Abstract

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 MNASF 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.

INTRODUCTION

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).

Inclusion criteria Exclusion criteria Sample Age > 65 yrs Maxillofacial surgery RadiotherapySelf-sufficient Institutionalized patients Systemic diseasesOutcome: nutritional status Self-declaration or interview about nutritional intake Declaration regarding food intake that was not obtained Food diaryBlood examsAnalysis 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 I.Inclusion and exclusion criteria for study selection. 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 denturesIG: 75.3 yrsCG: 78.6 yrs70 randomized, 62 finished the trial at 3 months59 finished the trial at 6 monthsLocation: 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-SFOral 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 jellyOutcome assessment at baseline, at 3 and 6 months post-treatment Between groupsAt 3 months: - Greater intake of chicken, fish with bones, carrots, pumpkins, and in the intake of protein in IG - Intake of proteins, magnesium and vitamin B1 higher in the IG - No differences in MNA-SF score - No difference in the OHIP-EDENT-J scores and in masticatory function At 6 months: - Plant protein intake higher in the IG; - Animal protein and vitamin B12 intakes higher in the CG. - Higher MNA-SF score in the IG Within groupsAt 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 groupsIncomplete blindingNutrient intake based on self-reported questionnaire Awad (2012) Edentulous for a minimum of 5 years, aged > 65 yrs255 randomized, 219 completed 12 months follow upLocation: Montreal (Canada)Period: NR IG: (n.110) IOD and maxillary CDCG: (n.109) CD Primary outcome: blood serum concentration of homocysteineSecondary 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 - No differences at 12 months in the primary and secondary nutritional outcomes - Significant differences in the individuals’ ability to chew a variety of foods Within groups - Decrease of some nutrients (B12, folate) from baseline to 6 and 12 months, in both groups - BMI stable over time in both groups Self-reported chewing abilityIncomplete blinding Hamdan (2013) Same population as Awad 2012255 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 CDCG: (n.114) complete CD Three standard 24-hour dietary recalls by telephone interviewOutcome assessment at baseline and at 12 months post-treatment Between groups - No differences in the intake of total dietary fiber (TDF), energy, macronutrients and 9 micronutrient Nutrient intake based on self-reported questionnaireIncomplete blindingSame Trial Registration Number as Awad 2012 McKenna (2014 and 2015)/Wallace (2018) Partially dentate patientsaged >65 yrs132 randomized, 89 finished the trial at 12 monthsLocation: 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-SFA range of haematological markersChewing ability: two coloured chewing gum.Outcome assessment at baseline and at 1,6 and 12 months post-treatment Between groups - No differences for all haematological markers, for MNA score and for chewing ability Within groups - Improvement in Vit.D levels and MNA score at 12 months in both groups. - Improvement in chewing ability at 12 months in both groups. Self-reported dietary intakeIncomplete blinding Morais (2003) Edentulous for a minimum of 5 years, aged65-75 yrs60 randomized, 56 finished the trial at 6 monthsLocation: Montreal (Canada)Period: NR IG: (n.29) IOD and maxillary CDCG: (n.27) conventional CD Food diary.BMI, various anthropometric measuresA range of haematological markers.Self reported chewing abilityOutcome assessment at baseline and at 1and 6 months post-treatment Between groups - No differences for all haematological markers, nutrient intake and anthropometric data Within groupsSome hematological markers (B12, Albumin), some anthropometric measures and some questions on masticatory functions improved post-treatment, more frequently in the IG Self-reported dietary intakeIncomplete 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 II.Characteristics and main results of included Randomized Controlled Trials. Author (year) Participants, location and period Objective Outcomes and measurements Synthesis of main results Comments Prospective cohort studiesNabeshima (2018) Partially dentate patients scheduled to receive new removable partial dentures (RPD) at a dental hospitalN.38 selected, 32 analysedMean 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 withRPDs 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 