Best Practice & Research Clinical Gastroenterology

Vol. 15, No. 6, pp. 885±896, 2001

doi:10.1053/bega.2001.0247, available online at http://www.idealibrary.com on

Nutrition and oral health

Ejvind Budtz-Jùrgensen Dr. Odont

Professor

Jean-Pierre Chung Dr. Med. Dent

Associate Professor

Division of Gerodontology and Removable Prosthodontics, University of Geneva, 19 rue BartheÂlemy-Menn,

CH-1205 Geneva, Switzerland

Charles-Henri Rapin Dr. Med

Professor
Policlinic of Geriatrics, University Hospitals of Geneva, 35 Rue des Bains, CH-1205 Geneva, Switzerland
Bioethical Center of Montreal, Canada

Reduced chewing function in community-dwelling older people with adequate general health is
linked to having fewer than 20 teeth present or to wearing removable dentures. By chewing for
longer periods of time or swallowing larger food particles they are normally able to compensate
for the impaired function. The masticatory function can be restored by adequate prosthetic
therapy, which results in increased activity of the masticatory muscles during chewing and
reduces the chewing time and the number of chewing strokes until swallowing. In frail or
dependent elderly people undernutrition is prevalent because of health problems, reduced
appetite and poor quality of life. Poor oral health and xerostomia are often associated with a
reduced body mass index and serum albumin level and the avoidance of dicult-to-chew foods.
Maintenance or re-establishment of masticatory function is an integral part of the medical health
care of these patients, with the aim of improving their nutritional status and quality of life.

Key words: masticatory function; nutrition; oral health; tooth loss; oral health care.

INTRODUCTION
Proper nutrition of the elderly is essential both for general and oral health. In this
context, oral health and oral comfort are a prerequisite for a good masticatory function
and adequate food intake. The preservation of a healthy natural dentition, or the
replacement of missing teeth with adequate prosthetic appliances, is essential for
masticatory function. A sucient amount of saliva is necessary for the maintenance of
oral health and comfort during mastication. Saliva contains minerals such as calcium,
phosphate or ¯uoride, which are essential for re-mineralization of surface carious
lesions. Saliva also plays a role in the clearance of pathogenic micro-organisms from the
mouth. Furthermore, saliva is important in the chewing process, since it plays a role in
binding the food fragments together as a coherent bolus that can be swallowed safely,
1521±6918/01/060885‡12 $35.00/00 *
c 2001 Harcourt Publishers Ltd.
886 E. Budtz-Jùrgensen et al

without the danger of stray particles entering the respiratory system. As a consequence,
the elderly who su€er from xerostomia will have less chewing comfort as the food will
tend to stick to the mucosa rather than together. Saliva is also rich in digestive and other
enzymes that dissolve the molecules needed in taste perception.
Taste and odour perception also play an important role in food intake. Among
elderly persons, there is a wide diversity in the sense of smell and odour perception,
but the perception threshold is not markedly reduced with age.1 Ageing is associated
with a decline in olfactory function resulting in higher odour detection thresholds for
both nasal2,3 and retronasal presentation of odours.4 Indeed, impaired or altered taste
and smell sensation in older persons is a frequent complication of general disorders
such as Alzheimer's or Parkinson's disease, chronic liver or kidney diseases, endocrine
disorders and drugs (e.g. drugs for arthritis, hypertension, heart disease or drugs to
improve mood or treat epilepsy) as well as oral disorders such as xerostomia, burning
mouth syndrome, periodontal disease or halitosis.5,6

ORAL HEALTH STATUS OF THE ELDERLY

The prevalence of periodontal disease, caries, tooth loss and edentulousness are the
accepted and most important criteria for assessing oral health status. The improved oral
health status of the adult population in industrially developed countries will have an
important impact on the oral health status of the future elderly.7 Thus, tooth retention
in the USA population is projected to increase from 9.0 to 15.6 teeth on average per
person between 1990 and 2025 for those aged 75 years or older. The percentage who are
edentulous in this age group is expected to decrease from 44% to 22.5%. These trends
will have a profound in¯uence on the future need for oral health care, particularly
among those who become frail and dependent. On the one hand, there will be a relative
decline in the need and demand for the replacement of missing teeth by prosthetic
therapy in order to maintain appropriate masticatory function. On the other hand, it
will be necessary to implement ecient preventative oral measures in this population in
order to maintain dental and oral health.

