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 \jeÙrƍē-ătƍrƍks\ à,
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(1909)Ê the branch of medicine that treats all
problems peculiar to the aging patient, including
the clinical problems of senescence and senility
ë primaryaging, which involves the natural process
of senescence. Examples include facial wrinkles
and the need for reading glasses.

ë Secondary aging, which involves

age-related diseases such as
cancer, parkinsonism,
osteoporosis, and
macular degeneration of the eye.
ë ½Elderly½ was once defined as being age 65 or
above, but the growing number of active and
healthy older people has caused that definition to
expand to ½young old½ (65 to 75), ½old old½ (75 to
85), and ½oldest old½ (85 and beyond). The over-85
age group is the one that is growing most rapidly.
ë jeriatric à 
à applies nutrition principles to
delay effects of aging and disease, to aid in the
management of the physical, psychological, and
psychosocial changes commonly associated with
growing old.

Proper nutrition is essential to the health and

comfort of oral tissues and healthy tissues enhance
the possibility of successful prosthodontic
treatment in the elderly.
ë a decline in quickness of response
ë a changed motor and visual coordination
ë a decreased interest
ë a lowered oxygen consumption
ë a decreased capability of adapting to altering conditions
ë a decrease in basal metabolism
ë a decreased kidney function
ë a decreased immune response
ë a decrease in gastric juice production
ë brain weight shrinks by 10-20% by
age 80
ÿ SA node loses 90% cells by age 75.
ë §eduction in total number of component cells.
ë Decrease in thickness
ë Loss of elasticity
ë Dryness and atrophy
ë Tendency to hyperkeratosis
  With a decline in lean body mass in the elderly, caloric needs decrease
and risk of falling increases.
 Vitamin D deficiency in turn, is a major cause of metabolic bone disease
in the elderly.
 Declines in gastric acidity often occur with age and can cause
malabsorption of food-bound vitamin B12.
 Many nutrient deficiencies common in the elderly, including zinc and
vitamin B6, seem to result in decreased or modified immune responses.
 Dehydration, caused by decline in kidney function and total body water
metabolism, is a major concern in the older population.
 Overt deficiency of several vitamins is associated with neurological
and/or behavioral impairment B1 (thiamin), B2, niacin, B6 [pyridoxine],
B12, foliate, pantothenic acid, vitamin C and vitamin E).
 Elders, particularly at risk, include those living
alone, the physically handicapped with insufficient
care, the isolated, those with chronic disease
and/or restrictive diets, reduced economic status
and the oldest old.
 Functional disabilities such as arthritis, stroke, vision,
or hearing impairment, can affect nutritional status
indirectly.
  Most elders take several prescription and over-
the-counter medications daily.

 Prescription drugs are the primary cause of

anorexia, nausea, vomiting, gastrointestinal
disturbances, xerostomia, taste loss and
interference with nutrient absorp-tion and
utilization. These conditions can lead to nutrient
deficiencies, weight loss and ultimately
malnutrition
A study by j.larson on nutritional status found that
hospitalization itself resulted in detioration of
nutritional status.(j.oral rehabilitation April 2004)
ëå


 Xerostomia affects almost one in five older

adults. Xerostomia is associated with difficulties in
chewing and swallowing, all of which can
adversely affect food selection and contribute to
poor nutritional status.

 The use of drugs with hypo salivary side effects

may have deleterious influence on denture bearing
tissues.
ë  Age-related changes in taste and smell may alter food
choice and decrease diet quality in some people. Factors
contributing to this reported decreased function may
include health disorders, medications, oral hygiene,
denture use and smoking.
 Sense of smell decreases markedly with age, much more
rapidly then the sense of taste. Diminished taste is the
result of aging.
 Sensory changes may diminish the appeal of some foods
(e.g., sensitivity to the bitterness of cruciferous
vegetables), limiting their consumption and potential
health benefits function.
.
  The hard palate contains taste buds, so taste sensitivity may be
reduced when an upper denture covers the hard palate. As a result,
swallowing can be poorly coordinated and dentures can become a
major contributing factor to death from choking.

