Relationship between oral rehabilitation and nutrients intake in the independent elderly: a systematic review of the literature
by
Elisabetta Bellia
1,*, 
Chiara Monagheddu
2,
Vincenzo Notaro
1,
Paola Ceruti
1 and
Francesco Bassi
1 1
Department of Surgical Sciences, CIR Dental School, Oral and Maxillofacial Rehabilitation, University of Torino, Italy
2
Department of quality and safety in health care, Unit of Clinical epidemiology, Città della Salute e della Scienza di Torino University Hospital and CPO Piemonte, Italy
*
Author to whom correspondence should be addressed.
J. Gerontol. Geriatr. 2023, 71(3), 187-205; https://doi.org/10.36150/2499-6564-N561
Submission received: 8 July 2022
/
Accepted: 10 July 2023
/
Published: 28 July 2023
Objective
When investigating nutrients intake in ageing patients, a compromised dental status leading to impaired masticatory performance has been considered associated with nutrients deficiency. The aim of the study was to investigate the association between oral rehabilitation and nutrients intake in independent elderly.
Methods
PubMed, Web of Science, Cochrane Library e Tripdatabase were searched for eligible studies published between 1991 and 2020. The search comprised articles written in English, selected using the key words “denture” OR “mastication” AND “nutrition” OR “elderly”. Samples of patients with age not inferior to 65 years and with independent life conditions were considered.
Results
Among 1362 studies found searching the databases, 10 articles referred to 4 randomized controlled trials and 8 observational studies fulfilled the inclusion criteria. The overall results of the observational studies suggested that a proper oral rehabilitation provides the elderly with a higher nutrients intake. Three RCT comparing different prosthetic treatments found no difference in the nutrients intake between the two study groups. One RCT compared the effect of nutritional advice vs standard advice on dentures’ maintenance: at 6 months the intervention group showed a higher intake of plant protein and a higher MNA-SF score, while the control group showed a higher intake of animal protein and vitamin B12.
Conclusions
Congruous prosthetic rehabilitations alone can’t assure adequate nutrients intake in the elderly, but the influence of other factors is suggested: nutritional counseling seems an important factor to improve nutrients intake and it’s recommended to be associated with the prosthetic rehabilitation.
Key words:
nutrients; aged; mastication; dental prosthesis; counselingINTRODUCTION
The increase of life expectancy, typical of the last decades, has determined a significant growth of the elderly in all developed countries. The quality of aging and the heterogeneity of the elderly population can be affected by the occurrence of two conditions: frailty and sarcopenia.
Frailty was defined “a state of reduced physiologic reserve associated with increased susceptibility to disability 1. According to De Jong 2, the most important factors related to frailty are physical inactivity and malnutrition, even though many other factors contribute to this condition: chronic diseases, bad lifestyle, side effects of multiple drugs intake, sudden and negative events. One of the major predictor of frailty is sarcopenia, a typical aging related process in the elderly, characterized by the loss of muscle mass and strength and physical performance decline and significantly influenced by malnutrition 3-5.
Edentulism is a condition that can determine a significant reduction of the quality of life, and its prevalence is going to increase, due to the progressive ageing of the population. In 2002, Douglass 6 predicted that in the USA, by the year 2020, the adult population needing a rehabilitation with a complete denture would increase from 33.6 millions to 37.9 millions. Always in 2002, the Mc Gill consensus 7 provided a minimum standard of care for edentulous patients, that is a conventional maxillary complete denture and a mandibular implant retained overdenture (MIR-OVD). The consensus was based on the assumption that numerous people wearing conventional dentures report that they can’t eat many foods, particularly those that are hard or tough. This forces them to change their diets in unhealthy ways and causes their nutrition to be poorer than that of people with natural teeth. The consensus also reported evidence that people who receive mandibular two implants overdentures modify their diet, improving their nutritional state, thus having a strong positive impact on general health, particularly for senior adults who are vulnerable to malnutrition. With ageing, the progressive teeth loss determines a change of nutrition habits, depending on the compensation performed by the prosthetic intervention. If missing teeth are not replaced, a modification of masticatory mechanical function may occur and removable prosthetic rehabilitation is unable to fully restore the masticatory performance to that of a dentate patient, (especially when eating fibrous or hard food) regardless of the congruity of the prosthesis itself. Thus, literature 8-10 investigated the association between oral rehabilitation and nutrients intake, and when the masticatory effectiveness of these patients resulted impaired by an improper or missing rehabilitation, it was considered associated with macro and micronutrients deficiency in their diet. However, these articles don’t cover completely all the literature describing this association.
AIM OF THE STUDY
The aim of the study was to perform a literature systematic review to investigate, in the population aged >= 65 years and not institutionalized, the association between oral rehabilitation and nutrients intake.
MATERIALS AND METHODS
PubMed, Web of Science, Cochrane Library e Tripdatabase were searched for eligible studies published between 1991 and 2020. The search comprised articles written in English, which were selected using the following match of MeSH terms and boolean operators:”dentures” OR “mastication” AND “nutritional status” OR “aged”. Two reviewers independently evaluated eligible studies and assessed the risk of bias for randomized clinical trials, applying criteria for quality assessment based on the Cochrane guidelines. Samples of patients with age not inferior to 65 years and with independent life conditions were taken into account. (Tab. I). Every article was evaluated and classified according to the author, nationality, typology of the study, samples characteristics (number, age, sex), mastication, factors associated to mastication (MAFs, including the number of teeth, number of antagonist couples, if the patient was dentate or completely edentulous, if the dentition was adequate or not and the adequateness of the prosthesis) and principal outcomes of interest. The methods chosen to evaluate mastication included self-evaluation of mastication through scales, questionnaires and food diaries and the ability of the subject to break the food into small pieces by means of masticatory efficiency tests.