Functionally independent elderly

Generally, the periodontal health of the elderly has improved during the last 10±20
years, re¯ecting improvements in oral health attitude and preventative measures.
However, in practice 100% are a€ected by gingivitis and 20±30% have at least one deep
periodontal pocket requiring complex periodontal therapy.8 In the elderly, the most
important risk indicators of periodontal disease are large number of teeth present, low
educational level, age and current smoking habits.9
In the elderly, root caries are a major problem due to recession of the gingival tissues.
The exposed root surface becomes easily a€ected by caries, particularly in those who
have already had caries, who have poor oral hygiene, a low salivary ¯ow rate or who
wear removable dentures.8 Root caries are dicult to treat eciently using
conventional restorative therapy. However, with proper oral hygiene measures and
improvements in diet, active root caries can often be converted into inactive lesions.10
The prevalence of edentulousness in the elderly population is associated with age,
female sex, low education, low social class and income level, and living in a rural
area.11,12 As mentioned previously, the relative prevalence of edentulousness among
older, functionally independent adults is about to decrease drastically. However, due
 Nutrition and oral health 887

to demographic changes the absolute number of edentulous elderly people will remain
high in industrialized countries. Based on objective criteria the quality of existing
dentures is clinically poor, but complaints regarding comfort or oral pain are rare.13
Thus, patients tend to wear old dentures that ®t poorly, but they are rarely motivated
to seek and bene®t from prosthodontic treatment.

Frail or functionally dependent elderly

In the frail or functionally dependent elderly, oral health status is profoundly
in¯uenced by the patient's medical problems, drug history and their psychosocial
situation. The functionally dependent elderly living in an institution make up about 5%
of the population over the age of 65 years, but it is projected that some 20% of persons
over 65 will spend at least a part of their life in nursing homes.14 The frail elderly
constitute about 20% of the elderly. They have partial loss of independence and more
serious medical or emotional problems. The majority are able to live in the
community with support services, but they can only visit a dental oce if helped.
The oral health status of individuals living in nursing homes has been well
documented.15±18 These studies have indicated that frail and dependent individuals tend
to have only a few functional teeth left and their oral health status is generally poor. The
oral problems of particular importance are a high prevalence of root-surface caries, the
presence of root remnants, poor oral hygiene and the presence of very old ill-®tting
dentures. The poor oral hygiene is the major problem, since this may give rise to dental
emergencies and an elevated risk of aspiration pneumonia.19,20 Impaired manual
dexterity combined with cognitive deterioration makes it dicult for these residents to
carry out oral self-care. Therefore, they must rely on caregivers' help for their daily oral
hygiene. However, sta€ members are often overworked and give low priority to oral
hygiene compared with other tasks. Furthermore, sta€ are often uninformed about
proper oral hygiene techniques.21,22 The extent to which the poor oral health status in
the frail and dependent elderly may be an important factor in predisposing them to
proteocaloric undernutrition will be discussed later in this chapter.

NUTRITION INTAKES AND ORAL HEALTH

It is important for older individuals to be able to comminute food during mastication

and to prepare the ingested food for swallowing and further processing in the digestive
tract (Table 1). However, many factors other than masticatory function per se are
essential for good nutritional status in the elderly. Thus, medical problems,
socioeconomic situation and dietary habits have an in¯uence on dietary selection and
nutritional intakes.

Masticatory function
Adequate dental/prosthetic status and muscle function are essential for masticatory
function. With age there is a signi®cant decrease in the cross-sectional area and the
density of the masticatory muscles.23 This reduction is most important in edentulous
individuals throughout the age spectrum compared with those who have natural teeth
left. These observations are consistent with general age-related changes of muscle tissue
in the body as a whole and may be a contributing factor to the reduction of masticatory
force with age.24 Thus, retention of teeth or rebuilding the dentition by tooth or
888 E. Budtz-Jùrgensen et al

Table 1. Oral and general conditions with

an impact on masticatory function and
alimentation in older individuals.

