Inuence of denture improvement on the nutritional status

and quality of life of geriatric patients

Bernd Wo stmann
a,
*, Karin Michel
a
, Bernd Brinkert
b
, Andrea Melchheier-Weskott
b
,
Peter Rehmann
a
, Markus Balkenhol
a
a
Department of Prosthodontics, Justus-Liebig University, Schlangenzahl 14, D-35392 Gieen, Germany
b
Private Practice, Olfen, Germany
1. Introduction
Several studies have described a correlation between the
dental status, the masticatory performance
1
and the nutri-
tional status of elderly patients.
25
Although masticatory
performance tends to decline with decreasing number of
teeth, the relationship between masticatory function and
impaired food intake has been established more rarely for
partially edentulous than for fully edentulous patients.
6,7
Several studies report that an impaired ability to chew has
a negative effect on food selection and diet
810
which is not
necessarily reected by the haematological analysis of
j our na l of d e nt i s t r y 3 6 ( 2 0 0 8 ) 8 1 6 8 2 1
a r t i c l e i n f o
Article history:
Received 4 March 2008
Received in revised form
25 May 2008
Accepted 31 May 2008
Keywords:
Masticatory function
Nutritional status
Oral health-related quality of life
Denture improvement
a b s t r a c t
Recent research suggests that there is a correlation between nutrition, oral health, dietary
habits, patients satisfaction and their socio-economic status. However, the dependent and
independent variables have remained unclear.
Objective: This exploratory interventional study aimed to identify the impact of denture
improvement on the nutritional status as well as the oral health-related quality of life in
geriatric patients.
Materials and methods: Forty-seven patients who were capable of feeding themselves (mini-
mum age: 60 years) and with dentures requiring repair or replacement were selected from a
random sample of 100 residents of two nursing homes. Before and 6 months after the
dentures were optimised a Mini Nutritional Assessment (MNA) and a masticatory function
test were carried out. Nutritional markers (pre-albumin, serum albumin, zinc) were deter-
mined and an OHIP-G14 (Oral Health Impact Prole, German version) was recorded in order
to determine the effect of the optimised oral situation on the patients nutritional status and
oral health-related quality of life.
Results: Despite the highly signicant improvement in masticatory ability after the opti-
misation of the dentures, no general improvement regarding the nutritional status was
observed since the albumin, zinc and MNA values remained unchanged and pre-albumin
even decreased.
Conclusion: Since masticatory ability and masticatory efciency are not the only factors
affecting this, prosthetic measures alone apparently cannot effect a lasting improvement in
nutritional status as masticatory ability and masticatory efciency are not the only factors
of inuence. Nutrition is not only a matter of masticatory function, but also depends on
other inuencing factors (e.g. habits, taste and cultural customs as well as nancial and
organisational aspects).
# 2008 Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: +49 641 99 46143; fax: +49 641 99 46139.
E-mail address: Bernd.Woestmann@dentist.med.uni-giessen.de (B. Wo stmann).
avai l abl e at www. sci encedi r ect . com
j our nal homepage: www. i nt l . el sevi er heal t h. com/ j our nal s/ j den
0300-5712/$ see front matter # 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jdent.2008.05.017
nutrition markers.
11
Although some authors demonstrated
that masticatory performance does not affect general health,
12
recent research suggests that there is a correlation between
nutrition, oral health, dietary habits, patients satisfaction and
their socio-economic status. However, the dependent and
independent variables remain unclear.
1316
Most patients tend to overestimate considerably the
condition of their dentition and nutritional status. Conse-
quently, noticeable discrepancies between the subjective self-
estimation of patients and objective evaluation of the dental
status have been reported.
17,18
In general, masticatory performance and oral health-
related quality of life improve after optimising prosthetic
restorations,
3,19
as reported in some studies. However,
nutritional habits do not change signicantly.
20
Nevertheless,
it remains unclear whether improving a conventional pros-
thetic restoration affects the nutritional status, especially the
blood-derived values of key nutrients.
13
The objective of the
present study was hence to identify the impact of improve-
ments in the prosthetic restorationonthe nutritional status as
well as the oral health-related quality of life.
The following two-fold null hypothesis was tested: opti-
mising the condition of the prosthetic restoration does not
improve the nutritional status (1) or the oral health-related
quality of life of geriatric patients (2).
2. Methods
2.1. Patients
The dental status was examined and categorised in 100
randomly selected residents (age over 60) of two nursing
homes in Olfen and Lu dinghausen, Germany (Table 1) using a
four-grade evaluation scale.