RESULTS
1362 studies were found searching the four databases. After duplicates and non-original articles were removed, 1110 studies underwent a first screening, by analyzing the title and abstract, and 1035 studies were excluded. 75 potentially relevant studies were downloaded as full text and 57 of them were excluded, mostly because not fulfilling the inclusion criteria (Appendix, Table S2). 18 articles referred to 12 studies fulfilled the inclusion criteria and were included in the review (Fig. 1).
We included 10 articles referred to 4 Randomized Controlled Trials (RCT) studies on persons aged >= 65 years not institutionalized (Tab. II). RCT risk of bias assessment (Appendix, Table S1) showed that the majority of the studies have a low risk of bias, being “blinding” the criteria that scored the most unclear/ unrevealed risk of bias. Two RCT 11-13 compared the effects of two different prosthetic interventions (IOD vs CD); both studies did not show any differences in the intake of nutrients or related to the hematological markers between the two study groups and found some inconsistent results over time within each group. One RCT 14-16 compared a functionally oriented treatment vs RPD, founding no differences in the intake of nutrients or hematological markers between the two study groups, and with some improvement over time in both groups. One RCT 17-20 compared the effect of a nutritional advice vs standard advice on dentures’ maintenance in people with new complete dentures; both groups improved masticatory function at 3 months; at 6 months the intervention group showed a higher intake of plant protein and a higher MNA-SF score, while the control group showed a higher intake of animal protein and vitamin B12.
8 observational studies were included (Tab. III); the 2 prospective cohorts evaluated the effects of a prosthetic rehabilitation alone 21 or coupled with a dietary counseling 22 with a “before/after” design; both studies show an improvement in some food and nutrient intake after prosthetic rehabilitation, although one of them did not adjust for potential confounders 21. We included 6 cross sectional surveys 23-28, more frequently performed on subset of subjects form larger population surveys or cohorts, aiming to evaluate the association between oral status (e.g. number of teeth, wearing denture, occlusal force) and nutritional intake, in two studies both self-reported by subjects. Overall results suggest that a better masticatory performance provides the elderly with a higher micro and macro-nutrients intake, in particular vegetables. Due to the heterogeneity in the definitions of outcomes, exposures and covariates controlled for in the statistical analyses in the observational studies included in the review we did not perform a formal meta-analysis. We also did not perform a formal meta-analysis of RCT results due to the small number of available studies for each specific clinical question.
DISCUSSION
Cross-sectional studies included in the review mostly indicate a positive association between oral rehabilitation and nutrients intake. However, when approaching cross-sectional studies, some limitations should be acknowledged; first of all, the cross-sectional design does not allow to investigate the temporality of the association, i.e.to explain if food intake variations occurred before mastication impairment or as a consequence of it; this aspect could be better addressed with an observational prospective study design. However, in a recent systematic review 29 that took into account 8 longitudinal studies in 4 different countries (without age selection of participants), the authors pointed out that most results were contradictory and the quality of the evidence was weak, leading to the conclusion that there is no strong evidence on the effect of tooth loss on diet and nutrition, with inconsistent results among the few studies identified (Tab. S3). The observational studies included in this review often included small samples of subjects, and the association with confounding factors, such as comorbidities, educational level and socio-economic status, was sometimes not considered. As regards the randomized clinical trials the three trials 11-16 comparing the effects of two different prosthetic interventions did not show any differences in the intake of nutrients or in the hematological markers between the two study groups; when performed, the analysis of within groups variations shows mostly an improvement in masticatory functions/chewing ability in both groups, but inconsistent results regarding nutritional intake over time within each group. One RCT 17-20 compared the effect of a nutritional advice vs standard advice on dentures’ maintenance in people with new complete dentures: both groups improved masticatory function at 3 months; at 6 months the intervention group showed a higher intake of plant protein and a higher MNA-SF score, although the control group showed a higher intake of animal protein and vitamin B12. Therefore, the outcomes of the RCTs overall indicate that a congruous prosthetic rehabilitation alone can’t assure adequate nutrients intake, so that the diet in the elderly doesn’t depend only on the use of an adequate prosthesis: the influence of other factors is suggested, among which salivary flux and multiple drug intake, social and economic factors, phycological factors, physical activity and alcohol consumption. First of all, when approaching an ageing population it is important to remind that the decline of nutrition and the loss of appetite, which can be disease related or drug induced 30 is somehow expected and that might result in a gradual malnutrition 31,32. Psychological disorders, among which depression is the most frequent, are often associated with loss of appetite 33.Other psychological factors contributing to malnutrition and anorexia are traumatic life events such as loneliness, death of a spouse, or social factors such as social isolation, loss of independence and socio-economic inequality 34. Impaired vision can affect food access making food preparation, cooking and reading food labels more difficult 35. Moreover, the sense of smell and taste decreases with age and this contributes to diminished food intake in the elderly and has a negative impact on the type of food ingested, typically resulting in a less varied diet 36. With age, there is an increasing susceptibility to various pathological conditions such as Candidal infections, burning mouth syndrome, and denture-related lesions, that contribute to maintain the vicious cycle of malnutrition. Furthermore, the decline in saliva secretion during aging causes xerostomia, which adversely affects masticatory function making the food bolus formation difficult 37 and impairing taste sensitivity 38. Nutrient intake is also affected by excessive alcohol consumption, which decreases the appetite, discouraging caloric intake from food, with a corresponding reduction in other nutrients and compromising the absorption of nutrients 39. The impact of different factors, other than mastication and prosthetic status, has been discussed and confirmed by recent reviews. (Appendix, Table S3) In his systematic review, Bezerra 40 questions if the real impact of dental implant-supported prostheses on the nutritional status of partially and complete edentulous patients. Patients wearing implant overdentures presented better masticatory function in comparison to conventional complete denture wearers, but bioavailability of several nutrients remained within the same range, especially on the long-term. Therefore, the authors concluded that oral rehabilitation should be planned using a multidisciplinary approach, in order to enhance food choices and promote health benefits to the patients. Yamazaki et al. 41 came to the same conclusion, stating that the modifying effect of implant retained overdenture treatment on nutritional status might be limited and that further studies are needed to evaluate the effectiveness and efficacy of denture treatments. One RCT included in our review 20 suggests some improvement of the nutritional intake only when the prosthetic treatment was associated with proper dietary advice. The narrative synthesis of a recent systematic review 42 (Tab. S3) also indicates support for dietary intervention coupled with oral rehabilitation on diet. In this context, a key role can be played by nutritional counselling, that should be encouraged and combined with the prosthetic treatment to improve food intake. When treating elderly patients, especially after completing a prosthetic rehabilitation, the treatment should be finalized by giving simple dietary advice,orally or by means of a pamphlet, and possibly further reinforced by proper nutritional counseling performed by nutritionists in order to improve nutrients intake of healthy elderly and those at risk of malnutrition, and to prevent the occurrence and the progression of systemic conditions such as sarcopenia, osteoporosis and cardiovascular diseases.