Tooth loss
Quality of dental prostheses
Masticatory muscles
Strength
Neuromuscular function
Salivary gland dysfunction and xerostomia
Smell and taste perception
Modi®ed threshold
Modi®ed perception
Dietary habits
Socio-economic factors
General health status

implant supported prostheses are means by which masticatory muscle mass and
function can be maintained in older individuals.25 With regard to a qualitative evaluation
of the masticatory function, two ideas are of importance: (i) masticatory ability, which is
the individual's self-assessed masticatory function and (ii) masticatory eciency or
performance, which is an objective assessment of masticatory function carried out
either by fractional sieving to separate out food particles after chewing, or by counts of
the number of chewing strokes before swallowing.26
In order to evaluate the masticatory ability, questionnaires are administered that
contain questions relating to chewing function, speci®c questions relating to the types
of food that are dicult to chew, and questions relating to swallowing and oral
comfort (Table 1).27±29 Studies on masticatory ability indicate that elderly people with
reduced dentition are, to a large extent, able to compensate for tooth loss, either by
chewing on the side where most teeth are left, by chewing longer, or by swallowing
larger food particles. With regard to the masticatory ability, studies show that
removable partial or complete dentures are a poor substitute for natural teeth. Those
who have more than 20 natural teeth left report no chewing problems. In edentulous
people wearing complete dentures, a considerable improvement in masticatory ability
can be obtained by the placement of implants to retain the dentures.30 Elderly people
who are comfortable with their prosthetic restorations replacing posterior tooth loss,
generally indicate an unimpaired masticatory ability.31 Thus, acceptance and oral
comfort with the prosthetic appliance are more important for masticatory ability than
the number of teeth replaced by the prosthesis. It is noteworthy that complaints
related to loss of appetite and xerostomia often coincide with poor masticatory
ability.29 In this situation, a poor general health condition may be the principal cause of
loss of appetite, xerostomia and the perceived masticatory ability, and may re¯ect poor
general oral comfort.
Chewing eciency, or the rate of breakdown of food during mastication, is clearly
correlated to features of the dentition, such as number of posterior teeth and the
quality of the occlusal relationships.32 For any particular type of food there is an
optimum number of chews.33 Chewing is continued until the food fragments bind
together as a coherent bolus that can be swallowed safely. If chewing is carried out for
too long, excess saliva will weaken the cohesive forces and allow the bolus to fall apart.
Poor masticatory function is usually compensated for by using a greater number of
chewing strokes prior to swallowing.34,35 This means that elderly people with severely
 Nutrition and oral health 889

reduced dentition, where the missing teeth have not been replaced by a prosthesis,
need more time to ®nish their meal. This is a particular problem if the stimulated
salivary ¯ow rate is reduced, which can increase chewing time by up to 100%.36
Therefore, preservation of natural occlusal tooth contacts is important in maintaining
masticatory function. With increased retention of natural teeth among `new elderly',
the need for preventive measures and dental care will increase so as to prevent tooth
loss. For those who are partially or totally dependent, the carers will have to assume
the daily oral hygiene care for these individuals.
When posterior teeth are lost, they can be replaced by ®xed or removable partial
dentures if the patient expresses a demand for rehabilitation. Treatment of edentulous
patients with implant-supported ®xed or removable dentures is an excellent option to
treatment with conventional complete dentures, since both the masticatory ability and
eciency will be better.37
Saliva plays an important role in the masticatory process by acting as a lubricant and
by binding the chewed food together. There is a reduction of the non-stimulated
salivary ¯ow rate with age; however, there is no evidence that the functional or
stimulated salivary ¯ow rate is reduced with age.38 But, older people su€er from more
diseases and consume more medications than younger people. In elderly people there
are three main causes of salivary hypofunction or xerostomia (Table 2): dehydration,
damage to the salivary glands, or interference with the neural transmission initiating
salivary secretion.39,40 In frail and dependent elderly, dehydration is frequently
associated with insucient water intake, renal water loss associated with diabetes
mellitus, or protein±calorie undernutrition. Thus, there exists a certain relationship
between reduced salivary ¯ow rate, impaired masticatory function, loss of appetite and
clinical evidence of undernutrition.41 Since salivary ¯ow is stimulated during normal
masticatory function, a decrease in the function of the masticatory muscles may induce
atrophy of the salivary glands and reduce synthesis and secretion of saliva.39 Thus,
appropriate masticatory function is important for proper alimentation, maintenance of
the salivary ¯ow and the overall quality of life for the elderly.

