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

All people have some basic needs of nutritional intake, for growth, development, maintenance and metabolism. Enjoyment of food is an important determinant of an adults quality of life. Loose teeth, edentulousness or ill fitting dentures may preclude eating favourite food as well as limit the intake of essential nutrients. Decreased chewing ability, fear of choking while eating, and irritation of the oral mucosa when food particles get under dentures may influence food choices of the denture wearer. Conversely, affects the health of the oral tissues and the patients adaptation to the new prosthesis. In fact, 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. Hence denture failures can also be due to poorly nourished tissues. Clinical symptoms of malnutrition are often observed first in the oral cavity. Because of rapid cell turn over (3-7 days) in the mouth, a regular balanced intake of essential nutrients is required for the maintenance of oral epithelium. Inadequate long term nutrition may result in angular cheilitis, glossitis and slow tissue healing. The nutritional status of a denture wearer is influenced by economic hardship, social isolation, degenerative diseases medication regimens and dietary supplementation practices. 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

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, B vitamins, protein Maintain epithelial integrity Vitamin A Collagen in basement membrane Vitamin C, 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, fibrous foods is beneficial to periodontal health Increases salivary flow Promotes a strong periodontal ligament

AGING FACTORS THAT AFFECT NUTRITIONAL STATUS

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

diets in response to chewing difficulties and dentures can exacerbate this condition. Dehydration, caused by declines in kidney function and total body water metabolism, is a major concern in the older population. Dehydration can be insidious and unrecognized until serious side effects occur. Overt deficiency of several vitamins is associated with neurological and behavioural impairment B1 (thiamin), B2, niacin, B6 (pyridoxine), B12, Foliate, Panthothenic acid, vitamin C and Vitamin E. PSYCHOSOCIAL FACTORS: Psychosocial factors may play even greater roles than physical, medical, and dental issues in determining the health and well-being of elders. Elders particularly at risk include those living alone, the physically handicapped with insufficient care, the isolated, those with chronic disease and restrictive diets, and the oldest old. Poverty is also a major contributor to malnutrition.

PHARMACOLOGIC FACTORS: MEDICATIONS AND ALCOHOL Most elders take several prescription and over-the-counter medications daily. These drugs can interact with food and diet, sometimes with serious side effects. Declining physiologic function can keep drugs in the body for longer periods of time than is desirable. Drugs can affect the absorption and utilization of some foods and nutrients, and vice versa.

Prescription drugs are the primary cause of anorexia, nausea, vomiting, gastrointestinal disturbances, xerostomia, taste loss, and interference with nutrient absorption and utilization. These

conditions can lead to nutrient deficiencies, weight loss, and ultimate malnutrition.

Drugs that exert an effect on taste and appetite Reduce taste Baclofen, carbamazepine, lincomycin, penicillamine, phenylbutazone Captopril, griseofulvin, lithium carbonate Ethambutol, gold compounds Carbamazepine, phenylbutazone Anticonvulsants, antineoplastic, carbonic anhydrase inhibitor, digitalis, estrogens, flurazepam, indomethacin, lithium salts, metronidiazole, tetracyclins, 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. Saliva provides natural protection to the hard and soft tissues of the oral cavity. When salivary levels decline, teeth become more susceptible to dental caries. The exposed root surfaces of teeth are particularly at risk. Xerostomia can also impair complete denture retention and is associated with increased periodontal disease, burning or soreness of the oral mucosa, and difficulties in chewing and swallowing all of which can adversely affect food selection and contribute to poor nutritional status. 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, age-related changes in taste and smell may alter food choice and decrease diet quality in some people. Factors contributing to this report decreased function may include health disorders, medications, oral hygiene, denture use, and smoking. Effects of dentures on taste and swallowing: A full upper denture can have an impact on taste and swallowing ability. The hard palate contains taste buds, so taste sensitivity may be reduced when an upper denture covers the hard palate. It also becomes difficult to determine the location of food in the mouth when the upper palate is covered. As a result, swallowing can be poorly coordinated and dentures can become a major contributing factor to deaths from choking.

THE IMPACT OF DENTAL STATUS ON FOOD INTAKE

1) The food choices of older adults are closely linked to dental status and masticatory efficiency. 2) The loss of teeth often leads adults to select soft diet; soft foods are often lower in nutrient density and fiber. 3) An individuals masticatory ability is mainly determined by age, oral motor function, adequate saliva and the number of occluding pairs of teeth in the mouth. 4) There is general agreement that the masticatory function of denture wearer is greatly inferior to person with intact dentition. Denture wearer must complete a greater number of chewing strokes to prepare food for swallowing. 5) In a study of the united states, 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. 6) Studies in Finland showed that the wearing of dentures for several years, improved the quality of their diet. 7) The condition of an individuals denture also may influence food selection. When old complete dentures with poor retention were replaced with new dentures the masticatory performance of the patients improved. The use of osseointegrated implants also increased the chewing ability and varieties of foods were eaten. 8) The comfort of wearing dentures is dependent on the lubricating ability of saliva in the mouth. If the oral mucosa is dry, chewing is difficult, denture retention is compromised and mucosal soreness (or) ulcerations develop. Salivary flow facilitates mastication, formation of food bolus and swallowing.