[à 
ài  
 As adults age, they tend to use more strokes and chew longer, to
prepare food for swallowing.

 Masticatory efficiency in complete denture wearers is

approximately 80% lower than in people with intact natural
dentition.(j.oral rehabilitation 2006,33;301-308)
 1. Some people compensate for decline in masticatory ability by
choosing processed or cooked foods rather than fresh food and by
chewing longer before swallowing.

2. Others may eliminate entire food groups from their diets.

Dentate adults tend to eat more fruits and vegetables than full-denture
wearers.

 §eplacing ill-fitting dentures with new ones does not necessarily

result in significant improvements in dietary intake.

 Similarly, exchanging optimal complete dentures for implant-

supported dentures, has not resulted in significant improvement in food
selection or nutrient intake.
ë  Energy needs decline with age due to a decrease in basal metabolism and
decreased physical activity.
 Cross-sectional surveys show that the average energy consumption of 65-
74 year old women is about 1300 Kcal and 1800 Kcal for men of the same
age.
 Deficiency causes dull, dry, sparse easily plucked hair, parotid gland
enlargement, muscle wasting, pallor, pale atrophic tongue, spoon nails and
pale conjunctiva.
ë ˜ 
 
 Caloric requirements decrease with advancing age, owing to reduced
energy expenditures and a decrease in basal metabolic rate.
 The mean §DA is 1600 Kcal for women and 2400 Kcal for men.
ë
 As the patients become older, the amount of protein required increases.
 Protein depletion of body stores in the elderly, is seen primarily as a decrease
of the skeletal muscle mass. Proteins is a must for denture wearers.(American
journal of clinical nutrition vol 85,no 5)
 The §DA for proteins, for persons aged 51 and over, is 0.8-g protein/kg body
weight per day. (56 gms for males and 46 gms for females, or 9 and 10%
respectively, of the recommended calorie intake). However, because of the
general decline in energy intake, as age increases, the recommendation is that
the elderly should satisfy 12% or more of their energy intake with protein-rich
foods.
 The best sources of proteins for the elderly diet are dairy products, poultry,
meats and fish in the boiled and not dried form. Nuts, grains, legumes and
vegetables contain protein, which if eaten in the proper combination, is of the
same quality as animal sources of protein.
 Deficiency of proteins causes edema.
ë  The elderly consume a large proportion of their
calories as carbohydrates, possibly at the expense
of protein, because of their low cost, ability to be
stored without refrigeration and ease of preparation.
 The recommended range of intake is 50 to 60 per cent of total calories.
 Food sources include grains and cereals, vegetables, fruits and dairy products.

·

 An important component of complex carbohydrates is fiber, which promotes
bowel function, may reduce serum cholesterol and is thought to prevent
diverticular disease.
 §educed selection of foods rich in fiber that are hard to chew, could provoke
gastrointestinal disturbances in some edentulous elderly, with deficient
masticatory performance.
 Elderly are particularly susceptible
to negative water balance, usually
caused by excessive water loss through
damaged kidney.
 Inadequate intake of fluid by the elderly will lead to
rapid dehydration and associated problems such as
hypotension, elevated body temperature and dryness of the
mucosa, decreased urine output and mental confusion.
 Under normal conditions, fluid intake should be at least
30 ml per kg body weight per day.
ë
 The §DA for vitamin A is 800-1000 micrograms §E |

 Vitamin A in food
in two forms: retinal, or active Vitamin A in
animal foods (liver, milk and milk products and beta-carotene or
pro-vitamin A, found in deep green and yellow fruits and vegetables
(apricots, carrots, spinach).

 Deficiency causes Bitot's spots (eyes), conjunctival and corneal

xerosis (dryness), xerosis of skin, follicular hyperkeratosis, decreased
salivary flow, dryness and keratosis of oral mucosa and decreased taste
acuity.

