearer if an analysis of the jaw
movements involved in mastication is made. The process of
eating actually involves three steps: biting or incising; chewing
or pulverizing and finally swallowing.

Incising food involves a grasping and tearing action by the

incisor teeth requiring opening of the mouth wider, an action that
can dislodge the denture when the leverage force of the incising
action is exerted in the anterior segment of the mouth, the only
equal and opposite force to prevent dislodging the denture is the
seal created by the postdam compressive force of the denture on
the soft palate.

The chewing and pulverizing of the bolus of the food by

the molars and bicuspids are less difficult than incising, but still,
coordination of the many muscles of mastication that produce the
hinge and sliding movement of the mandible during eating
requires some experiences.

Therefore, although the logical sequence of eating food is

biting, chewing and swallowing, it is much easier for the new
denture patient to master this complex of masticatory movements
in the reverse order, namely, swallowing first, chewing second

28
and biting last. Consequently the food of a consistency that will
require only swallowing such as liquids such as liquids should be
prescribed for the first 2 days.

The use of soft foods is advocated for the next few days
and a firm or regular diet can be eaten by the end of the week.

Diet for the first day:

On the first post insertion day, a new denture wearer can

have liquid diet which may consists of fruit juices, milk etc.

Diet for the second and third day:

Patient can have soft food that require a minimum of

chewing like tender cooked vegetables, macroni or noodles, fluid
milk, eggs may be scrambled or soft cooked.

Diet for the fourth day and later:

By the fourth day as soon as the sore spots have healed, in

addition to soft diet, firmer foods can be eaten, in most
instances, these foods should be cut small pieces before eating.

29
 LOW COST BALANCED DIET

Food products Quantity (gms)

Cereals
460
Pulses
40
Leafy vegetables
50
Other vegetables
60
Roots and tubers
50
Milk
150
Oil and fat
40
Sugar and Jaggery
30

30
 INTAKE OF NUTRIENTS
Quantity (gms)
Food products
Calories 2738.60 Kcal

Proteins 66.60 gms

Calcium 781.60 mg

Iron 62.20 mg

Vitamin A 715.00 μg

Riboflavin 1.15 mg

Thiamine 2.45 mg

Vitamin C 74.80 mg

Niacin 15.66 mg

Total fat 66.90 gms

31
 FIVE FOOD GROUP SYSTEM

Food Group Main Nutrients

Energy, Protein, Invisible fat, Vitamin

Cereals Grains and products
B1, Vitamin B2, Folic acid, Iron,
Rice, Wheat, Ragi, Bajra, Maize, Jawar, Barley, Fibre
Riceflakes, Wheatflour
Energy, Protein, Invisible fat, Vitamin
Pulses and legumes
B1, Vitamin B2, Folic acid, Calcium,
Bengal gram, Black gram, Green gram, red gram, Iron, Fibre
Lentil, Cowpea, Peas, Rajmah, Soyabeans, Beans
etc
Milk and Meat Products
Protein, fat, vitamin B2, Calcium
Milk:
Milk, Curd, Skimmed milk, Cheese Protein, fat, vitamin B2

Meat:
Chicken, Liver, Fish, Egg, Meat
Fruits and Vegetables
Carotenoids, Vitamin C, Fiber
Fruits:
Mango, Guava, Tomato, Papaya, Orange, Sweet Invisible fats, Carotenoids, vitamin
Lime, Watermelon B2, Folic acid, Calcium, Iron, Fibre

Vegetables ( Green leafy): Carotenoids, Folic acid, Calcium,

Amaranth, Spinach, Gogu, Drumstick leaves, Fibre
Coriander leaves, Mustard leaves, Fenugreek
leaves

Other Vegetables:
Carrots, Brinjal, Ladies finger, Capsicum, Beans,
onions, Drumstick, Cauliflower

Fats and Sugars

Fats: Energy, Fat, Essential Fatty acids
Butter, Ghee, hydrogenated oils, Cooking oils like
groundnut, Mustard, coconut
Energy
Sugars:
Sugar, Jaggery

