Nutrition : care in edentulous patient

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Click to edit Master subtitle style Presented by

Dr shria dhaon Mds 2nd year

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Nutrition is interpreted as the study of the organic

process by which an organism assimilates and uses food and liquids for normal functioning, growth and maintenance and to maintain the balance between health and disease. Also included is the idea of an optimal balance of nutrients and whole foods, to enable the optimal performance of the body.

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Terminologies Nutrition:- the science of how the body utilizes food to

meet requirements for development, growth, repair and maintenance

..utilization of food by living organisms

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Diet:

the total oral intake of substance that furnish nourishment and calories Nutrients: are the constituents of food necessary to sustain the normal functions of the body

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Nutrition in denture wearing patient

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Enjoyment of food is regarded as an important determinant of an adults quality of life Loose teeth ,edentulism or ill fitting dentures may preclude eating favorite foods and limit intake of essential nutrients conversely affecting the health of oral tissues

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The National Institute on Aging has judged that in

the area of geriatrics, there is a triad, nutritionhealth-aging, which cannot be separated and are parts of an integral whole.*
It is felt that malnutrition is the antecedent of

disease.Since aging is a life process, good nutrition and health practices must be applied throughout life.
Watkin D: Logical bases for action in nutrition and aging. J Am

Geriatr Soc 26(5): 193-202, 1978 5/1/12

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Decreased chewing ability ,fear of choking while

eating & irritation of oral mucosa under dentures may influence food choices of denture wearer
Caf coronary Nutrition status of patient effects the health of oral

tissues and oral tissue adaptation to new denture

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Factors affecting nutritional status of the elderly

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S Physiologic al changes

Nutrition al status of elderly Psycholo gical or social changes

depression lonliness

Economi cal changes Medicatio n or disease

Sight

Smell Teeth Memory Ability to move

heart disease diabetes, osteoporosis etc.

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Impact Of Dental Status On Food Intake

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Food choices of older adults are closely linked to dental status and masticatory efficiency Loss of teeth often leads adults to select diets that are lower in nutrient density When compared to dentate individuals edentulous consume fewer vegetables , less fibre and carotene and more cholesterol , saturated fat and calories

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Do prostheses affect dietary intake?

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The studies to date, because of the way they were

conducted, provide unclear results. Dentures appear to improve dietary quality somewhat but do not really compensate for loss of teeth.
Papas et al. (1998a) evaluated the impact of full

dentures and noted lower intake of protein and 19 other nutrients. In a separate population, Papas et al. (1998b) reported that subjects who wore dentures consumed more refined carbohydrates, sugar, and dietary cholesterol than their dentate 5/1/12 counterparts.

Importance of Proper Nutrition

Enough intake of essential nutrients to maintain good
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health..
Fat

Carbohydrates

Protein Vitamins Minerals Water

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Nutritional Importance of Carbohydrates

Contributes to 60-70% of total caloric
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requirement

Types of Carbohydrates
Simple

candy, sweets, fruit glucose or fructose molecules

individual

Complex

rice, breads, potatoes of glucose molecules

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Chains

Nutritional Importance of Proteins

Body building food repair n replacement of
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body tissues

fundamental basis of cell structure and its function 10 -15% of total body energy is derived from protein osmotic pressure, clotting of blood, muscle contraction Starvationmajor supplier of energy Types of Amino Acids

Nonessential (14) can be made by body Essential (8) must be made by body
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Sources of Protein

Nutritional Importance of Fats

Provides 9Kcal/g of energy Lipids contains 15-50% of body energy requirement Fat is stored in adipose tissue and serve as energy
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reserve
Protect internal organs, regulate temp, store energy

during starvation
Forms cellular components
Essential Fatty Acids .which body cannot

synthesize

fatty acids- linoleic and linolenic acid5/1/12

Functions of EFA :

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Structural component of biological membrane Participate in transport and utilization of cholestrol Prevent fat accumulation EFA rich food is sunflower oil,cotton seed oil,

soyabean oil,meat ,pork and chicken

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deficiency-

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-impairment in growth and reproduction

-

BMR Toad skin (phrynoderma)- scaly dermatitis, hair loss, poor wound healing

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Nutritional importance of vitamins

Organic substances that regulate numerous and
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diverse physiological processes in the body

Do not contain calories

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Nutritional importance of minerals

