ArticlePDF AvailableLiterature Review

The nutritional effect of tooth loss



In view of the high prevalence of edentulousness in developed countries, the evidence is reviewed for the effects of tooth loss on nutrition and health in the following categories of effects: mortality; food choice and nutrient intake; gastrointestinal irritation; digestion and nutrient absorption; nutritional status. The evidence indicates reduced consumption of meat, fresh fruit, and vegetables, and total energy resulting in lower Hb and vitamin C levels, increased gastrointestinal irritation and increased mortality from choking but no striking differences in digestion or nutritional status. However, most studies are not carefully controlled for other social and health factors.
The nutritional effects of tooth 10551
Catherine A Geissler,2 BDS, PhD and John F Bates,3 DDS, Dr Odont
ABSTRACT In view of the high prevalence of edentulousness in developed countries, the
evidence is reviewed for the effects oftooth loss on nutrition and health in the following categories
of effects: mortality; food choice and nutrient intake; gastrointestinal irritation; digestion and
nutrient absorption; nutritional status. The evidence indicates reduced consumption of meat,
fresh fruit, and vegetables, and totalenergy resulting in lower Hb and vitamin C levels, increased
gastrointestinal irritationand increased mortality from choking but no striking differences in
digestion or nutritional status. However, most studies are not carefully controlled for other social
and health factors. Am iC/in Nutr l984;39:478-489.
KEY WORDS Tooth loss, mortality, food choice, gastrointestinal irritation, digestion, nu-
tritional status
Forty-four percent of all adults in Scot-
land have no teeth (1). In England and Wales
the figure for the same year 1968 was 37%
(2) but the latest 1978 survey shows an im-
provement to 29% (3). The situation is com-
parable in the United States, Sweden, Ice-
land, and other developed countries for
which data are available (4). These astonish-
ing figures raise the question of the effect of
such poor dentition on health and nutrition.
They refer only to people who have had all
their teeth extracted and do not include
those with poor mastication due to the loss
ofsome teeth. The average masticatory per-
formance ofdenture wearers has been shown
to be only 12% of normal physiological per-
formance (5). Decay is the principal cause
of tooth loss, followed by periodontal dis-
Dental research has concentrated on the
effects of diet on dental caries and little
attention has been paid to the effect of tooth
loss on health and nutrition. Dental caries is
by far the most prevalent nutritional disease
in the world (6) and particularily in the
developed countries where only a tiny mi-
nority escape. More than 99% of these pop-
ulations suffer dental decay. Despite this fact
dental caries is generally overlooked as a
nutritional disease probably because its ap-
parent effects on health and well-being are
not dramatic: it does not obviously endanger
life as coronary heart disease or protein en-
ergy malnutrition can; it is not severely crip-
pling as blindness due to vitamin A defi-
ciency is; and it is not such a health and
social stigma as is obesity.
For wild and even domesticated animals
tooth loss can be fatal. For primitive man
teeth were probably as essential but for mod-
em man commercial food processing and
refining, home mincers and blenders have
removed much of the need for teeth. It is
technically possible to have complete diets
in liquid form, ranging from milk, the nat-
ural food that provides all requirements at
the time of life when the rate of growth is
greatest, to slimmers diets in cans. However,
socially a soft diet is impractical. In practice
certain kinds of foods are avoided, or they
are eaten but scarcely chewed. This could
theoretically be expected to affect the health
by altering the intake or absorption of nu-
trients. Diets that are more liquid are gen-
erallyless calorie-dense, a fact that is used
IFrom the Department of Nutrition, Queen Eliza-
beth College, University of London, Campden Hill,
London, England and Department of Restorative Den-
tistry, The Welsh National School of Medicine, Dental
School, Heath Park, Cardiff, Wales.
2[turer Department of Nutrition, Queen Eliza-
beth College. Author to whom requests for reprints
should be addressed. 3Professor, Department of Res-
torative Dentistry, The Welsh National School of Med-
The American Journal of clinical Nutrition 39: MARCH 1984, pp 478-489. Printed in U.S.A.
© 1984 American Society for Clinical Nutrition
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in the drastic slimming method of wiring
the teeth together so that only liquids can be
consumed. In the toothless consumption of
a soft diet might have the same effects, lead-
ing to weight loss whether this were desirable
or not. Tooth loss is naturally most prevalent
in the elderly, 80% being edentulous in Eng-
land and Wales (2). As the population in
this age category increases, any problems
associated with tooth loss are likely to be-
come more prevalent.