BDHQBlood samples: carotenoids and vitamin C in 6-hour fasting blood samplesQuestionnaire and blood samples at baseline (before RPD), and at 1 and 3 months after RPD At univariate analysis: - mean vegetable intake increased significantly at 3 months after treatment, from 249 to 323 g/day - mean fruit intake did not change substantially, from 162 to 173 g/day at 3 months (univariate analysis) - serum carotenoids and vitamin C levels measured with 6-hour fasting blood samples remained constant Self-reported food intakeSmall sample sizeThe 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 yrsN.150 analyzedLocation: 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 rehabilitation34.7% 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: - 47.3% underweight (BMI < 18.5), - 32.7% at risk of malnutrition (MNA score 17-23.5) and 16.7% malnourished (MNA score < 17) At the univariate analysis, improvement in the MNA and BMI after 6 and 12 months from prosthetic rehabilitation Self-reported dietary intakeInformation on comorbidities, educational level, socio-economic status not collected Cross-sectional surveysChoi (2014) Subjects aged >= 65 yearsN. 722Median age: nrWomen: 58.2Location: KoreaPeriod: 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 questionnaire24-h dietary recall methodProsthodontic 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 studyN.760Age 79-81 yrsWomen: 52.1%Location: two regions of JapanPeriod: 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 baselinevisit of Japanese octogenarians included in the prospective cohort study “SONIC”Oral examination to evaluate: -number of teeth - bilateral maximal occlusal force (grouped by tertiles) in the intercuspal position using pressure-sensitive sheets Food intake (Diet during the preceding month): brief-type self-administered diet history questionnaire (BDHQ) 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 number of teeth was not associated with the energy-adjusted intake of any food group examined - a decline in occlusal force was significantly associated with a lower intake of vegetables, fish and shellfish, protein, polyunsaturated fatty acids, dietary fiber and most vitamins and minerals 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 andinsured medically with two of the four health funds.N.1776Mean age NRWomen: NRLocation: IsraelPeriod: 2005-2006 To assess the impact of dental status and visits on dietary intake of the Israeli elderly Study based on data collectedfrom 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 subjectivedental 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: - elderly who had no dentures had significantly better intakes of 4 out of 5 parameters - energy, fiber, protein and vegetables than the elderly with dentures 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 independentlyN. 3134Median age:71.0 yrWomen: 49.2Location: JapanPeriod: 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 forceThe baseline health examination included a dental examination, measurement of occlusal force, measurement of height and body weight, blood collection, and a questionnaire about lifestyleNutritional 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 - among males, no association between reduced number of teeth and maximum occlusion force and the nutritional indices -among females: a maximum occlusal force of 100 to 300 N or less than 100 N were associated with serum albumin levels below 4.4 g/dL, not with BMI below lower quartile. No consistent association between number of teeth and nutritional indices No differences in nutritional indices for people with or without occlusal support in the molar regionIn both males and females, the maximum occlusal force decreased significantly with the number of teeth Stoffel (2018) Individuals 65-74 yrs residing in householdsN.287Mean 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 MNADemographic, 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 helpN.294Mean 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-SFDemographic characteristics, eating habits, dental status (complete denture:CD, partial denture: PD, no denture:ND) and health status: self completed questionnaireTaste sensitivity: salt-impregnated taste paper testBMI and protein mass: bioelectrical impedance analysis Response rate = 95% (294/310)64.3% wore PD, 9.9% wore CD23.5% 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 CDSelf-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. Table III.Characteristics and results of included observational studies (Prospective cohort or Cross-sectional survey). ReferencesBuckner DM, Wagner EH. Preventing frail healt. Clin Geriatr Med. 1992; 8:1-17. De Jong N. Nutrition and senescence: health aging for all in the new millennium. Nutrition. 