The exposure to nutritional counseling is crucial and depends on several variables. Even if nutritionists are the most prepared professionals to monitor food consumption and train eating habits, access to these professionals might be limited, especially among the lower income population. A recent study 43 pointed out that undergoing medical consultation in the previous year increased the probability by three of having received nutritional counseling, thus enlightening the role of the physicians as promoters of nutritional counseling, based on their frequent and direct contact with patients. According to Antoniadu 44, the actual needs of independent elderly adults suggest that health research and oral health care should learn to design and manage olistic and personal treatment plans, including lifestyle, psychological and nutritional approaches: therefore, the professionals working in the field of gerodontology should be educated on the nutritional needs of the elderly. In this context, the strategy to improve nutrients intake in the elderly population should take into account the fortification of food products with selected ingredients, such as vitamins and minerals 45 and providing food with adequate sensory values and optimal nutritional quality 46. In particular, dietary indications should be focused on increasing protein intake 47, in order to maintain muscular mass and reduce the occurrence and severity of sarcopenia, meaning that it is necessary to take high-quality protein during each meal in order to reach an optimal daily intake of of 1.0-1.2 g/kg 48,49. Meals should also be balanced by introducing nutrients that prevent osteoporosis occurrence, not only calcium and vitamin D, but also iron, copper, vitamin K, phosphorus, manganese, boron, potassium and selenium: in this context, bone remodeling and bone mineral density can be successfully sustained by introducing a balanced amount of fruit, dried fruits, fibre, vegetables, probiotic and dairy foods 50-54.
CONCLUSIONS
Based on the available data, there aren’t enough studies to draw definitive conclusions, but further research is required to improve current knowledge of these associations and to acquire uniform and comparable results. These data will be useful to develop welfare politics customized for an ageing population even when independent. Healthy nutrition, together with congruous prosthetic solutions and increased masticatory function, is necessary to change and improve diet habits. Nutritional counselling seems an important factor to improve nutrients intake in the elderly and it is recommended to be associated with the prosthetic rehabilitation treatment. The multidisciplinary cooperation of dental professionals, dietetics practitioners, and primary care providers to improve dietary habits and nutritional intake seems therefore mandatory.
Acknowledgments
We thank Dr. Claudia Galassi for her help in reviewing the manuscript.
Conflict of interest statement
The authors declare no conflict of interest.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Author contributions
BE: contributed to study design, data acquisition and interpretation and drafted the manuscript; MC: designed the research strategy, coordinated the data-analysis and interpretation; NV: contributed to study design and critically revised the manuscript; PC: contributed to study conception and critically revised the manuscript; BF: contributed to study conception and design and critically revised the manuscript.
Figures and tables
Figure 1.
Flow-chart of the screening process (adapted from PRISMA).
Table I.
Inclusion and exclusion criteria for study selection.
| Inclusion criteria | Exclusion criteria | |
|---|---|---|
| Sample | Age > 65 yrs | Maxillofacial surgery |
| Radiotherapy | ||
| Self-sufficient | Institutionalized patients | |
| Systemic diseases | ||
| Outcome: nutritional status | Self-declaration or interview about nutritional intake | Declaration regarding food intake that was not obtained |
| Food diary | ||
| Blood exams | ||
| Analysis | Every association between oral status/masticatory function and food and nutrients intake | Studies that do not search for an association between oral status/masticatory function and food and nutrients intake |
Table II.
Characteristics and main results of included Randomized Controlled Trials.