9) Xerostomia may contribute to geriatric malnutrition. Xerostomia (dry mouth) is a clinical manifestation of salivary

gland dysfunction. Causes of xerostomia may be use of medication, therapeutic radiation to the head and neck, diabetes, depression, alcoholism, pernicious anemia, menopause, vit A or vit B complex deficiency. 10) Milk has been proposed as saliva substitute; milk not only aids in lubricating the tissues, but also has a buffering capacity. As dry mouth may result in inadequate nutritional intake, the use of milk serves as saliva substitute and also an excellent source of nutrients.

GASTRO INTESTINAL FUNCTIONING

Little research exists on the effect of tooth loss on gastrointestinal functioning. 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. Individuals with poor masticatory ability often swallow large pieces of food. When a denture covers the upper palate, it is difficult to detect the location of food in the mouth. 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, which may cause death.

NUTRITIONAL NEEDS OF ELDERLY

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

 enlarged parotid glands 2) Vit B- complex, iron, protein Lips : Chelosis Angular stomatitis Angular scars Inflammation Tongue : Edema Magenta tongue Atrophy of filiform papillae Burning sensation Soreness Pale, bald Edematous oral mucosa Tender gingiva Spontaneous bleeding of gingival Haemorrhages in interdental papillae

3) Vit C

9) Heavy smokers, alcohol abusers, or persons with high aspirin intake have a higher daily requirement of vit C. Vit c Ascorbic acid plays a role in collagen synthesis (essential for wound healing) 10) Deficiency of thiamine, niacin, pyridoxine, folate (vit-B) and ascorbic acid are commonly seen in alcoholics. 11) Osteopenia in males, may be due to chronic alcohol intake.

(PALMER CA. GERODONTIC NUTRITION AND DIETARY COUNSELING FOR PROSTHODONTIC PATIENTS. DENT CLIN N AM 2003; 47:355-71)

In general, the food guide pyramid for healthy older adults is narrower than the original pyramid, recognizing that seniors usually need less energy and therefore usually eat less. The bread, cereal, 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 emphasis on fluids is due to older adults reduced sense of thirst that can lead to drinking less fluid. This two-quart daily fluid intake can include juice, milk and non-caffeinated soft drinks and beverages, as well as water. However, alcohol and drinks containing caffeine can cause the body to lose fluids and become dehydrated. Dehydration can make kidney function and constipation worse.

Another key difference from the original food guide pyramid is the flag at the top to indicate a recommendation for the dietary supplements calcium, vitamin D and vitamin B-12. These supplements are sometimes recommended because older adults eat less and do not absorb and process nutrients as efficiently as younger people. Total calcium intake each day should be 1200-1400 milligrams, which is the equivalent of three servings of calcium-rich dairy products (such as milk, hard cheese or yogurt). Supplements, such as calcium citrate and calcium carbonate are available to make up the difference. Daily vitamin D intake should be 600 international units (IUs), which is equivalent to three 8-ounce glasses of milk. Sunlight provides vitamin D, too, but many seniors often have limited exposure to it, thereby requiring a supplement if their milk intake is less than the three glasses. Seniors do not easily absorb vitamin B-12. Fortified breakfast cereal can help as it contains vitamin B-12 in a form that the body will absorb. A total of 2.4 micrograms is recommended each day. Taking a multivitamin for seniors will ensure an adequate intake of both vitamin D and B-12. Another difference for the pyramid for seniors is the addition of a fiber icon (f+). Fiber comes from many sources, including whole fruits and vegetables, whole grains and legumes. Fiber is very important because it helps prevent constipation, hemorrhoids and diverticulosis (inflammation of small pockets lining the intestines). It is also associated with lower cholesterol levels, and a reduced risk of heart disease and cancer. A total of 20-30 grams of fiber is recommended each day for optimal health. Eating the recommended number of servings of foods that contain fiber will usually provide that intake.

CALCIUM AND BONE HEALTH

Bone loss is a normal part of aging that affects the maxilla and mandible, as well as the spine and long bones skeletal sites where trabecular bone is more prominent than cortical bone, are affected first (alveolar bone, vertebrae, 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.