21
Additionally, a medical history
was recorded. The patients received a set meal for lunch and
dinner but had the opportunity to ask for additional items of
their choice. For breakfast, they could also select from
different items.
Fromthe randomsample, the patients whose dental status
was classied as being in need of improvement (Table 1,
categories 3 and 4) and who were capable of feeding
themselves (n = 47; 19 male = m and 28 female = f) were
selected for this study. Patients addicted to medication,
alcohol and/or drugs, suffering from malignant tumours,
undergoing radiation therapy or who were unwilling to
consent or incapable of consenting to participate in the study
were excluded (n = 13; 6 m/7 f), thus leaving a total of 34
patients (13 m/21 f) for inclusion.
Five patients (1 m/4 f) were provided with newfull dentures,
12 receivednewremovable partial dentures (4 m/8 f) and3 (1 m/
2 f) a new xed restoration. In 14 cases (7 m/7 f), the existing
restorations were optimised. In all patients, a follow-up
examination was completed 6 months after treatment. The
investigators (two dentists) were calibrated prior to the study.
The study was approved by the Ethics Committee of the
Justus Liebig University, Giessen (Germany).
2.2. Methods
Both at the baseline examinations and at follow-up after 6
months, the dental status was evaluated and the following
tests were performed:
Mini Mental Status (MMS)
22
according to Folstein;
Mini Nutritional Assessment (MNA)
23
;
Serum parameters: Ten millilitres of blood were taken from
each patient to determine the serum values of pre-albumin,
serum albumin and zinc. All blood samples were taken
between 8 and 9 a.m. All patients had fasted for 12 h prior to
sampling. Albumin and pre-albumin were measured by
nephelometry, and zinc by atom absorption spectrometry;
OHIP-G14
24,25
;
A test of masticatory function in order to evaluate the
masticatory efciency.
26
2.2.1. MMS according to Folstein
The MMS
22
is a screening test for dementia diseases which
tests time and 3D orientation, memory, ability to concentrate
(attention, and ability to remember) and the coordination
capacity. A maximum of 30 points is awarded in this test.
Scores of 1823 points indicate slight cognitive limitations and
scores lower than18 points signal severe cognitive limitations.
2.2.2. Mini Nutritional Assessment
The MNA
23,27,28
is a validated screening method for identifying
theriskof malnutritionor decient nutritionaswell asverifying
an insufcient level of nutrition. The assessment consists of 18
parameters (questions relating to the history, anthropometric
data) witha maximumtotal of 30 points. Scores between17and
23.5 indicate a risk of decient nutrition whereas scores lower
than 17 are usually an indication of malnutrition.
2.2.3. Serum parameters
Albumin, pre-albuminandzinc are considered to be important
nutritional markers. Albumin, which represents approxi-
mately 60% of the total plasma protein, maintains the colloid
osmotic pressure in plasma, transports and stores multiple
ligands and acts as a source for endogenous amino acids. The
standard level in serum ranges between 3.5 and 5.5 g/dl.
29,30
Pre-albumin is a transport protein for vitamin A and
thyroxine. Its standard level in serum ranges between 16 and
35 mg/dl.
29
Zinc is an essential micro-nutrient required for DNA
synthesis, cell division and protein synthesis. Approximately
300 enzymes are known to contain zinc. It is assumed that
several hundred nucleoproteins containing zinc are involved
Table 1 Evaluation of the dental status
Score Description
1 Dentition/prosthesis in excellent clinical condition
2 Dentition/prosthesis in acceptable clinical condition
a
3 Dentition/prosthesis requires treatment/repair/
modication to prevent harm to the patient
4 Dentition/prosthesis is seriously defective and
actually harms the patient, requiring immediate
treatment/repair/modication
a
Minimal deficits which do not require treatment.
j o ur na l o f d e nt i s t r y 3 6 ( 2 0 0 8 ) 8 1 6 8 2 1 817
in the gene expression of various proteins. The standard level
in serum ranges between 0.5 and 1.5 mg/ml.
31,32
2.2.4. Oral Health Impact Prole
The OHIP-14 is a valid, reliable and widely used short version of
the OHIP instrument normed for older adults.
25,33
The abridged
Germanversion(OHIP-G14) was used inthis study.