 Long standing deficiency may cause hyperplasia of the gums, as well

as generalized gingivitis

à
 Evidence of thiamine deficiency occurs most often in the poor,
institutionalized and alcoholic segment of the elderly population.
 The §DA has been set at 0.5 per 1000 calories, or at least 1 mg daily.
 Food sources include meats (especially pork and chicken), peas, whole
grains, fortified grains, cereals and yeast.
 Deficiency causes beriberi.
à    à 
à 
 §anges from 50 to 90% of the elderly affected, which may be an important
cause of the increased prevalence of the carpal tunnel syndrome (an inflamed
tendon attached to the wrist bone.) in the elderly.
ë  The §DA is 1.2-1.4 mg |

 Deficiency causes nasolabial seborrhea, glossitis.

à  
 à

 The §DA is 3.0 microgram.

 Is found in kidney, heart, milk, eggs, liver and green leafy

vegetables.

 Deficiency causes nasolabial seborrhea, fissuring and redness of

eyelid corners and mouth magenta-colored tongue.
ë à ˜
 The §DA is about 60 microgram |

 Food sources include citrus fruits, tomatoes, potatoes and leafy vegetables.

 Deficiency causes spongy, bleeding gums, petechiae, delayed healing

tissues, painful joints.

ë à 
 The elderly are frequently deficient in Vitamin D because of lack of sun
exposure and an inability to synthesize Vitamin D in skin and convert it in
the kidney. Vitamin D is found in fish liver oils.
|
ë
 The §DA is 5 microgram.
 Deficiency causes bow legs, beading of ribs.

ë à 

 Vitamin E deficiency in the elderly does not

seem to be a problem. Total plasma vitamin E
levels increase with age.
 The §DA is 8-10 mg alpha-TE
ë Yà
 
A study conducted by J. Crystal Braxter illustrated deficiencies in
magnesium, fluoride, folic acid, zinc and calcium, in the geriatric
population.
ë
·  
 Economically deprived and institutionalized elderly are at the most
risk
foliate deficiency.
 §DA is 500 microgram.
 jood food sources of include leafy green vegetables, oranges, liver,
legumes and yeast.
 Deficiency causes megaloblastic anemia, mouth ulcers, glossodynia,
glossitis, stomatitis.
ë
 The recommended daily allowance of calcium is 800 mg/day.

 Because calcium absorption is decreased in the elderly (lack of

hydrochloric acid in the stomach), the calcium must be acidulated before
digestion.
 Lactase deficiency resulting in lactose intolerance is also common in
elderly persons. This is another reason for modifying the milk for elderly
persons.
 Food sources of calcium include milk and milk products, dried beans
and peas, canned Salmon, leafy green vegetables and tofu.
 Elderly patients with complete dentures often experience a rapid and
excessive ridge resorption, which may be related to negative balance of
calcium, which contributes to development of osteoporosis.
ë

 A recent review concluded that the prevalence of iron deficiency, is relatively rare
among the healthy elderly. When anemia is found in an older person, blood loss should be
suspected.
 The §DA for iron is 10 mg.
jood food sources include meat, fish, poultry, whole grains, fortified breads and cereals,
leafy green vegetables, dried beans and peas.
 Deficiency causes burning tongue, dry mouth, anemia's and angular cheilosis.
ë