CLIMACTERIC
Climacteric is a period in both males and females, when an important change in bodily function occurs. In females this period is termed menopause and in males it is called andropause. The glandular functional changes have varying effects Generalized osteoporosis reduction in bone mass with pain, deformity (or) pathologic fracture. 2) Burning palate, burning tongue etc. Resorption of alveolar ridge is a wide spread problem.
1)

A greater degree of residual ridge resorption is seen in women than in men. Bone loss is accelerated in the first 6 months after tooth extraction and resorption is greater in the mandible than maxilla. Dietary calcium is critical to maintaining the body skeleton. Calcium intake by older adults will not restore the bone, but will improve calcium balance and slow the rate of bone loss. Denture patients with excessive ridge resorption report lower calcium intake. Recommended daily allowance RDA (1997) Age (yr) 31 50 51 70 > 70 Calcium ( g) 1000 1200 1200 Vitamin D ( g) 5 10 15

To receive 1000 to 1200 g of calcium, adults must drink 3 or 4 glasses of low fat milk / day.

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

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. 2) The quality of a denture wearing patients diet can be improved with nutrition counseling. 3) Elderly population over 70 years of age is more likely to have poor diets, and nutrition risk increases with advancing age. 4) Maintenance of oral epithelium, rapid cell turnover in the mouth, requires a regular balanced intake of essential nutrients. 5) To lower the rate of alveolar ridge resorption, increased intake of calcium and vitamins is required. Dietary evaluation and counseling should be included in prosthodontic treatment, if patient has any of the following physical or social conditions.
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. 2) Evaluate the diet, assess nutritional risk 3) Teach about the components of a diet that will support the oral mucosa, bone health and total body health. 4) Guidance in the establishment of goals to improve the diet 5) Follow up.

ASSESSING THE NUTRITIONAL STATUS TRIPHASIC NUTRITIONAL ANALYSIS

(BANDODKAR K.A., ARAS M. NUTRITION FOR GERIATRIC DENTURE PATIENTS. JIPS 2006; 6, 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, screening for clinical signs of deficiency, conducting selected anthropological measurements and assessing the adequacy of dietary intake. Qualitative dietary assessment The purpose of the dietary assessment is to determine what an individual is eating now, 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. This questionnaire may be administered by health care professionals and applied in both inpatient and outpatient settings. If potential nutritional problems are detected, based on any of these parameters, the nutritional evaluation should progress to phase II. However, if at the conclusion of phase I, enough information is available to ensure a rational basis for therapy, the nutritional assessment should be terminated and approximate dietary counseling instituted.

QUESTIONNAIRE Q. NO. 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. I eat fewer than 2 meals a day I eat few fruits, vegetables or milk products I have three or more glasses of beer, liquor or wine per day I have tooth or mouth problems that make it difficult for me to eat I dont 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, 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

When the parameters described here indicate the existence of a nutritional problem, more information should be accumulated. A semi-quantitative dietary analysis and routine blood chemistry should be undertaken. Semi-quantitative dietary analysis At this level of evaluation, dietary intake is assessed using more quantitative means. 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. Average caloric and nutrient intakes can be quantitated and compared with norms. The services of a registered dietician, serving as a consultant, are invaluable at this level of assessment. Biochemical assessment Common automated blood tests are also useful in providing more definitive information regarding the nutritional status of patients. However, 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, as well as the effects of drugs and chronic disease. 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. The analysis in this phase includes comprehensive nutritional biochemical assays of blood, urine and tissues, as well as tests of metabolic and endocrine function.

RISK FACTORS FOR MALNUTRITION IN DENTURE PATIENT

Unplanned weight gain or loss of > 10 lb, in the last 6 months. Undergoing chemotherapy or radiation therapy Poor dentition or ill fitting prosthesis Oral lesions glossitis, 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, fruits, vegetables whole grams and cereals. 3) Eat atleast 5 servings of fruit and vegetables daily. 4) Select fish, poultry, meat (or) dried peas and beans every day 5) Consume 4 servings of calcium rich foods daily. 6) Limit intake of bakery products high in fat and simple sugars. 7) Limit intake of prepared and processed foods high in sodium and fat 8) Consume 8 glasses of water daily, juice or milk daily.

CONCLUSION The success of complete denture prosthesis is mainly influenced by the mucosal condition of the denture bearing areas. Many denture failures are the result of nutritional deficiencies. Good health and nutrition of older patients are necessary for the successful wearing of dentures. So the patient has to be well nourished and consume a well balanced diet. Dietary guidance based on assessment of the edentulous patient nutrition history and diet should be an integral part of comprehensive prosthodontic treatment.

REFERENCES PROSTHODONTIC TREATMENT OF EDENTULOUS PATIENTS BOUCHERS 12TH EDITION ESSENTIALS OF COMPLETE DENTURE PROSTHODONTICS - SHELDON WINKLER BANDODKAR K.A., ARAS M. NUTRITION FOR GERIATRIC DENTURE PATIENTS. JIPS 2006; 6, 1:22-28 PALMER CA. GERODONTIC NUTRITION AND DIETARY COUNSELING FOR PROSTHODONTIC PATIENTS. DENT CLIN N AM 2003; 47:355-71