Table 2. Causes of salivary gland hypofunction.

Dehydration
Impaired water intake
Loss of water through the skin
Blood loss
Diarrhoea
Renal water loss
Protein±caloric undernutrition
Damage to the salivary gland
Irradiation to the head and neck region
Autoimmune diseases (e.g. SjoÈgren's syndrome)
HIV
Ageing
Interference with neural transmission
Medications
Autonomic dysfunction
Conditions a€ecting the central nervous system (e.g. Alzheimer's disease)
Psychogenic disorders (e.g. depression, anxiety)
Trauma
Decreased masticatory function

Source: Adapted from Sreebny39 and Fisher & Ship.40

890 E. Budtz-Jùrgensen et al

Dietary habits and nutritional status of older adults

Nutritional factors have a great impact on health versus disease late in life. Estimates
indicate that one-third to one-half of health problems in elderly individuals are a direct
or indirect consequence of nutritional de®ciency.42 The prevalence of undernutrition
is not very high in independent-living older adults (5±8%), but it may reach signi®cant
levels (30±60%) among those who live in nursing homes, are homebound, or are
hospitalized.43 In addition to social, psychological and biological factors, age-related
undernutrition is associated with culturally mediated in¯uences leading to dietary
restrictions and poor nutrition in old age.44,45 Sociomedical factors such as housing and
living conditions, economic situation, loneliness and subjective health perception may
in¯uence diet and nutrition.41,46 Some health-related behaviours also may have a
negative e€ect on nutrition e.g. alcohol consumption, use of tobacco products and
reduced motor activity. Indeed, subjects who age successfully have better eating
behaviours and better general health status than those who age unsuccessfully.47
Whereas the dietary intake and nutritional state of community-dwelling older adults
in perhaps not always ideal, many reports have been published pointing to the fact that
severe undernutrition among the hospitalized elderly and elderly in long-term care
facilities is associated with increased morbidity and mortality.45,48±50 Following hospital
discharge, undernutrition predisposes the patient to increased morbidity and mortality.
However, such complications can often be reduced simply by providing nutritional
support.
Can undernutrition in nursing home residents be prevented? Many factors in¯uence
undernutrition, including general health status, cognitive status, degree of immobility,
anorectic medication and the ability to chew and swallow. There are no proven optimal
strategies to normalize nutrition in the elderly or to improve long-term clinical
outcomes and quality of life; however, a better meal environment as well as dietary
supplements my be bene®cial.51,52 The extent to which oral status / improvement of oral
status may in¯uence dietary habits and nutritional status is considered below.

NUTRITIONAL STATUS AND MASTICATORY FUNCTION

Four factors are related to dietary selection and the nutritional status of older
individuals: general health, socioeconomic status, dietary habits and oral health status.
These factors are inter-related, which means that the cause of under- or malnutrition
is normally multifactorial.