24
The OHIP-
14providesthreesummaryscores: aseverityscorerepresenting
the sumof all ratings; anextent score representing the number
of items rated fairly often or often and a prevalence score
representingthosepatientswhoratedat least oneitemasfairly
often. The severity score is the overall measure of the OHIP
whereas the prevalence score characterizes the proportion of
patients with at least some impact. The magnitude of this
impact is characterized by the extent score.
34
2.2.5. Masticatory efciency test
The test method (MET) described by Wo stmann, Nguyen and
Wickop was employed to analyze the masticatory efciency.
26
This involves having the patient chew a standardized cube of
carrot (2 cm 2 cm 1 cm) as small as possible within45 s but
without swallowing a single part of it. The chewed pieces of
carrot are then collected in a Petri dish and the degree of their
breakdown(grade 1: breakdown = ne-grade 6: breakdownnot
possible) is evaluated visually by comparison with a reference
scale.
26
The comparison was done by the calibrated investi-
gators. The patients masticatory efciency was rated as 1 very
high, 2 high, 3 average, 4 reduced, 5 low, 6 poor.
2.3. Statistical analysis
Prior tothe study a power calculationwas performedtoidentify
the necessary number of subjects to be included. Serum
albumin level was selected as the primary target variable.
Based on the ndings of Chai et al.,
35
who reported a difference
in serum albumin of about 3 6 g/l in geriatric patients with
different dental status, 33 patients (power = 0.80; a = 0.05) were
calculated to be necessary to identify this difference. Since we
assumed that not all residents of the nursing homes in our
investigation were either in need of treatment or that not all
would be willing to participate in the study, we decided to start
with a three-fold sample size of 100 patients.
All data sets for MNA, serum albumin, pre-albumin and
zinc were subjected to a Kolmogorov-Smirnov test ( p = 0.05) to
check for normal distribution and the Levene test to check for
homogeneity of variance ( p = 0.05). As the values were
normally distributed, signicant differences were identied
between paired sample groups using the t-test ( p = 0.05).
Additionally, a Tukey post-hoc analysis was carried out to
identify differences between the subgroups. For statistical
evaluation of data with an ordinal level of measurement (MET,
OHIP-G14), the Wilcoxon matched pairs test was used.
All data analysis was carried out with the software
packages SPSS 13.0 and BIAS 8.1.
3. Results
The meanage of the patients inthis study was 72.6 (6.7) years
with a residual dentition of 7.4 (7.6) teeth (Tables 2 and 3). At
baseline, the dentures were 10.1 (7.3) years old. An ill-tting
denture base was the most frequent reason for treatment
(58.8%).
The MMSremainedunchangedat baseline andat follow-up
for all patients. The average MNA (Table 4) value increased
only slightly from 25.5 3.7 (baseline) to 25.8 3.6 at follow-
up ( p > 0.05).
Prior to treatment, the albumin values of two patients were
below the normal range. At follow-up, the albumin values
were all within the standard limits. One patient exhibited a
low pre-albumin value at baseline and at the follow-up
appointment. The serum concentration of zinc did not
increase signicantly after the treatment; no serum zinc
values outside the standardlimits were observed. Pre-albumin
and albumin were signicantly lower in edentulous patients
than in the group with more then 10 teeth at follow-up
( p < 0.05, Tukey test, Table 5).
At baseline, 16 patients were only able to break down the
carrot cube very slightly (grade 5, n = 8) or not at all (grade 6,
n = 8). At follow-up, only one patient was completely unable to
Table 2 Patient characteristics
Age Patients (n) [m/f]
6064 5 [2/3]
6569 5 [1/4]
7074 15 [5/10]
7579 5 [4/1]
8085 4 [1/3]
8590 0
Cognitive Limitations (MNS)
None 19 [7/12]
Slight 8 [2/6]
Severe 7 [4/3]
Overall 34 [13/21]
Table 3 Dental status at baseline and follow-up
Description Patients (n) [m/f] at baseline Patients (n) [m/f] after treatment
Edentulous 11 [3/8] 13 [3/10]
110 remaining teeth 11 [5/6] 11 [5/6]
Full denture in one jaw, xed/removable in the other 3 [3/0] 3 [3/0]
No full denture 8 [2/6] 8 [2/6]
More than 10 remaining teeth 12 [5/7] 10 [5/5]
Full denture in one jaw, xed/removable in the other 2 [1/1] 2 [1/1]
No full denture 10 [4/6] 8 [4/4]
Overall 34 [13/21] 34 [13/21]
j our na l of d e nt i s t r y 3 6 ( 2 0 0 8 ) 8 1 6 8 2 1 818
chew the carrot cube and two patients were only able to break
it down slightly (Table 6). The masticatory efciency score
therefore decreased (=increase in performance) signicantly
overall from 4.1 to 3.1 ( p < 0.001).