Inorganic elements found in food that are essential
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to life processes
About 25 are essential Classified as major or trace minerals Sodium, zinc, iron, fluoride, calcium, phosphorus,

magnesium, potassium

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Functions of Water
Comprises about 60% of body weight Chief component of blood plasma Aids in temperature regulation Lubricates joints Shock absorber in eyes, spinal cord Active participant in many chemical reactions Helps in excretion
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Age (years)

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Water (ml/kg body wt) 120 -100 60 - 80 41 - 55 20 -30

Infants children Adolscent Adult

Birth- 1 0 -10 11- 18 19 - 51

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Why do elderly or aging patients have

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malnutrition??

Factors determine the nutritional status of the geriatric patient :

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Factors affecting nutritional status of the elderly

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Physiologi c changes

Sight Smell taste Teeth Memory Ability to move

Nutrition al status of elderly Psycholo gical or depression social lonliness changes Medicatio n or disease heart disease

Economi cal changes

diabetes, osteoporosis etc.

ENERGY INTAKE OR EXPENDITURE DECREASES HIGHER DEMAND FOR NUTRIENT CONTENT OF DIET

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 Biological concomitants of the aging process Reduced taste and smell acuity accompanies aging The largest study is that by Mattes et al. (1990),

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who evaluated 118 patients with taste distortion and taste loss.
They evaluated that sensory perception of taste

,texture acceptability is rated lowest in complete denture wearers

Ability to sense thirst is reduced,leading

dehydration
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Dry mouth and altered taste decrease PLEASURE of

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Eating.

Eating habits are those of having large amounts of

commercially prepared convenience foods. low in proteins & vitamins.

Such diets are rich in carbohydrates and calories but With aging lean body mass is replaced by

fat,reducing metabolic rate

Energy needs decline due to reduced basal

metabolism and physical activities

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The onset of chronic disease leads to low physical

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activity
Bone loss is normal part of aging,trabecular bone is

affected first
several factors contribute to age related bone loss,

leading to osteoporosis :genetic background

hormonal status bone density low exersice level inadequate nutrition 5/1/12

 Dehydration:

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Major problem in seniors Due to sense of thirst is reduced Water lost by kidneys, intestine , lungs and skin is

2500cc/day must be balanced

Kidney function is depressed in elderly ,due to

glomerular leakage
The filteration system of kidney works hard to

excrete toxic additives and preservatives present in food everyday for years and years
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Kidney must eliminate these toxins if the person has

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to survive ,over years kidney damage is cumulative

Dehydration can affect: Saliva: Impotant for mastication, food is formed into

bolus ,which then swallowed and digested

When salivary flow is low it causes xerostomia or

dry mouth

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Causes: physiologic Menopause Reduce water intake

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Chronic glomerular leakage psychological Depression Disease

DiabetesPernicious anemia , vitamin A and vitamin B deficiency 5/1/12 HIV infection and other auto immune diseases

Medications

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Therapeutic radiations

Anti hyper tensives Anti depressents Anti histamines Broncho dilators Anti parkinsonians Anti spasmodics Anti cholinergics Mouth washes, alcohols
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Clinical symptoms and signs seen by

prosthodontist

skin of the patient is wrinkled with loss of

turgidity is seen
Cornea of the eye is dry,

diminished tear secretion old patient cry inside

Muscle strength is diminished and facial contour

collapse.
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Clinical symptoms and signs seen by prosthodontist Oral mucosa is dry ,hot and fragile Reduced salivary secretion,saliva is thick ,foamy and

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ropey

Gloves sticks to mucosal surface

Materia alba accumulates due to lack of self cleasning

activity

Dorsum of the tongue is fissured*atrophy of filiform

papillae

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Treatment: for patient on medications or radiation

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therapy

Salivary substitute should be provided for relief

which includes :
Sialogogues: sugar free gums , lozenges candies If drug is suspected to be the cause consulting with

physician drug can be alternated or dosage can be modified

.
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 In such cases, measurement of a patient's nonstimulated

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salivary flow rates before and after altering their medication may be useful in gauging the success of treatment.