Community-dwelling elderly
Is a good masticatory function important for food intake and digestion? This question
has been elucidated by two classical studies.53,54 In the study by Baxter53, the
nutritional intake in three groups of community-dwelling elderly was compared:
wearers of complete maxillary and mandibular dentures, wearers of complete
maxillary and partial mandibular dentures replacing posterior tooth loss and dentate
individuals with at least 20 functional teeth. Whereas the intake of certain nutrients
varied signi®cantly from the recommended allowances, the variations were not related
to the subjects' age or dental status. In the study by Farrell54, chewed and non-chewed
food, placed in small sacks, was swallowed by healthy adult individuals. After having
passed the digestive system the degree of digestion of the food was examined. The
 Nutrition and oral health 891

results showed that chewed and non-chewed food was digested to the same degree
and suggested that masticatory function was not important for nutrition. This may be
true for healthy individuals, but the situation is quite di€erent for elderly individuals.
Indeed, a high incidence of digestive complaints was observed in individuals with a
poor dental status.55 Since prosthetic therapy reduced the symptoms signi®cantly, it
was concluded that poor masticatory function may give rise to digestive symptoms.
The reason for the digestive problems could be that subjects with inadequate dentition
tended to swallow larger food particles.56
Several more recent studies have indicated that oral health status may have
implications for dietary intakes.57±60 Thus, elderly persons wearing complete dentures
tended to have lower intakes of protein and vitamin A and C and a lower intake of
dicult-to-chew food items, such as roots, vegetables, fruits and meat, than those with
natural dentition. Similarly, elderly individuals having a compromised dentition or
wearing complete dentures consumed lower levels of proteins and ®bre, as well as
nutrients such as thiamine, iron, folic acid, vitamin A and carotene.57
In two recent Swedish studies, subjective chewing problems were associated with
poor dental status, de®cient dietary intakes, negative socioeconomic conditions and
self-reported general health problems.46,61 Appollonio et al62 studied the in¯uence of
dental health status on dietary intake, morbidity and survival rate during a 6-year
period in a cohort of 1200 community-dwelling subjects, 70±75 years old living in
Brescia, Italy. They found that subjects with inadequate natural dentition and not
wearing dentures had lower intakes of vitamins, proteins and calories, and a higher
morbidity and mortality rate than did subjects with adequate natural dentition or
edentulous subjects wearing dentures in both jaws. The authors concluded that a
functionally inadequate dental status has a negative impact on the dietary intake of
community-dwelling elderly adults, and that the use of dentures can counteract this
e€ect and is associated with a more satisfactory dietary intake. These ®ndings were
supported in two other studies of independent-living elderly people, showing that the
nutritional quality of the diet fell as the number of teeth declined.59,63

Residents in long-term care facilities

About 60% of residents living in long-term care facilities su€er from undernutrition,
with the major causes being general medical problems, reduced appetite and poor
quality of life.64 However, oral problems such as poor oral hygiene, xerostomia and the
inability to chew are common in frail older adults. Indeed, these are the best predictors
of signi®cant involuntary weight loss.65 In one study, the relationship between general
health, oral health and undernutrition was examined in 324 residents in a long-term
care facility.66 Their functional status was evaluated using the Barthel index and their
nutritional status using the Body Mass Index (BMI) and serum albumin concentration. It
was found that serum albumin level and BMI were reduced in dentate individuals, whose
oral function was compromised by having fewer than six occluding teeth, mobile teeth
or four or more retained roots, and in the edentulous elderly who did not wear
dentures or who wore dentures with defective bases. Using the Mini Nutritional
Assessment, lower scores were observed in edentulous subjects without any or with
just one complete denture, than in edentulous subjects with two dentures or dentate
subjects with or without partial dentures.67 In this study, those with a more
compromised dental situation reported eating more mashed food.
Certain associations have been demonstrated between undernutrition, as indicated
by anthropometric measures, and serum albumin level on the one hand, and loss of
892 E. Budtz-Jùrgensen et al

appetite, reduced stimulated salivary ¯ow rate and impaired masticatory function on the
other.36,41,68 Thus, there was a signi®cant association between low salivary ¯ow rate and
low serum albumin levels, whereas the number of masticatory movements until
swallowing a standard biscuit was increased in patients with low skinfold thickness. It
has also been reported that patients with complaints related to xerostomia report
diculties in chewing and that they tend to avoid the intake of crunchy food such as
vegetables, dry food such as bread, or sticky food such as peanut butter.69 In addition to
problems with eating, xerostomia may also be a negative factor with respect to the
ability of elderly people to communicate and participate in social interaction.70