| Author (year) | Participants, location | Intervention (IG)/comparator (CG) | Outcomes and measurements | Synthesis of main results | Comments |
|---|---|---|---|---|---|
| Amagai (2017)/Suzuki (2018)/Kanazawa (2019)/Suzuki (2019) | edentulous elderly patients requiring new complete dentures IG: 75.3 yrs CG: 78.6 yrs 70 randomized, 62 finished the trial at 3 months 59 finished the trial at 6 months Location: Tokyo (Japan) Period: 2015-2016 | IG: (n.31 at 3 months, 30 at 6 months) complete denture treatment + dietary advice in a pamphlet form (indicating “what” and “how much” should be eaten in a day) CG: (n.31 at 3 months, 29 at 6 months) complete denture treatment + advice pertaining to the care and maintenance of the dentures | Food intake: brief-type self-administered diet history questionnaire (BDHQ). Self reported MNA-SF Oral health related quality of life: Japanese version of the Oral Health Impact Profile for edentulous people (OHIP-EDENT-J) Masticatory function:color-changeable chewing gum and a test gummy jelly Outcome assessment at baseline, at 3 and 6 months post-treatment | Between groups At 3 months:
At 3 months: Both groups improved in the OHIP-EDENT-J scores and in masticatory function | At baseline, protein intake met the recommended dietary reference intakes for Japanese in both groups Incomplete blinding Nutrient intake based on self-reported questionnaire |
| Awad (2012) | Edentulous for a minimum of 5 years, aged > 65 yrs 255 randomized, 219 completed 12 months follow up Location: Montreal (Canada) Period: NR | IG: (n.110) IOD and maxillary CD CG: (n.109) CD | Primary outcome: blood serum concentration of homocysteine Secondary outcomes: a range of haematological markers, BMI. Self reported chewing ability (Likert scale questionnaire) Outcome assessment at baseline and at 12 months post-treatment | Between groups
| Self-reported chewing ability Incomplete blinding |
| Hamdan (2013) | Same population as Awad 2012 255 randomized, 217 finished the trial for the investigated outcome at 12 months. Same Location and period as Awad 2012 | IG: (n.103) IOD and maxillary CD CG: (n.114) complete CD | Three standard 24-hour dietary recalls by telephone interview Outcome assessment at baseline and at 12 months post-treatment | Between groups
| Nutrient intake based on self-reported questionnaire Incomplete blinding Same Trial Registration Number as Awad 2012 |
| McKenna (2014 and 2015)/Wallace (2018) | Partially dentate patients aged >65 yrs 132 randomized, 89 finished the trial at 12 months Location: Cork (Ireland) Period: NR | IG: (n.45) functionally orientated treatment (shortened dental arch) CG: (n.44) (conventional treatment) removable partial dentures | Food intake: self reported MNA and MNA-SF A range of haematological markers Chewing ability: two coloured chewing gum. Outcome assessment at baseline and at 1,6 and 12 months post-treatment | Between groups
| Self-reported dietary intake Incomplete blinding |
| Morais (2003) | Edentulous for a minimum of 5 years, aged 65-75 yrs 60 randomized, 56 finished the trial at 6 months Location: Montreal (Canada) Period: NR | IG: (n.29) IOD and maxillary CD CG: (n.27) conventional CD | Food diary. BMI, various anthropometric measures A range of haematological markers. Self reported chewing ability Outcome assessment at baseline and at 1and 6 months post-treatment | Between groups
Some hematological markers (B12, Albumin), some anthropometric measures and some questions on masticatory functions improved post-treatment, more frequently in the IG | Self-reported dietary intake Incomplete blinding |
| NR: not reported; IOD: mandibular implant overdenture; CD: complete denture; MNA: mini nutritional assessment; MNA-SF: mini nutritional assessment-short form; BMI: body mass index; SDA: shortened dental arch; RPD: removable partial denture. | |||||
Table III.
Characteristics and results of included observational studies (Prospective cohort or Cross-sectional survey).
Table III.
Characteristics and results of included observational studies (Prospective cohort or Cross-sectional survey).
| Author (year) | Participants, location and period | Objective | Outcomes and measurements | Synthesis of main results | Comments |
|---|---|---|---|---|---|
| Prospective cohort studies | |||||
| Nabeshima (2018) | Partially dentate patients scheduled to receive new removable partial dentures (RPD) at a dental hospital N.38 selected, 32 analysed Mean age 73.2 yrs (SD 7.7) Women: 65.8% Location: Tokyo (Japan) Period: 2015-2017 | Evaluate if a dietary counselling (aimed at increasing dietary fruit and vegetable intake and improving dietary habits) administered in conjunction with RPDs would increase fruit and vegetable intake. Patients received dietary counseling provided by a dentist twice, directly after treatment and at 1 month follow-up evaluation | Included only patients who were scheduled to receive RPD and were currently eating < 350 g of vegetables per day (i.e.the daily intake recommended in Japan). Food and nutrient intake: estimated from self-administered BDHQ Blood samples: carotenoids and vitamin C in 6-hour fasting blood samples Questionnaire and blood samples at baseline (before RPD), and at 1 and 3 months after RPD | At univariate analysis:
| Self-reported food intake Small sample size The authors report that at baseline mean fruit intake (162 g/day) of the study population was greater than in the Japanese population as a whole (109 g/day) |
| Tanasić (2017) | Patients partially or completely edentulous with a need for rehabilitation, aged >= 65 yrs N.150 analyzed Location: Belgrade (Serbia) Period: 2011-2015 | To test if prosthetic restorations improve the nutritional status of patients | BMI and MNA recorded before and at 6 and 12 months after prosthetic rehabilitation 34.7% and 30.7% of patients received an implant supported maxillary and mandibular overdentures, respectively; 65.3% and 69.3% of patients received maxillary and mandibular RDB, respectively | At baseline:
| Self-reported dietary intake Information on comorbidities, educational level, socio-economic status not collected |
| Cross-sectional surveys | |||||
| Choi (2014) | Subjects aged >= 65 years N. 722 Median age: nr Women: 58.2 Location: Korea Period: 2007 | To examine the relationship between the oral health and nutritional intake of people aged 65 and older | Study based on the results from 4th Korea National Health and Nutrition Examination Survey (KNHANES), for subjects aged >= 65 yrs and who answered both the health check-up and nutrition questionnaire 24-h dietary recall method Prosthodontic status evaluated during health examination | At a multivariate analysis adjusted for gender and income, daily nutritional intakes of energy, protein, fat, ash, calcium, phosphorus and thiamine were decreased significantly in elderly with partial or full dentures compared with those with no prosthesis or with a fixed prosthesis | Self-reported dietary intake |