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Pilocarpine hydrocholoride and Cevimiline

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hydrochloride are commonly used drugs for salivary stimulation and produce clinically significant increase in salivary flow in xerostomic patients

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In severe xerostomic cases, saliva substitutes or

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salivary stimulants may be used.To minimize patient discomfort, soft denture liners can also be used. Often, a combination of treatments may be required.
Saliva substitutes containing thickening agents for

longer relief and increased moistening and lubrication of the oral surfaces have been developed. These are available as solutions, sprays or gels

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contents:

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carboxymethylcellulose, electrolytes and flavoring

agents eg wet mouth (ICPA Health Products Ltd), aqwet (Cipla Ltd)
Main problem is to deliver this substitute constantly

into patients mouth without affecting his normal routine. Where all treatment modalities have proven unsuccessful, the incorporation of artificial salivary reservoir in dentures, has been proposed

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Dentures incorporating metal bases may exhibit

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improved accuracy of fit and effective wetting contributing to better retention Metal based prosthesis are also easier to clean and have less plaque accumulation.
Patients wearing implant supported dentures

report improved oral comfort and function when compared with conventional, mucosa-supported prosthesis.

Removable prosthodontic therapy and xerostomia. Treatment considerations. Joseph J Massad, David R Cagna Dent Today June 2002 ,vol. 21, Issue 6, 80-7.

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Patient treatment for physiologic changes

Milk is also proposed as salivary substitute ,aids in
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lubrication, pleasure eating , buffering action

Additional recommendation: breverages producing

more saliva-water with slice of lemon,lemonade

Diet planning

Patient is advised for bound water intake in form of

soups as they are more effectively absorbed by intestine and carried to tissue cell by vascular system
Vegetable fibres are strongly hydrophilic and also

softens the feces for elderly patient 5/1/12

Dentifrices:

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Biotene and Oralbalance products are available

over-the-counter from Laclede, Inc. (These are antixerostomia dentifrices that contain three salivary enzymes, lactoperoxidase, glucose oxidase and lysozyme, specifically formulated to activate intra-oral bacterial systems
Currently available formulations include:

Biotene Dry Mouth Toothpaste Biotene Gentle Mouthwash

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Calcium deficiency and bone loss

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Bone loss is normal part of

aging that effects maxilla and mandible

Sites where trabecular bone is

more prominent like alveolar bone ,Vertebrae ,Wrist

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Thus, increase bone loss leads to a condition called

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as osteoporosis Osteoporosis causes weak bones., bones looses mineral calcium. They become fragile and break easily. Fracture usually at hip , spine and wrist

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 How can we evaluate??? Dentist is the first to detect Trabecular bone is source of calcium used to

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meet tissue calcium needs

Alveolar bone loss precedes loss of calcium

from the vertebrae and long bones

In a Study done by , Wical & Swoope in 1974,

They found that there was a positive correlation between LOW CALCIUM intake, calcium phosphorus imbalance 5/1/12 & severe ridge

How to get enough calcium everyday??

Treatment:
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Dietary calcium intake is critical Major source of calcium-are milk cheese , Turnips ,calcium fortified fruit juices.

yogurt,green broccoli, salmon and sardines.

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Advice patient to drink 3 or 4 glasses of low fat milk

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everyday
Eat 5- 7 oz of cheese every day Adequate intake of Vitamin D is also

recommended,as it ennhances calcium resorption in intestine

Daily dose of 10g is recommended Sources : fish fish liver oil, egg yolk,sunlight

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In lactate intorlant individuals-calcium supplements

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are recommended

Osteoporotic individuals: Calcium supplements include

Calcium carbonate - 40% Elemental Calcium Calcium citrate - Absorbed BETTER by Older women

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Protein deficiency
In elderly protein depletion of body source is seen as
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decrease in body mass

Muscles account for 45% of body mass which drops

to 27% in old patient

Recommended requirement adult-0.8-1.0 g/kg

body wt.
How will we identify it?? Reduction in muscle mass is more conspicous in

muscles of mastication
There is marked decrease in muscle strength and

bulk

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Treatment: for physiologic factor:

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Patient is advised for mutual supplementation

ie.,cereals,wheat and rice along with pulses like bengal gram ,2-3 servings of 1 cup (cooked)
Other good source is meat ,fish-which can be

advised 2-3 oz
2 eggs per day

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Vitamin and mineral deficiency

RECOMMENDED DIETARY ALLOWANCE (RDA) Represents quantity of nutrients advised daily Vitamin C: RDA for ascorbic acid is 500mg/day Synthesize collagen ,basic structure of tendons and
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pdl

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How will we evaluate??