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 FOOD EXCHANGE LIST

Sl. No. of Protein Energy

No. Food Group Exchanges (g) (Kcal)
1. Milk 4 20.0 400

2. Legumes and 2 12.0 200

pulses
3. Flesh food ½ 5.0 50

4. Vegetable A 2 --- ---

5. Vegetable B 2 --- 100

6. Fruit 2 --- 100

7. Cereal 6 12.0 600

8. Fat 2 --- 200

9. Sugar 25 g --- 100

49.0 1750
TOTAL

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 MENU PLAN

Tea : 1 cup

Breakfast : Bread - 1 slice with ½

tsp butter
Egg (Soft Boiled) -1
Milk - 1 cup with sugar
Banana - 1 small

Lunch : Chapati -1
Rice - ½ cup
Dal - 1 cup
Alu Palak - 1 cup
Curds - ½ cup
Orange Or Sweet Lime -1

Tea : Tea - 1 cup

Biscuits -2

Dinner : Chapati -1
Rice - ½ cup
Mung Usal - 1 cup
Dudhi / Pumpkin Vegetables - 1 cup
Curds - ½ cup
Salads - Cooked beet,
Carrot, Raw Onion,
Cabbage

Bedtime : Warm Milk - 1 cup

34
SUMMARY & CONCLUSION:
Providing for the food, diet and nutritional needs of elderly patients
should be considered as indispensable part of total dental care and supportive
management. It is the responsibility if the dentist to provide the patient with
this nutritional information for achieving optimal oral health, because what
helps prevent oral disease will be equally useful in preventing general illness.
The best possible general advice is that patient’s daily diet should
include vegetables and fruits; bread and cereals; milk, poultry and fish; and
legumes plus significant amounts of water. For the geriatric wearer of new
dentures, each diet prescription should be based on an analysis and evaluation
of person’s food habits and reasons for them and the actual food intake.
Furthermore, the physical nature of the diet should be consistent with the
patients experience and ability to swallow, chew, and bite with the dental
prosthesis, and with other medical problems, such as diabetes diets, low
cholesterol diets, and so on.

35
 REFERENCES

1) Nutrition in clinical dentistry. – Nizel A.D., W.B.

Saunders (1969), Page 241-426.

2) Essentials for complete denture prosthodontics – Sheldon

Wrinkler, 2 n d edition, Page 15-21.

3) Influence of diet on denture-bearing tissues. – Maury

Massler. D.C.N.A. 1984; 28(4): 211-221.

4) Nutrition for denture patient. J. Prosth. Dent. 1960; 10:

53-60.

5) Nutrition suggestions for prosthetic patient. J. Prosthet.

Dent. 1966; 16: 829-834.

6) The role of nutrition in conditioning edentulous patients.

– W.O. Ramsey. J. Prosth. Dent. 1970; 23: 130-135.

7) The dental hygienists guide to nutritional care. Judi

Ratlift Davis, Cynthia A. Stegemen.

8) Dental care for the elderly. Cohen and Thomson.

9) Nutritive values of Indian foods: National Institute of

Nutrition, Hyderabad

36
DIET & NUTRITION IN GERIATRIC
PATIENTS
CONTENTS

 INTRODUCTION

 AGE AND CHANGING PHYSIOLOGY

 NUTRITIONAL CONSIDERATIONS FOR

GERIATRIC PERSONS

 ROLE OF NUTRITION IN

EDENTULOUS PATIENT

 FACTORS AFFECTING NUTRITIONAL

STATUS

 NUTRITIONALLY RELATED ORAL

PROBLEMS IN ELDERLY PATIENTS

 NUTRITION FOR DENTURE PATIENT

 DEFICIENCY OF NUTRIENTS

 NUTRITION FOR NEW DENTURE PATIENT

 SUMMARY AND CONCLUSION

37
 REFERENCES

38