| Inomata (2017) | Individuals 79-81 yrs residing close to the visit venue, from an ongoing cohort study N.760 Age 79-81 yrs Women: 52.1% Location: two regions of Japan Period: 2011-2012 | To determine the association of dietary intake with the number of teeth and occlusal force in community dwelling 80-y-old Japanese people | Data obtained from the baseline visit of Japanese octogenarians included in the prospective cohort study “SONIC” Oral examination to evaluate:
| Response rate = 17.5% (941/5378) 181 subjects further excluded (extremely low or high reported energy intake, those currently receiving dietary counseling, or with intentional dietary change during the preceding year) In multivariate analysis adjusted for gender, educational level, financial status, area of residence, family structure and BMI:
| The average number of teeth of the study participants (15.2) was higher than the data for Japanese aged 80 y to 84 y (12.2) Self-reported dietary intake |
| Natapov (2018) | Individuals > 65 yrs living in the community and insured medically with two of the four health funds. N.1776 Mean age NR Women: NR Location: Israel Period: 2005-2006 | To assess the impact of dental status and visits on dietary intake of the Israeli elderly | Study based on data collected from those interviewed for the first National Health and Nutrition Survey of the Elderly (Mabat Zahav), carried out in 2005-6. Patients interviewed in their homes by trained interviewers.Food intake: 24 h dietary recall method. Questionnaire: demographic, socio-economic, behavioral and general health conditions, and subjective dental health status, including owning removable (partial or full) dentures | Response rate (questionnaire filled) = 96% (1776/ 1852) At a multivariate analysis adjusted for education, interest in association between nutrition and health and reading nutrition labels:
| Self-report of both outcomes and main exposures (nutritional status, eating habits, dental status) |
| Okamoto (2019) | Volunteers from the Nara prefecture aged >= 65 years at the baseline survey, who were living in their own homes and were able to walk independently N. 3134 Median age:71.0 yr Women: 49.2 Location: Japan Period: 2007 | Hypotheses tested: (i) A smaller number of teeth is associated with lower maximum occlusal force, fewer masticable foods, lower serum albumin levels, and a lower BMI. (ii) Among people with approximately the same numbers of teeth, people without occlusal support in the molar region have a lower masticatory ability, serum albumin levels, and BMI than people with such support | Data retrieved from the baseline data of the 2007 Fujiwara-kyo study (prospective cohort study on elderly), for subjects with available data on occlusal force The baseline health examination included a dental examination, measurement of occlusal force, measurement of height and body weight, blood collection, and a questionnaire about lifestyle Nutritional indices: serum albumin and BMI | At multivariate analyses with serum albumin levels below the lower quartile (< 4.4g/dL) and a BMI below the lower quartile (< 21 kg/m2) as dependent variables, and number of teeth, maximal occlusal force, age, education length, alcohol consumption, smoking status, grip strength, and disease history as explanatory variables
In both males and females, the maximum occlusal force decreased significantly with the number of teeth | |
| Stoffel (2018) | Individuals 65-74 yrs residing in households N.287 Mean age 69.3 yrs (SD 3.52) Women: 64.5% Location: Cruz Alta (Brasil) Period: July-August 2016 | To assess nutritional status and associated factors in elderly individuals | Nutritional status: self reported MNA Demographic, socio-economic, behavioral and general health conditions: self completed questionnaire (PCA Tool-SB Brazil) Clinical visit: dental status (including need of prosthesis), anthropometric measurements | 48.4% at nutritional risk (45.3% at risk of malnutrition and 3.1% malnourished) In a multivariate analysis including as predictors the use of prosthesis and access to a dentist, compared to persons complete or partially dentate, those edentulous wearing no or only one prosthesis were at higher nutritional risk, while no increased nutritional risk was observed for those edentulous wearing two prosthesis. A higher nutritional risk was also observed for those reporting no access to a dentist in the previous 12 months | Self-reported dietary intake |
| Su (2020) | Attendees of two elderly welfare centers aged ≥ 65 years, able to walk without help N.294 Mean age 75.8 yrs (SD 5.8) Women: 71.1% Location: Sapporo (Japan) Period: August-September 2018 | To determine if older adults wearing complete or partial dentures have a higher risk of malnutrition | Nutritional status: self reported MNA-SF Demographic characteristics, eating habits, dental status (complete denture:CD, partial denture: PD, no denture:ND) and health status: self completed questionnaire Taste sensitivity: salt-impregnated taste paper test BMI and protein mass: bioelectrical impedance analysis | Response rate = 95% (294/310) 64.3% wore PD, 9.9% wore CD 23.5% at risk of malnutrition (MNA-SF < 12) At the multivariate analysis, including age, gender, suspected dysphagia, frailty, protein mass, and awareness of salt restriction, the risk of malnutrition was positively associated with suspected dysphagia and frailty, and negatively associated with protein mass, awareness of salt restriction and wearing PD compared to ND (OR 0.39, 95% CI, 0.20-0.77); wearing a CD compared to ND showed a lower risk of malnutrition, although not statistically significant (OR 0.63, 95% CI 0.22-1.83) | Small number of persons wearing a CD Self-report of both outcomes and main exposures (nutritional status, eating habits, dental status) |
| NR: not reported; IOD: mandibular implant overdenture; CD: complete denture; MNA: mini nutritional assessment; MNA-SF: mini nutritional assessment-short form; BMI: body mass index; RPD: removable partial denture. | |||||
APPENDIX
Table S1.
Risk of bias assessment for randomized clinical trials.
| Author | Random sequence generation | Allocation concealment | Blinding | Incomplete outcome data | Selective reporting | Free of other bias |
|---|---|---|---|---|---|---|
| Amagai (2017)/Suzuki (2018)/Kanazawa (2019)/Suzuki (2019) | L | L | U | L | L | U |
| Awad (2012) | L | U | U | L | L | L |
| Hamdan (2013)* | L | U | U | L | L | L |
| McKenna (2014/2015) Wallace (2017) | L | L | U | L | L | L |
| Morais (2003) | L | U | U | L | L | U |
| H: high risk of bias; L: low risk of bias; U: unclear or unrevealed risk of bias. *Same Trial Registration Number as Awad 2012. | ||||||
Table S2.