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Slow healing of wounds ,after extraction Hypermobility of teeth

Edematous oral mucosa Tender & bleeding gingiva

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Treatment

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Dietary sources includes CITRUS fruits, peppers,

melons, KIWI fruit, mangos, papaya & strawberry

Advised dosage is 1 orange,1/2 grapefruit or cup

fruit juice ,2-4 serving /day for 5 days

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Vitamin B complex:

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Folic acid plays an important role in cell division &

RBC formation inadequate intake of folate may result in anemia

How will we evaluate??? Clinical symptoms of sour or metallic taste

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Lips: chelosis

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angular stomatitis inflammation edema magenta tongue atrophy of filiform pappila burning sensation
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Tongue:

Treatment:

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Dietary sources include Oranges , Cantaloupe,

Broccoli, asparagus & dried beans

Recommended 1 cup cooked dry beans 2-3 servings

/day for 10 days

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minerals
Sodium
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Regulates balance of body fluids Nerve function Acid base balance Blood pressure Deficiency.. Headache Weakness, cramps Inc fluid retention in body
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Zinc

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Reqd for digestion n metabolism Wound healing Tissue growth Reproduction Deficiency leads to: Retarded growth Taste/smell alteration Dec immune function
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Iron

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Growth
Immune system health Hb formation Deficiency: Anemia Loss of weight Gastric disturbances Pallor
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Phosphorus

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Formation of bones n teeth Metabolism Muscle activity Acid base balance Deficiency: Weakness, loss of appetite Retarded growth Porous bone
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Minerals and vitamins are in small amount are

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essential to issue health

Many patients can be benefited from dietary

correction and combined with nutritional supplements

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It is often difficult ,based on visual inspection or an Patient should be carefully screened Providing nutrition care for edentulous patient

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interview ,to identify patient need of nutritional care

entails following steps

1. obtain nutritional history,record of food intake over

3-5 days
2 .Evaluate diet,assess nutritional risk 3.Teach about components of diet ,that will supoort

oral mucosa ,bone health and total body health

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4.Help patient to establish goals

Step 1
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Step 2
When record is obtained ,nutrient analysis is obtained
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by either

on a computer with dietary analysis software Or the reported foods can be classified into 5 basic

type described on food pyramid guide

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Step 3
The relationship of diet to the health of oral tissue and
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patients diet evaluation is done

Start with a positive note Explain about bone health and calcium relatonship Use food guide pyramid as a visual tool to educate

patient

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Step 4
Small changes can be incorporated to patients diet
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within the patients budget

A diet precription can be made for the patient The result of diet assessment should always recorded Important detail:advice patient to reduce the daily fat

intake to 20-35% of total calories

Evidence of link between dietary intake of

fat,cholestrol and occurrence of hyperlipidemias

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Dietary counseling for Denture wearers

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Helping new denture wearers learn to chew Diet for the first day after denture insertion : full-

liquid diet
Vegetable fruit group: juices Bread cereal group: gruels cooked in milk or water Milk group: in any form, : pasteurized milk, Meat group:meat broths or soups

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Diet for the 2nd and 3rd day after denture insertion:

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pureed diet to soft diet

Bread/cereal group-cooked cereals, milk, toast and

soften bread, puffed rice

Vegetable group- juices, well cooked carrots, green

beans, mashed potatoes, creamed vegetablesFruit group- well-cooked fruits (no seeds), juices chicken or beef in sauce

Meat group- soft boil eggs, chopped beef, ground liver,

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Diet for the fourth day and later: soft diet to regular

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diet as tolerated eaten

As soon as sore spots are healed, firmer foods can be Best to cut food into small pieces Success of dentures-manage sandwiches and salads of

raw fruit and vegetables

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conclusion
Edentulous patients are particularly vulnerable to
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compromised nutritional health , dietary guidance is an integral part of treatment of denture wearing patient

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bibliography
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Prosthodontic treatment for edentulous patients

zarb and Bolender;12th edi.

Nutrition in clinical dentistry Nizel n Papas;3rd edi Essential of complete denture prosthodontic

Sheldon Wrinkler;2nd ed

Syllabus of complete denture Chales Heartwell Textbook of Biochemistry Satyanarayan

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THANK YOU
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