Ëà
 Zinc utilization declines with advancing age, because intestinal absorption decreases
after the age of 65 years.
 The §DA is 15 mg.
 jood sources of zinc are animal products, whole grains and dried beans.
 Deficiency causes decreased taste acuity, mental lethargy and slow wound healing.
ë Enjoyment of food is regarded as an important determinant of an
adult¶s quality of life.
Loose teeth,
edentulism, or
ill-fitting dentures
may prelude eating favorite foods, as well as limit the intake of
essential nutrients.
ÿ Decreased chewing ability,
fear of choking while eating, and
irritation of the oral mucosa
when food particles get under the dentures may influence food
choices of the denture wearer.
ë Clinical symptoms of malnutrition are often first
observed in the oral cavity.
ë Because of rapid cell turnover (every 3 to 7 days) in
the mouth, a regular, balanced intake of essential
nutrients is required for the maintenance of the oral
epithelium.
ë Inadequate long term nutrition may result in angular
cheilitis,glossitis, and slow tissue healing.
ë The amount of alveolar bone resorption that occurs
after tooth extractions may be exacerbated by low
calcium and vitamin D intakes.
ë Undernutrition increases with advancing age.
ë Persons older than 70 years of age are more likely
to have nutritionally poor diets.
ë Dentate status can affect eating ability and thus the
diet quality.
ë In elderly people, oral health problems may
contribute to involuntary weight loss and a lower
body mass index.
ë Poor oral health leads to impaired masticatory
function. Whether MF plays a role in food selection is
still matter of debate, but impaired masticatory function
leads to inadequate food choice and therefore alter
nutrition intake.