As no OHIP-G14 data was collected from the 7 patients (3
edentulous subjects, 2 with less than 10 and 2 with more
than 10 teeth) with severe cognitive restrictions, only 27
patients were evaluated. Although the results of this
questionnaire varied slightly, no signicant differences were
observed between baseline and follow-up for the severity
score 23.9 (4.0) vs. 23.8 (3.8), for the prevalence (35.2% vs.
33.4%) and for all single items. The biggest change (0.3) was
observed in item 4 (uncomfortable to eat any foods because of
problems with mouth or dentures) whereas the items 3 ( pain), 5
(self-concious because of mouth or dentures) and 7 (diet
unsatisfactory) remained completely unchanged. Only the
extent score decreased signicantly from 3.6 1.5 to
2.7 1.3 ( p < 0.05).
4. Discussion
In several studies, a correlation between the condition of the
dentition, the masticatory performance
1
and the nutritional
status of elderly patients
25
has been observed. However,
information about the effect of denture improvement on the
nutritional status is lacking, especially regarding blood-
derived values of key nutrients.
13
The present study was
hence designed to identify the impact of improvements in the
prosthetic restoration on the nutritional status as well as the
oral health-related quality of life.
Optimising the dental status leads to improved masticatory
efciency and conrms previously reported ndings.
36,37
The
masticatory efciency test used in this study is somewhat
limited as chewed samples are compared visually to reference
pictures rather than being measured. However, it is a method
which is easy to use and has proven its suitability in previous
studies
38
and the data obtained is considered reliable.
A further advantage of this masticatory efciency test is
that the carrot cubes are well accepted for test chewing.
Previous studies have also shown that elderly patients tend to
reject other kinds of test food.
38
Despite the increase in masticatory efciency, no funda-
mental improvement in the other test variables was apparent
after the optimised restorations had been in situ for 6 months.
The null hypothesis could hence not be rejected. Several
studies showed similar results even though the methods used
were different.
2,3,5,26
The change in dietary habits resulting from a declining
masticatory performance over a period of years must not be
underestimated. This change is unlikely to be reversed even
though the masticatory efciency is improved.
2,19,39,40
It is
rather the socio-economic status (e.g. nancial and organisa-
tional aspects) and factors such as habits and above all the
individuals taste which play a more important role for the
selectionof food than does the availability of foodstuffs.
20,4143
Although the patients in this study could ask for additional
food items to their set meals, they were very probably not
offered an adequate diversity that could have allowed themto
explore their new-found chewing efciency. As we wanted to
establish whether a patient who is given the opportunity to
select additional food items to augment his set meal makes
Table 4 Changes in MNA-Scores
MNA score
(mean S.D.)
Baseline Follow-up
Edentulous (n = 13) 24.2 3.9 24.8 3.4
110 remaining teeth (n = 11) 26.8 1.6 27.1 1.7
More than 10 remaining teeth (n = 10) 25.6 4.6 25.3 3.6
Overall (n = 34) 25.5 3.7 25.8 3.6
No signicant differences between baseline and follow-up
( p > 0.05 paired t-test; applies to rows); no signicant differences
between subgroups ( p > 0.05 Tukey post-hoc test; applies to
columns).
Table 5 Changes in serum albumin, pre-albumin and zinc recorded at baseline and follow-up investigation
Serum albumin
(mean S.D.) [g/dl]
Pre-albumin
(mean S.D.) [mg/dl]
Zinc (mean S.D.)
[mg/ml]
Baseline Follow-up Baseline Follow-up Baseline Follow-up
Edentulous (n = 13) 3.94 0.38 4.05 0.36
a
27.31 112.49 22.07 7.89
a
0.80 0.17 0.89 0.16
110 remaining teeth (n = 11) 4.21 0.61 4.22 0.44 37.88 12.64 27.00 7.89 0.92 0.12 0.82 0.20
More than 10 remaining teeth (n = 10) 4.18 0.25
*
4.55 0.44
*,a
33.86 15.32
a
29.88 8.11
*,a
0.85 0.10 0.91 0.19
Overall (n = 34) 4.1 0.45 4.25 0.45 32.22 13.67
*
25.63 7.18
*
0.86 0.14 0.89 0.18
*
Difference between baseline and follow-up significant, p < 0.01 paired t-test (applies to rows).
a
Difference between subgroups significant, p < 0.05 Tukey post-hoc test (applies to columns).