Characteristics of excluded studies.
| N | First author | Journal, year | Title | Reasons for exclusion |
|---|---|---|---|---|
| 1 | Amaral | Braz. Dent. J. vol. 30 no.1 Ribeirão Preto Jan/Feb 2019 Epub Mar 11 | Sensorial ability, mastication and nutrition of single-implant overdentures wearers | 2 |
| 2 | Banerjee | Indian J Dent Res 2018;29(5):562-567. | Evaluation of relationship between nutritional status and oral health related quality of life in complete denture wearers. | 2 |
| 3 | Beck A.M | Nutrition 2008;24(11-12):1073-1080. | Multifaceted nutritional intervention among nursing-home residents has a positive influence on nutrition and function | 1 |
| 4 | Bori | J Oral Rehabil 2020;47(9):1142-1149 | The relationship between masticatory performance and intakes of foods and nutrients in Japanese male workers: a cross-sectional study | 2 |
| 5 | Carletti | Spec Care Dentist 2019;39:471-477 | Prostheses satisfaction and diet of elderly wearing a single implant overdenture: a six-month assessment | 2 |
| 6 | Cho | Gerodontology 2019;36(2):99-106 | Subjective chewing ability and health-related quality of life among the elderly | 1 |
| 7 | Damayanthi | Annals of Global Health 2017 83:1(77) | Malnutrition and associated factors among community- dwelling elderly in Sri Lanka | 1 |
| 8 | De Almeida | Clinical Nutrition 2016;35 Supplement 1 (S57) | Handgrip strength, mini nutritional assessment and swallowing findings in the elderly without swallowing complaints | 1 |
| 9 | El Osta | Clin Nutr ESPEN 2017;18:49-54. | Impact of implant-supported prostheses on nutritional status and oral health perception in edentulous patients | 2 |
| 10 | Fukutake | J prosthodont Res 2019;63(1):105-109 | Relationship between oral stereognostic ability and dietary intake in older Japanese adults with complete dentures | 1 |
| 11 | Garrett | J Prosthet Dent 1997;77(2):153-161 | Veterans Administration Cooperative Dental Implant Study-comparisons between fixed partial dentures supported by blade-vent implants and removable partial dentures. Part V: comparisons of pretreatment and posttreatment dietary intakes | 2 |
| 12 | Gjengedal | Int J Prosthodont 2012;25:340-347 | Randomized clinical trial comparing dietary intake in patients with implant-retained overdentures and conventionally relined denture. | 2 |
| 13 | Goncalves | Int J Oral Maxillofac Implants, 2015;30(2):391-396 | Effects of implant-based prostheses on mastication, nutritional intake, and oral health-related quality of life in partially edentulous patients: a paired clinical trial | 2 |
| 14 | Hama | J Oral Rehabil 2020;47(8):998-1006. | Factors related to removable denture use in independent older people: a cross-sectional study | 1 |
| 15 | Hamada | J Prosthet Dent 2001;85:53-60. | A randomized clinical trial comparing the efficacy of mandibular implant-supported overdentures and conventional dentures in diabetic patients. Part IV: comparisons of dietary intake. | 2,4 |
| 16 | Hatta | Geriatrics and Gerontology International 2017 17:1 (177-179) | Correlation between nutritional status and frailty regarding saliva secretion and occlusal force in community-dwelling older people | 1 |
| 17 | Hearne | Age and Ageing 2017 46 Supplement 3 (iii13) | A snapshot of dental health among inpatients on a geriatric ward | 3 |
| 18 | Huppertz | Journal of the American Medical Directors Association 2017;18:11 (948-954) | Association between malnutrition and oral health in dutch nursing home residents: results of the LPZ Study | 3,4 |
| 19 | Iwasa | Nihon Koshu Eisei Zassh 2019;66(3):151-160 | Psychometric properties of the diet-related quality of life (DRQOL) scale and its short version among older adults | 5 (full article is available in Japanese only) |
| 20 | Iwasaki | Geriatr Gerontol Int 2018;18(6):860-866 | Association between objectively measured chewing ability and frailty: a cross-sectional study in central Thailand | 1 |
| 21 | Iwasaki | Geriatrics and Gerontology International 2016;16:4 (500-507) | Hyposalivation and dietary nutrient intake among community-based older Japanese | 1 |
| 22 | Jauhiainen | J Nutr Health Aging 2017;21(5):492-500. | Food consumption and nutrient intake in relation to denture use in 55- to 84-year-old men and women – results of a population based survey | 2 |
| 23 | Kalaykova | J Dent 2019;88:103159 | Impact of restorative treatment of tooth wear upon masticatory performance | 1 |
| 24 | Kang | Int J Environ Res Public Health 2020;17(2):547 | Association between dental treatment, quality of life, and activity limitation according to masticatory discomfort: evidence from the Korean National Health and Nutrition Examination Survey (2013-2015) | 1 |
| 25 | Khandelwal | Annals of Nutrition and Metabolism 2017;71 Supplement 2 (1074) | Prevalence and factors associated with underweight, overweight and obesity amongst elderly population living at high altitude regions of rural Uttarakhand, India | 1 |
| 26 | Kikutani | Gerodontology 2006;23(2):93-98 | Effects of oral functional training for nutritional improvement in Japanese older people requiring long-term care | 3 |
| 27 | Kim | Sci Rep 2020 Jul 17;10(1):11859 | Did expanded access to denture services improve chewing ability in the Korean older population? Results of a regression discontinuity analysis | 1 |
| 28 | Kimura | Geriatr Gerontol Int 2019;19(12):1290-1292 | Association between anorexia and poor chewing ability among community-dwelling older adults in Japan | 1 |
| 29 | Kito | J Nutr Health Aging 2019;23(7):669-676 | Positive effects of “textured lunches” gatherings and oral exercises combined with physical exercises on oral and physical function in older individuals: a cluster randomized controlled trial | 1 |