2000; 16:537-549. DOI Santilli V, Bernetti A, Mangone M. Clinical definition of sarcopenia. Clin Cases Miner Bone Metab. 2014; 11:177-180. Cooper C, Dere W, Evans W. Frailty and sarcopenia: definitions and outcome parameters. Osteoporos Int. 2012; 23:1839-1848. DOI Kim JS, Wilson JM, Lee SR. Dietary implications on mechanisms of sarcopenia: roles of protein, amino acids and antioxidants. J Nutr Biochem. 2010; 21:1-13. DOI Douglass CW, Shih A, Ostry L. Will there be a need for complete dentures in the United States in 2020?. J Prosthet Dent. 2002; 87:5-8. DOI Feine JS, Carlsson GE, Awad MA. The McGill consensus statement on overdentures. Mandibular two-implant overdentures as first choice standard of care for edentulous patients. Gerodont. 2002; 19:3-4. Hutton B, Feine J, Morais J. Is there an association between edentulism and nutritional state?. J Can Dent Assoc. 2002; 68:182-187. N’gom PI, Woda A. Influence of impaired mastication on nutrition. J Prosthet Dent. 2002; 87:667-673. DOI Walls AW, Steele JG. The relationship between oral health and nutrition in older people. Mech Ageing Dev. 2004; 125:853-857. DOI Awad MA, Morais JA, Wollin S. Implant overdentures and nutrition: a randomized controlled trial. J Dent Res. 2012; 91:39-46. DOI Hamdan NM, Gray-Donald K, Awad MA. Do implant overdentures improve dietary intake? A randomized clinical trial. J Dent Res. 2013; 92:146S-153S. DOI Morais JA, Heydecke G, Pawliuk J. The effects of mandibular two-implant overdentures on nutrition in elderly edentulous individuals. J Dent Res. 2003; 82:53-58. DOI McKenna G, Allen PF, O’Mahony D. Comparison of functionally orientated tooth replacement and removable partial dentures on the nutritional status of partially dentate older patients: a randomised controlled clinical trial. J Dent. 2014; 42:653-659. DOI McKenna G, Allen PF, O’Mahony D. Impact of tooth replacement on the nutritional status of partially dentate elders. Clin Oral Investig. 2015; 19:1991-1998. DOI Wallace S, Samietz S, Abbas M. Impact of prosthodontic rehabilitation on the masticatory performance of partially dentate older patients: Can it predict nutritional state? Results from a RCT. J Dent. 2018; 68:66-71. DOI Amagai N, Komagamine Y, Kanazawa M. The effect of prosthetic rehabilitation and simple dietary counseling on foodintake and oral health related quality of life among the edentulous individuals: a randomized controlled trial. J Dent. 2017; 65:89-94. DOI Suzuki H, Kanazawa M, Komagamine Y. The effect of new complete denture fabrication and simplified dietary advice on nutrient intake and masticatory function of edentulous elderly: a randomized-controlled trial. Clin Nutr. 2018; 37:1441-1447. DOI Kanazawa M, Suzuki H, Komagamine Y. Combined effects of new complete denture fabrication and simplified dietary advice on nutrient intake in edentulous elderly patients for 6 months. Clin Oral Investig. 2019; 23:2245-2252. DOI Suzuki H, Kanazawa M, Komagamine Y. Influence of simplified dietary advice combined with new complete denture fabrication on masticatory function of complete denture wearers. J Oral Rehabil. 2019; 46:1100-1106. DOI Tanasić I, Radakoví T, Tihaˇcek-Sˇojí L. Effect of Prosthetic Rehabilitation on Nutritional Status in Older Adults. Top Clin Nutr. 2017; 32:330-339. Nabeshima G, Fueki K, Inamochi Y. Effect of dietary counselling with prosthetic restoration on fruit and vegetable intake in partially dentate patients: a prospective study. J Oral Rehabil. 2018; 45:618-626. DOI Choi YK, Park DY, Kim Y. Relationship between prosthodontic status and nutritional intake in the elderly in Korea: National Health and Nutrition Examination Survey (NHANES IV). Int J Dent Hyg. 2014; 12:285-290. DOI Inomata C, Ikebe K, Okubo H. Dietary intake is associated with occlusal force rather than number of teeth in 80-y-old Japanese. JDR Clin Trans Res. 2017; 2:187-197. DOI Natapov L, Kushnir D, Goldsmith R. Dental status, visits, and functional ability and dietary intake of elderly in Israel. Isr J Health Policy Res. 2018; 7:58. DOI Okamoto N, Amano N, Nakamura T. Relationship between tooth loss, low masticatory ability, and nutritional indices in the elderly: a cross-sectional study. BMC Oral Health. 2019; 19:110. DOI Stoffel L, Muniz F, Colussi P. Nutritional assessment and associated factors in the elderly: a population-based cross-sectional study. Nutrients. 