ORAL HEALTH CARE

Today, primary oral health care for disabled elderly people living in institutionalized or
non-institutionalized settings is poorly developed, even in the highly industrialized and
rich Western countries. The reason may be that dental and oral diseases are not
perceived as conditions that are likely to have a negative e€ect on general health and the
quality of life of old people. This was supported by a recent study of the attitude of
institutional sta€ regarding oral health problems.19 Thus, the management of the
nursing homes was unaware of the oral health situation of the residents, the carers were
poorly informed to understand and take care of the residents' oral and dental health and
there was poor communication between the nursing home and the dentist living in the
area. Furthermore, domiciliary dental care services need to be developed by improving
pre- and post-doctoral training programmes and by establishing a realistic remuneration
for dental teams providing this care.71,72
The planning of dental and prosthetic care and treatment for frail or dependent older
adults in long-term care facilities requires knowledge about the patient's oral and
general health status, as well as information about the existing dental service, including
the sta€'s attitude toward dental care.73 Therefore, the dentist should be integrated into
the health care team and it is also important to include the family in any decision-
making. When planning prosthodontic therapy for frail or dependent elderly people in
order to restore or improve masticatory function, the following issues should be
addressed:
. The treatment plan should be realistic, taking into consideration the resident's
physical and mental situation as well as their present oral health status.
. It is important to consider whether the resident has a perceived need and expressed
demand.
. The dentist should consider the cost±bene®t ratios; that is, the bene®t from the
treatment in terms of improved oral function and quality of life should always be
greater than the mental anguish, physical pain and discomfort experienced during
treatment.
If the resident's life expectancy is limited, palliative treatments are generally
indicated. However, if the life expectancy is several years, a more comprehensive
treatment may be indicated including extraction of now useless teeth and the
implementation of preventive measures to avoid the need for future extractions.
Necessary prosthetic therapy should take place immediately and not be postponed
until a time when the resident may be unable to co-operate.
The caregiver's role in supporting the resident in maintaining daily oral hygiene is
fundamental for the outcome of prosthetic or restorative treatment. This means that if
 Nutrition and oral health 893

Practice points
. impaired or altered taste and smell sensation in older persons is a frequent
complication of general disorders
. elderly individuals with a poor general health status frequently have poor oral
health
. masticatory function in elderly individuals depends on the number of remaining
teeth, the quality of prosthetic restorations, masticatory muscle mass and function
and the salivary ¯ow rate
. assessment of masticatory ability and chewing eciency should be an integral part
of the nutritional assessment of elderly individuals

Research agenda
. the in¯uence of oral health on nutrition and general health needs to be de®ned
. appropriate policies to improve and maintain oral health in frail and dependent
elderly people need to be developed
. appropriate routines to improve or maintain oral health in frail and dependent
elderly have to be implemented

appropriate oral hygiene cannot be maintained, only palliative care should be carried
out. It is, therefore, very important that the caregivers are motivated and trained to
provide the necessary follow-up care to restorative and prosthetic therapy in order for
the patient to bene®t from such therapy.

SUMMARY

In healthy older individuals the intake of nutrients and energy is, by and large,
satisfactory. Furthermore, masticatory function is likely to improve if missing teeth are
replaced by conventional or implant-based prosthodontics.74 In those with an impaired
masticatory function, the food choices may be limited and the oral comfort and quality
of life rather poor without necessarily giving rise to a de®cient nutritional status.
In frail and dependent elderly people the situation is quite di€erent, since they are
often a€ected by proteocaloric undernutrition. Therefore, maintenance or re-
establishment of a proper masticatory function should be considered as an integral
part of the medical health care for these individuals. Indeed, oral comfort and
appropriate masticatory function and nutrition are important for the quality of life of
elderly people.75 The relative importance of oral health and masticatory function
compared with general health and socioeconomic status as factors predisposing for
undernutrition is not known.

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