| 30 | Komagamine | Trials 2016 17:1 | Combined effect of new complete dentures and simple dietary advice on nutritional status in edentulous patients: study protocol for a randomized controlled trial | 5 (the article presents the registered protocol of the RCT of Amagai 2017) |
| 31 | Konopka | Dental and Medical Problems 2017;54:4 (369-382) | Oral health parameters in the regional study among young seniors in an urban area of Wrocław | 1 |
| 32 | Krzyminska-Siemaszko | Eur Rev Med Pharmacol Sci 2016;20(21):4565-4573. | Health status correlates of malnutrition in the polish elderly population. Results of the Polsenior Study | 1 |
| 33 | Lee | Geriatr Gerontol Int 2018;18(4):592-598 | Association between number of teeth, use of dentures and musculoskeletal frailty among older adults | 2 |
| 34 | Matsuo | J Oral Rehabil 2020;47(2):180-186 | Effects of textured foods on masticatory muscle activity in older adults with oral hypofunction | 1 |
| 35 | Mitri | Gerodontology 2020;37(2):200-207 | Factors associated with oral health-related quality of life among Lebanese community-dwelling elderly | 1 |
| 36 | McKenna G | Irish Journal of Medical Science 2012;181;191-299. | The effect of tooth replacement strategies on the nutritional status of older patients | 5 (the article regarded a topic that was further discussed in others, more recent articles that have been included in our review) |
| 37 | McKenna G | Gerodontology 2012;29(2):E883-890. | Impact of tooth replacement strategies on the nutritional status of partially-dentate elders. | 5 (the article regarded a topic that was further discussed in others, more recent articles that have been included in our review) |
| 38 | McKenna G | European Geriatric Medicine 2011;2(Suppl 2):S1-S23 (7th Congress of the EUGMS, Màlaga, 28th-30th September 2011) | Comparison of tooth replacement strategies on the nutritional status of older patients: a randomised controlled clinical trial | 5 (the text was not a full article but a conference abstract, regarding a topic that was further published in an article with a similar title, that was included in our review) |
| 39 | Moynihan | J Dent, 2000;28(8):557-563 | Nutrient intake in partially dentate patients: the effect of prosthetic rehabilitation. | 2 |
| 40 | Muller | J Dent Res 2013;92(12 Suppl):154S-1560S | Implant-supported mandibular overdentures in very old adults: a randomized controlled trial | 3 |
| 41 | Muller | Braz Dent J 2008;19(2):145-150 | Nutritional and anthropometric analysis of edentulous patients wearing implant overdentures or conventional dentures | 2 |
| 42 | Nanri | Eur J Clin Nutr 2019;73(4):577-584. | Frequency of fruit and vegetable consumption and the oral health-related quality of life among Japanese elderly: a cross-sectional study from the Kyoto-Kameoka study | 1 |
| 43 | Oh | European Geriatric Medicine 2017;8(Suppl 1) (S124) | Factors associated with vitamin d deficiency in the elderly: the korean national health and nutrition examinationsurvey 2010-2012 | 1 |
| 44 | Ohkubo | Bull Tokyo Dent Coll 2020;4;61(3):161-168 | Differences in elderly and non-elderly outpatient subjective evaluation of “Easy-to-Eat Meals” after dental treatment | 1 |
| 45 | Okabe | J Nutr Health Aging 2016;20(7):697-704 | Swallowing function and nutritional status in japanese elderly people receiving home-care services: a 1-year longitudinal study | 2 |
| 46 | Park | Geriatr Gerontol Int 2017;17(1):78-84 | Predictors of chewing ability among community-residing older adults in Korea | 1 |
| 47 | Petry | Codas, 2019;31(3) | Autoperception of food conditions of elderly dental prosthetic users | 1 |
| 48 | Peyron | Food Funct 2018;9(2):1112-1122 | Oral declines and mastication deficiencies cause alteration of food bolus properties | 1 |
| 49 | Puri | J Prosthet Dent 2016;116(6):867-873 | Evaluation of correlations between frequencies of complete denture relines and serum levels of 3 bone metabolic markers: a cross-sectional pilot study | 1 |
| 50 | Sebring | J Prosthet Dent 1995;74:358-363 | Nutritional adequacy of reported intake of edentulous subjects treated with new conventional or implant-supported mandibular dentures | 2 |
| 51 | Shiohama | Clin Nutr 2018;37(1):406-407 | No clinically significant effect of new complete denture fabrication and simple dietary advice on nutrient intake and masticatory function of edentulous older people | 5 (not an original article, but a letter to the editor, complaining about the validity of other previously published studies, regarding the investigated topic) |
| 52 | Suzuki | J Oral Rehabil, 2019 Dec;46(12):1100-1106. | Influence of simplified dietary advice combined with new complete denture fabrication on masticatory function of complete denture wearers | 1 |
| 53 | Tanasić | Int J Prosthodont 2016;29(5):484-486. | Association between dentition status and malnutrition risk in Serbian elders | 5 (patients partially included in a further publication already included in our review) |
| 54 | van der Glas | J Texture Stud, 2020;51(1):169-184. | Optimizing a determination of chewing efficiency using a solid test food | 1 |
| 55 | van der Meij | Journal of the American Geriatrics Society 2017;65:10 (2190-2197) | Poor appetite and dietary intake in community-dwelling older adults | 1 |
| 56 | Watanabe | Int J Environ Res Public Health 2020;17(12):4555 | Association between mixing ability of masticatory functions measured using color-changing chewing gum and frailty among japanese older adults: the Kyoto-Kameoka Study | 1 |
| 57 | Wostmann | PLoS One 2016;11(1) | Pilot study on the influence of nutritional counselling and implant therapy on the nutritional status in dentally compromised patients | 2 |
Reasons for Exclusion Legend:
| ||||
Table S3.