2018; 55-56:104-110. DOI Su Y, Yuki M, Hirayama K. Denture wearing and malnutrition risk among community-dwelling older adults. Nutrients. 2020; 12:151. DOI Gaewkhiew P, Sabbah W, Bernabé E. Does tooth loss affect dietary intake and nutritional status? A systematic review of longitudinal studies. J Dent. 2017; 67:1-8. DOI Di Francesco V, Zamboni M, Zoico E. Unbalanced serum leptin and ghrelin dynamics prolong postprandial satiety and inhibit hunger in healthy elderly: another reason for the “anorexia of aging. Am J Clin Nutr. 2006; 83:1149-1152. DOI Nieuwenhuizen WF, Weenen H, Rigby P. Older adults and patients in need of nutritional support: review of current treatment options and factors influencing nutritional intake. Clin Nutr. 2010; 29:160-169. DOI Wysokinski A, Sobow T, Kłoszewska I. Mechanisms of the anorexia of aging: a review. Age (Dordr). 2015; 37:9821. DOI Stewart R, Sabbah W, Tsakos G. Oral health and cognitive function in the Third National Health and Nutrition Examination Survey (NHANES III). Psychosom. Medicine. 2008; 70:936-941. DOI Whitelock E, Ensaff H. On your own: older adults’ food choice and dietary habits. Nutrients. 2018; 10:413. DOI Jones N, Bartlett HE. Comparison of the eating behaviour and dietary consumption in older adults with and without visual impairment. B J Nutr. 2020; 123:712-720. DOI Ortinau LC, Culp JM, Hoertel HA. The effects of increased dietary protein yogurt snack in the afternoon on appetite control and eating initiation in healthy women. Nutr J. 2013; 12:71. DOI Vandenberghe-Descamps M, Laboure H, Prot A. Salivary flow decreases in healthy elderly people independently of dental status and drug intake. J Tex Stud. 2016; 47:353-360. Matsuo R. Role of saliva in the maintenance of taste sensitivity. Crit Rev Oral Biol Med. 2000; 11:216-229. DOI Pflipsen M, Zenchenko Y. Nutrition for oral health and oral manifestations of poor nutrition and unhealthy habits. Gen Dent. 2017; 65:36-43. Bezerra AP, Gama LT, Pereira LJ. Do implant-supported prostheses affect bioavailability of nutrients of complete and partially edentulous patients? A systematic review with meta-analysis. Clin Nutr. 2021; 40:3235-3249. DOI Yamazaki T, Martiniu AL, Irie K. Does a mandibular overdenture improve nutrient intake and markers of nutritional status better than conventional complete denture? A systematic review and meta-analysis. BMJ Open. 2016; 6:E011799. DOI McGowan L, McCrum LA, Watson S. The impact of oral rehabilitation coupled with healthy dietary advice on the nutritional status of adults: a systematic review and meta-analysis. Crit Rev Food Sci Nutr. 2020; 60:2127-2147. DOI de Oliveira Simões M, Carvalho Dumith S, Vitola Gonçalves C. Adults and the elderly who received nutritional counseling in a city of southern Brazil: a population-based study. Rev Bras Epidemiol. 2019; 22:E190060. DOI Antoniadou M, Varzakas T. Breaking the vicious circle of diet, malnutrition and oral health for the independent elderly. Crit Rev Food Sci Nutr. 2020; 20:1-23. DOI Baugreet S, Hamill RM, Kerry JP. Mitigating nutrition and health deficiencies in older adults: a role for food innovation?. J Food Sci. 2017; 82:848-855. DOI Schwartz C, Vandenberghe-Descamps M, Sulmont-Rosse C. Behavioral and physiological determinants of food choice and consumption at sensitive periods of the life span, a focus on infants and elderly. Innov Food Sci Emerg Tech. 2018; 46:91-106. Houston DK, Nicklas BJ, Ding J. Dietary protein intake is associated with lean mass change in older, community-dwelling adults: the Health, Aging, and Body Composition (Health ABC) study. Am J Clin Nutr. 2008; 87:150-155. DOI Yanai H. Nutrition for sarcopenia. J Clin Med Res. 2015; 7:926-931. DOI Paddon-Jones D, Campbell WW, Jacques PF. Protein and healthy aging. Am J Clin Nutr. 2015;101. DOI Mahdavi-Roshan M, Ebrahimi M, Ebrahimi A. Magnesium, zinc and calcium status in osteopenic and osteoporotic post-menopausal women. Clin Cases Min Bone Metab. 2015; 12:18-21. DOI Higgs J, Derbyshire E, Styles K. Nutrition and osteoporosis prevention for the orthopaedic surgeon: a wholefoods approach. EFORT Open Rev. 2017; 2:300-308. DOI Gennari C. Calcium and vitamin D nutrition and bone disease of the elderly. Public Health Nutr. 2001; 4:547-559. DOI Ilesanmi-Oyelere BL, Kruger MC. Nutrient and dietary patterns in relation to the pathogenesis of postmenopausal osteoporosis – a literature review. Life (Basel). 2020; 10:220. DOI Melse-Boonstra A. Bioavailability of micronutrients from nutrient-dense whole foods: zooming in on dairy, vegetables, and fruits. Front Nutr. 2020; 7:101. DOI