 The presence of natural teeth and well fitting dentures

were associated with higher and more varied nutrition
intakes and greater dietary quality, in the oldest old
Iowans sampled.
ë The food choices of older adults are closely linked to
dental status and masticatory efficiency.
ë Although an intact dentition is not a necessity for
maintaining nutritional health, the loss of teeth often
leads adults to select diets that are lower in nutrient
density.
ë Denture wearers report that food such as raw
carrots, lettuce, corn on the cob, raw
apples with peels, steaks, and chops
are difficult to chew.
ë Age,
ë oral motor function,
ë adequate saliva, and
ë number of occluding pairs of teeth in the mouth
mainly determine an individual¶s masticatory
ability.
When compared to those with natural dentition,
persons with removable complete dentures had
greatly reduced chewing ability.
Texture and hardness rather than taste and smell
determine acceptability of a food for many patients
with dentures
ë jenerally, the intake of hard food (raw vegetables or
fruits, fibrous meats, hard breads, seeds and nuts) is
reduced, whereas the intake of soft foods (ground beef,
breads, cereals, pastries and canned fruits and
vegetables) is increased.
ë Whether these changes in food selection negatively
affect nutritional status depends on nutrient density of
the food substituted, but softer foods are often lower in
nutrient density and fiber.
ë The inability to distinguish the sensory qualities of food
reduces a patient¶s enjoyment of eating and may lead to
reduced calorie intake.
ë Because a decrease in taste and smell acuity frequently
accompanies aging, it is difficult to separate the effects of
aging and denture wearing on sensory acuity.
ë Nearly all denture wearers report a transient decline in taste
acuity when dentures are first inserted. This is usually
attributed to denture base coverage of the hard palate.
ë However, the ability to taste usually improves as the patient
adapts to the dentures.
major problem for seniors
EDENTULOUS
ë The comfort of wearing dentures is dependent on the
lubricating ability of saliva in the mouth. If the oral
mucosa is dry, chewing is difficult, denture retention
is compromised, and mucosal soreness or ulcerations
develop.
DENTULOUS
ë Because salivary flow facilitates mastication,
formation of the food bolus, swallowing, and
digestion, it is a major contributor to the pleasure of
eating.
ë Energy needs decline with age because of a
decrease in basal metabolism and decreased
physical activity. With aging, lean body mass is
replaced by fat; this leads to a decrease in
metabolic rate.
ë When calorie intake is low, consumption of foods
of high nutrient density such as legumes, vegetable
soups, meat casseroles, fruit desserts, low-fat dairy
foods, and whole grain breads and cereals is
important.
ë The best means of reducing calorie intake is to
replace foods high in fat and sugar with complex
carbohydrates, and these should be the mainstay for
the elderly person¶s diet. In contrast to pastries,
whole-milk cheeses, luncheon meals, salad dressings,
and frozen desserts, the choice of
nonfat dairy products,
whole grain breads, cereals,
pasta, fruits, vegetables, beans,
and legumes will provide
important amounts of vitamins,
minerals, and fiber.
ë Fats contribute about 33% of total calories in the diet of the
average adult.
ë Because of growing epidemiological evidence of the link between
dietary intake of saturated fat, cholesterol, and occurrence of
hyperlipidemias, heart disease, certain cancers, and obesity, adults
are advised to maintain their dietary fat intake at 20% to 35% of
total calories.
ë Because physiological stresses are associated with age-related
degenerative diseases, protein needs of older adults are thought to
be slightly higher than those of younger persons. It is
recommended that 10% to 35% of total calories or 1g/Kg of body
weight come from protein.
ë This conclusion is based on studies of serum albumin levels and
nitrogen balance studies in older adults.
ë Vitamin B12 deficiency may lead to problems with
dementia in older adults. Vitamin B12 is found only in
animal products. Synthetic vitamin B12 obtained from
fortified foods or vitamin supplements is better
absorbed than protein bound vitamin B12.
ë Because of its role in collagen synthesis, ascorbic acid
(Vitamin C) is essential for wound healing. There is a
wide variation in vitamin C intakes of adults. Heavy
smokers, alcohol abusers, or persons with high aspirin
intake have a higher daily requirement for ascorbic
acid. The denture-wearing patient should be
encouraged to consume foods rich in vitamin C daily
such as citrus fruits, peppers, melons, kiwifruit,
mangos, papaya, and strawberries.
ë Vitamin E functions as an antioxidant in cell
membranes. By acting as a scavenger of free radicals,
vitamin E prevents oxidation of unsaturated cell
phospholipids. Dietary sources of vitamin E include
vegetable oils, nuts, margarines, and mayonnaise.
ë Magnesium is a component of the body skeleton, is a
cofactor for more than 300 enzymes, and plays a role
in neuromuscular transmission. The highest amounts
of magnesium are found in vegetables and unrefined
grains. Milk is a moderately good source.
ë Alcohol abuse appears to be a serious health problem
among some older persons. Alcoholism is often
undetected and untreated. The loss of spouse,
loneliness, depression, retirement, loss of status, and
reduced income, all contribute to excess alcohol intake
in older adults.
ë Deficiencies of thiamine, niacin, pyridoxine, folate (all
B-complex vitamins), and ascorbic acid are commonly
seen in alcoholics. Osteopenia in males without a
history of bone disease may be due to long-term alcohol
intake. When efforts to resolve tissue intolerance to a
prosthesis are unsuccessful, the misuse of alcohol
should be considered.
ë Bone loss is a normal part of aging that affects the maxilla and
