Nutrition in Etentulous Patients

8/3/2019 Nutrition in Etentulous Patients

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ROLE OF NUTRITION IN

MAINTAINANCE OF

ORAL HEALTH OF

EDENTULOUS PATIENTS

Presented ByDr. Kartik R. Morjaria

Post Graduate student

Department Of Prosthodontics

Karnavati School Of Dentistry

Guided ByDr. Dipti S. Shah

Dean, Professor & HOD

Department Of Prosthodontics

Karnavati School of Dentistry


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CONTENTS

1) INTRODUCTION

2) NUTRITION IN PREVENTION AND MANAGEMENT OF

PERIODONTAL DISEASE

3) AGING FACTORS THAT AFFECT NUTRITIONAL STATUS

4) THE IMPACT OF DENTAL STATUS ON FOOD INTAKE

5) GASTRO INTESTINAL FUNCTIONING

6) NUTRITIONAL NEEDS AND STATUS OF ELDERLY

7) FOOD PYRAMID FOR 70+ ADULTS

8) CALCIUM AND BONE HEALTH

9) CLIMATERIC

10) VITAMIN SUPPLEMENTATION

11) DIETARY COUNSELLING OF PATIENTS UNDERGOING

PROSTHODONTIC TREATMENT

12) TRIPHASIC NUTRITIONAL ANALYSIS

13) RISK FACTORS FOR MALNUTRITION IN DENTURE PATIENT

14) NUTRITION GUIDE LINES FOR PROSTHODONTIC PATIENT15) CONCLUSION

INTRODUCTION


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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 eatingfavourite 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 implant-

supported prosthesis may prove to be unsatisfactory for a patientbecause 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.

NUTRITION IN PREVENTION AND MANAGEMENT OF

PERIODONTAL DISEASE

Low Caloric

Intake

UNHEALTHY

ORAL TISSUES

Low nutrients

intake

Diabetes

Alcohol abuse

Medications

Smoking

Xerostomia

Soft Diet


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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 siteafter 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 NUTRITIONALSTATUS


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PHYSIOLOGIC FACTORS:

Declines in physical and cognitive status often increase withage. 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. Thishypochlorohydria 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 toillness, 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


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diets in response to chewing difficulties and dentures can

exacerbate this condition.

Dehydration, caused by declines in kidney function and totalbody 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 functioncan 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


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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

Alter taste perception Captopril, griseofulvin, lithium carbonate

Metallic taste Ethambutol, gold compounds

Bitter taste Carbamazepine, phenylbutazone

Decreased appetite Anticonvulsants, antineoplastic, carbonic

anhydrase inhibitor, digitalis, estrogens,

flurazepam, indomethacin, lithium salts,

metronidiazole, tetracyclins, thiazides

ORAL FACTORS THAT AFFECT THE DIET AND NUTRITIONAL

STATUS


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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, teethbecome 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 mouthwhen 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


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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 ofagriculture 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 isdry, 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


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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


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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 energyconsumption 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 Oral symptoms

1) Protein Decreased salivary flow,


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enlarged parotid glands

2) Vit B- complex, iron, protein Lips :

Chelosis Angular stomatitis

Angular scars

Inflammation

Tongue :

Edema

Magenta tongue

Atrophy of filiformpapillae

Burning sensation

Soreness

Pale, bald

3) Vit C Edematous oral mucosa

Tender gingiva

Spontaneous bleeding of

gingival Haemorrhages in

interdental papillae

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.


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(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 isbased 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.


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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 donot 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). Itis 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.


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CALCIUM AND BONE HEALTH

Bone loss is a normal part of aging that affects the maxilla andmandible, 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.


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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

1) 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.

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) Calcium (

g) Vitamin D (

g)31 50 1000 5

51 70 1200 10

> 70 1200 15

To receive 1000 to 1200 g of calcium, adults must drink 3 or

4 glasses of low fat milk / day.


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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


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DIETARY COUNSELLING OF PATIENTS UNDERGOING

PROSTHODONTIC TREATMENT1) The main objective of diet counseling for patients undergoing

prosthodontic care is to correct imbalances in nutrient intakethat 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.

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.


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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 professionalsand 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 approximatedietary counseling instituted.


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QUESTIONNAIRE

Q. NO. QUESTION SCORE1 I have an illness or condition that made me change

the kind and/or amount of food I eat.

2

2 I eat fewer than 2 meals a day 3

3 I eat few fruits, vegetables or milk products 2

4 I have three or more glasses of beer, liquor or wine

per day

2

5 I have tooth or mouth problems that make itdifficult for me to eat

2

6 I dont always have enough money to buy the food I

need

4

7 I eat alone most of the times 1

8 I take three or more different prescribed or over-

the-counter drugs a day

1

9 Without wanting to, I have lost or gained 10 poundsin the last six months

2

10 I am not always able to shop, cook and/or feed

myself

2

SCORES

TOTAL SCORE NUTRITIONAL RISK

0-2 Good nutritional health

3-5 Moderate nutritional risk

> 6 High nutritional risk

PHASE II


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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.


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RISK FACTORS FOR MALNUTRITION IN DENTURE

PATIENT

1) Unplanned weight gain or loss of > 10 lb, in the last 6 months.2) Undergoing chemotherapy or radiation therapy

3) Poor dentition or ill fitting prosthesis

4) Oral lesions glossitis, chelosis or burning tongue

5) Severely resorbed mandibular ridge

6) Alcohol or drug abuse

7) Eating less than 2 meals / day

NUTRITION GUIDE LINES FOR PROSTHODONTIC

PATIENT1) 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.


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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

Nutrition in Etentulous Patients

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