Table 6 Changes in masticatory efficiency between
baseline and follow-up
Masticatory efciency
score
a
Baseline Follow-up
Edentulous (n = 13) 4.6 1.6 3.3 1.3
110 remaining teeth (n = 11) 3.8 1.6 3.0 0.8
More than 10 remaining teeth (n = 10) 3.4 1.3 2.9 0.9
Overall (n = 34) 4.0 1.6
*
3.1 1.1
*
*
Difference between baseline and follow-up significant, p < 0.01
Wilcoxon matched pairs test.
a
1: very high, 2: high, 3: average, 4: reduced, 5: low, 6: poor
masticatory efficiency.
j o ur na l o f d e nt i s t r y 3 6 ( 2 0 0 8 ) 8 1 6 8 2 1 819
use of his improved masticatory ability, carers were not asked
to provide the patient withanother diet after the improvement
of the dental status. Only the patients were advised to ask for
food items they had probably avoided before the dental
treatment because of their reduced masticatory performance.
In addition, even non-institutionalized patients are often
obliged to stick to a special diet due to systemic diseases.
43
Thus, simply replacing missing teeth is by no means adequate
for improving nutritional behaviour.
19,44
Simultaneous dietary
consulting and prosthetic treatment in combination may
improve dietary habits as has been shown by Bradbury et al.
45
inrespect of fruit and vegetable intake. Althoughthere is some
evidence that the nutritional status in edentulous subjects
may improve after they are provided an implant-retained
denture,
46
which can be regarded as the most likely setting for
obtaining signicant improvements, more research is desir-
able to clarify this.
The signicant reduction in the pre-albumin score at
follow-up was unexpected. On the other hand, a small
increase in albumin scores could be observed. Consequently,
it is hypothesised that the pre-albumin reduction may be
fortuitous. We selected pre-albumin as a sensitive marker for
this study as it has a half-life of about 48 hcompared to 19 days
for albumin. The short half-life pre-albumin values are much
more exposed to chance changes in food intake. In view of
this, albumin may probably be regarded as the more reliably
marker. Additionally, it has to be considered that the patients
in our study were in a much better nutritional state than we
had expected. This made a perceivable improvement even
more unlikely. Considered retrospectively, it might have been
wise to include a nutrition diary in the study. However, when
planning the study we decided against a nutrition diary as we
wanted to record hard values unbiased by cognitive
limitations of the patients and possible noncompliance or
forgetfulness on the part of the carers.
The OHIP-G14 severity results clearly demonstrate that the
patients experienced a limited oral health. However, they did
not consider the problems with their dentures to be of prime
signicancewhichisreectedbythefact that sevenpatientsdid
not want to have their dentures optimised and had to be
excluded from the study. Overall the OHIP-14 data correspond
to the results of Hagglin et al. who investigated patients of
comparable age.
47
In our study the OHIP-G14 did not indicate
signicant changes compared to the baseline data, although a
slight improvement ineating-comfort was documentedandthe
extent score decreased. In comparison, John et al.
48
reported
considerable improvements. However, the patients in that
study were signicantly younger than our patients and they
wererecruitedfrompatients whowereaskingfor treatment ina
dental hospital andwerethereforemost probablyawareof their
limited dental status. Furthermore the longer total observation
time (upto12 months) may contribute, as the adaptationability
of elderly patients is reduced and adaptation periods of more
than 6 months have been observed.
49
Although some patients experienced an improved oral
comfort while eating (OHIP-item 4) after treatment, they did
not consider changes in their diet (OHIP-item 7). Subjectively,
some multimorbide patients may have not even noticed their
insufcient dental status as they experienced other problems
with a higher impact on their well-being.
5. Conclusion
The results of this study support the hypothesis that
prosthetic treatment alone is not adequate to attain a
signicant improvement in the nutritional status of dentally
compromised elderly as masticatory ability and efciency are
obviously not the only factors which inuence the health and
nutritional status of a patient.
Further investigations are required to establish to what
extent combining animprovement of the prosthodontic status
with a dietary consultation might be benecial for enhancing
the nutritional status in elderly patients.
Acknowledgements
We gratefully acknowledge the kind support received fromthe
following residential homes: St. Vitus-Stift GmbH, Olfen,
Germany and Altenzentrum Clara-Stift, Lu dinghausen, Ger-
many.
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