mandible, as well as the spine and long bones. Skeletal sites where
trabecular bone (the alveolar bone, vertebrae, wrist, and neck of
the femur) is more prominent than cortical bone are affected first.
Several factors are thought to contribute to age related bone loss
that leads to osteoporosis: genetic background, hormonal status,
bone density at maturity, a disturbance in the bone remodeling
process, a low exercise level, and inadequate nutrition. Low
calcium intake throughout life is a contributor to osteoporosis.
ë Osteopenia, loss of bone, affects women earlier
than men because of loss of estrogen at
menopause and a smaller skeleton. In women,
bone loss begins during fourth decade of life
or whenever estrogen secretion declines or ceases.
ë Trabecular bone in the alveolar processs is a source of
calcium that can be used to meet other needs.
ë It has been proposed that alveolar bone loss may
precede loss of mineral from the vertebrae and long
bones; thus the dentist may therefore be the first health
care provider to detect loss of bone mass.
ë Mandibular bone mass has been positively correlated
with total body calcium and the bone mass and the
vertebrae and wrist of healthy, dentate postmenopausal
and edentulous women with osteoporosis.
ë Dietary calcium intake is critical to maintain the body
skeleton. The most important means of preventing
metabolic bone disease is acquiring a dense skeleton
by the time bone maturation occurs between 30-35
years of age. A women who has a dense skeleton at
35 years of age will retain proportionately more
skeletal mineral content and be less susceptible to
fracture after menopause. Calcium intake of
postmenopausal women is
correlated with mandibular bone mass.
Patients with dentures who have
excessive ridge resorption report
lower calcium intakes.
ë A chronically low calcium intake results in a
negative calcium balance. For serum calcium
levels to be maintained, calcium will be mobilized
from bone, and this leads to demineralization of
the skeleton. Although a generous calcium intake
by older adults will not result in restoration of
bone mass, it will improve calcium balance and
slow the rate of bone loss.
ë Oxalates found in spinach and phytates found in whole-grain
products and legumes may form insoluble complexes with
calcium, thereby reducing the amount of calcium absorbed.
High intakes of sodium, animal protein, and alcohol increase
calcium losses in the urine. A moderate caffeine intake (300mg
or less per day) is recommended to prevent bone loss.
ë Major sources of calcium are milk, cheese, yogurt, and ice-
cream. Dairy foods are also a source of protein, riboflavin,
vitamin A, and vitamin D. Collard greens, kale, broccoli,
oysters, canned salmon, sardines, calcium fortified fruit juices
and cereals are non-dairy foods containing substantial amounts
of calcium. To receive 1000 to 1200 mg of calcium, adults
must drink three or four glasses of low-fat milk per day, eat 5
to 7 oz of hard cheeses, or consume very large quantities of
nondairy foods. Lactose-intolerant adults who avoid milk may
find yogurt or cheese acceptable
ë Poor vitamin D status is an important public health
problem. Adequate intake of vitamin D enhances
calcium absorption in the intestine. Low dietary intake,
minimal exposure to sunlight, and a lower rate of
conversion to the active metabolite in the liver and
kidney are responsible for low plasma levels of vit D in
the elderly population. The primary dietary source of vit
D is fortified dairy products. To promote bone health,
post menopausal women and andropausal men ages 51
to 70 should strive to obtain 10 ȝg of vit D and increase
intake to 15 ȝg at age 71.
ë If an individual lacks sun exposure, is lactose intolerant,
or dislikes dairy foods, a vit D supplement of 10ȝg is
desirable.
ë The most common forms of supplements are
calcium carbonate, calcium citrate, calcium lactate,
calcium gluconate, and calcium diphosphate.
Calcium carbonate contains the highest
concentration of elemental calcium (40%), but in
older women, body absorption of calcium citrate is
better. However, less elemental calcium is obtained
from each calcium citrate tablet. Calcium
supplements that contain vit D to enhance
absorption of calcium in the gut are useful if vit D
is not obtained from other sources.
ë Few adverse affects of calcium supplementation
have been observed. Some older women have
reported nausea, bloating or constipation.
Increasing calcium intake results in higher urinary
levels of calcium. A small percentage of
population, mainly men, are susceptible to forming
kidney stones; however, a high intake of dairy
foods does not appear to affect stone formation. A
physician should monitor the use of calcium
supplements by these persons. The maximum
calcium intake that poses no risk of adverse effects
is 2.5 g.
ë Consuming a variety of foods is considered the
best means of obtaining the balance of nutrients
required for good health. A varied diet also reduces
the risk of chronic disease. Atleast 50% of persons
older than 65 years of age report using vitamin-
mineral supplements, and one-fourth of adults use
herbal supplements. Persons who perceive
themselves to be in good health are
more likely to use dietary
supplements.
ë To increase energy level,
ë to extend life,
ë to prevent the onset of degenerative diseases,
ë to relieve the symptoms of chronic diseases, and
ë to make up deficits caused by unbalanced diets.
A large percentage of the supplements ingested are self-
prescribed and unrelated to any specific physiological
need.
ë #eriatrics are particularly
vulnerable to compromised
nutritional health.
The dentist who is aware of nutritional risk factors can
identify patients in need of nutritional guidance.
The ability of the oral tissues to withstand the stresses of
treatment is greater if the patient is well nourished.
Dietary guidance is an integral part of treatment for the
prosthodontic patient.
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