Summary of recently published systematic reviews investigating the association between oral status/masticatory function and food and nutrients intake.
Table S3.
Summary of recently published systematic reviews investigating the association between oral status/masticatory function and food and nutrients intake.
| Author (year) | Type of review | Main clinical question | Studies includeded | Study participants’ characteristics | Main results | Main conclusions |
|---|---|---|---|---|---|---|
| Association between tooth loss and nutritional status | ||||||
| Gaewkhiew (2017) | Systematic review | Explore whether tooth loss affects dietary intake and nutritional status among adults | 8 Longitudinal studies Population-based or clinical samples of adults | Mostly (6/8) aged >= 65yrs Mostly (6/8) living in community dwelling | Out of the 4 studies investigating the association between tooth loss and nutritional status 3 studies showed significant results. However, most results were contradicting. The quality of the evidence was weak | There is at present no strong evidence on the effect of tooth loss on diet and nutrition, with inconsistent results among the few studies identified. Additional high-quality longitudinal studies should address the limitations of previous studies identified in this review |
| Zelig (2020) | Systematic review and meta-analysis (MA) | Among adults aged ≥60 y living in developed countries, what are the associations between tooth loss and nutritional status as assessed by a validated nutrition screening or assessment tool? | 7 studies published 2009-2019 6 included in MA 6 cross-sectional, 1 cohort All studies judged as having a moderate risk of bias | Subjects aged >= 60 yrs Living in any setting Living in developed countries | Individuals who were completely edentulous or who lacked functional dentition had a 21% increased likelihood of being at risk of malnutrition or being malnourished, as compared with those who were dentulous or had functionally adequate dentition | Findings suggest that older adults with tooth loss are at greater risk of malnutrition than those with functionally adequate dentition |
| Association between oral rehabilitation and nutritional status | ||||||
| Yamazaki (2016) | Systematic review and meta-analysis | Investigate whether treatment with a mandibular implant supported overdenture improves nutrient intake and markers of nutritional status better than a conventional complete denture in edentulous patients | 8 studies (6 RCT and 2 prospective cohorts) 3 RCT included in MA (all with patients aged >= 65yrs) | No selection by age | Four studies reported changes in markers of nutritional status and nutrient intake after treatment with a prosthetic, regardless of type. In a meta-analysis of 322 participants aged 65 years or older from 3 studies, pooled analysis suggested no significant difference in change in BMI between an overdenture and conventional denture 6 months after treatment, and no significant difference in change in albumin or vitamin B12 between the two treatments | The modifying effect of overdenture treatment on nutritional status might be limited. Further studies are needed to evaluate the effectiveness and efficacy of denture treatments |
| Bezzerra (2021) | Systematic review and meta-analysis | Do complete and partial edentulous patients, using implant-supported prostheses, present better nutritional and masticatory functions when compared to those using conventional rehabilitations? | 14 studies (8 RCT, 5 paired clinical trials, 1 cohort study) 2 or 3 RCT included in the MAs for specific nutrients | Included only studies evaluating both masticatory and nutritional outcomes No selection by age | Patients wearing implant overdentures (IOD) presented better masticatory function in comparison to conventional complete denture (CD) wearers. However, bioavailability of several nutrients remained within the same range, except for serum folate that was lower in IOD patients after 6 and 12 months of rehabilitation | Current evidence indicates significant masticatory improvements for dental fixed implant supported prostheses in comparison to conventional removable prostheses. However, bioavailability remained stable for most of the nutrients, especially for complete edentulous patients |
| Association between dietary interventions coupled with oral rehabilitation and nutritional status | ||||||
| McGowan (2020) | Systematic review and meta-analysis | Synthesize literature relating to oral rehabilitation coupled with dietary intervention in adults | 9 studies (3 RCT, 1 parallel-group cohort, 5 single-arm before-after) 3 studies included in MA | No selection by age Living in any setting Most studies (6/9) included less than 60 participants | Fruit/vegetables intake results were pooled for 3 RCT studies using MA, resulting in a non significant difference between intervention and control group, with marked heterogeneity (p = 0.0007). Few interventions were theory-based and intervention components were poorly described. | Overall, narrative synthesis indicated support for dietary intervention coupled with oral rehabilitation on diet. Meta-analysis was only possible with three studies highlighting limitations. Large-scale, appropriately described trial methodologies are needed |
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Bellia, E.; Monagheddu, C.; Notaro, V.; Ceruti, P.; Bassi, F. Relationship between oral rehabilitation and nutrients intake in the independent elderly: a systematic review of the literature. J. Gerontol. Geriatr. 2023, 71, 187-205. https://doi.org/10.36150/2499-6564-N561
AMA Style
Bellia E, Monagheddu C, Notaro V, Ceruti P, Bassi F. Relationship between oral rehabilitation and nutrients intake in the independent elderly: a systematic review of the literature. Journal of Gerontology and Geriatrics. 2023; 71(3):187-205. https://doi.org/10.36150/2499-6564-N561
Chicago/Turabian StyleBellia, Elisabetta, Chiara Monagheddu, Vincenzo Notaro, Paola Ceruti, and Francesco Bassi. 2023. "Relationship between oral rehabilitation and nutrients intake in the independent elderly: a systematic review of the literature" Journal of Gerontology and Geriatrics 71, no. 3: 187-205. https://doi.org/10.36150/2499-6564-N561
APA StyleBellia, E., Monagheddu, C., Notaro, V., Ceruti, P., & Bassi, F. (2023). Relationship between oral rehabilitation and nutrients intake in the independent elderly: a systematic review of the literature. Journal of Gerontology and Geriatrics, 71(3), 187-205. https://doi.org/10.36150/2499-6564-N561