Herein we review the evidence for the
effects of tooth loss on nutrition and health.
It is investigated in the following categories
of effects: mortality; food choice and nu-
trient intake; gastrointestinal irritation;
digestion and nutrient absorption; and nu-
tritional status. The aesthetic effects and
their social consequences of embarassment
about speaking, eating, and sexual activity
are not considered here nor are the effects
on the mandibularjoint and associated pain.
Tooth loss is not generally thought of as a
fatal condition. However, there is consider-
able evidence that it is an important factor
in death caused by blockage of the air and
food passages. Choking on food is the sixth
most common cause of accidental death in
the United States, resulting in nearly 2500
fatalities annually as estimated by the Na-
tional Safety Council in 1972. On the basis
ofanswers to a questionnaire from coroners
and medical examiners representing a pop-
ulation of 40 million, Eller and Haugen (7)
estimate that 700 to 1000 deaths by choking
on food, as proved at autopsy, occur an-
nually in the United States but that many
more must pass unrecognized. Such deaths
are often falsely attributed to heart attacks
and the phenomenon has been variously
labeled “cafe coronary” or “backyard bar-
beque syndrome.” As a result of autopsies
performed in all cases in which sudden death
occurred during eating, Haugen encoun-
tered 55 cases due to food asphyxiation but
only one due to occlusive coronary artery
disease. Anderson (8) reviewed the literature
on death from foreign bodies and found a
dental factor implicated in the vast majority
of such cases. For example, of the 16 patients
presenting at a London hospital in 1 yr with
a foreign body in the throat, only three had
normal dentition and 10 had full upper and
lower dentures. This represented more than
twice the number of denture patients than
in a control series (9). Ray and Vinson (10)
studied more than 900 cases ofimpaction of
which about 600 were in the esophagus, and
consisted of mostly bones and meat. made-
quate mastication and the loss of sensation
in the mouth resulting from artificial den-
tures was a major factor in these cases. Even
intestinal obstruction with dried apricots has
been reported as a cause ofdeath (11).
Canadian data for mortality rates from
the inhalation and ingestion of food show
high rates in infants and the elderly (12). In
adults up to the age of 40 the rates are low,
less than 1/100,000 per annum. The figures
then increase progressively with age, so that
the rates for 70-yr-old men and women are
4.7 and 3.3, respectively, and for 80-yr olds
9. 1 and 6. 1, respectively. The age range at
which the rates are high correspond with the
period when greatest tooth loss occurs and
possibly loss of muscle coordination to con-
trol dentures and swallowing. No causal re-
lationship can be assumed but the circum-
stantial evidence supports the conclusions
from the case studies.
Another potentially fatal condition is can-
cer (13). Poor dentition was shown to be
associated with a higher risk (mortality ratio
3.2) ofdeveloping oral cancer. Other factors
associated were heavy smoking and drink-
ing. It was found that these risks were not
merely additive but synergistic. A substan-
tially higher risk than would have been ex-
pected was found in heavy smokers (mortal-
ity ratio 4.9) and heavy drinkers (mortality
ratio 5.2) with poor dentition. The risk for
men with all these traits was 7.7 times that
of men with none of the traits.
Altered food choice and nutrient intake
If mastication is difficult the choice of
foods is likely to be altered. Several reports
have been made of these changes but con-
clusions are often bedeviled by the methods
used or lack of information on the methods
used for recording dietary intake, evaluating
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adequacy of nutrient intake, and controlling
for social factors that affect food consump-
tion. For example Barone (14) stated that
the soft diet of geriatric patients high in
carbohydrate and low in protein was usually
the rule and that a “tea and toast” diet
resulted in widespread malnutrition. How-
ever, Hobson and Pemberton (1 5) studied a
weighed dietary survey of 330 elderly people
resident in Sheffield of whom 20% had a
“poor state ofnutrition” and concluded that
in old age inadequate dentition did not se-
riously affect dietary intake. Davidson et al
(16) found chewing efficiency to be related
only to protein intake in 104 members of a
Boston Age Center but details ofmethod are
not given other than that intake was assessed
by questionnaire and dental efficiency rated
by a dental team.
The most detailed reports are those of
M#{228}kil#{228}(17-20) who studied the effects of
complete dentures on dietary habits, flu-
tnent consumption, and blood nutrient 1ev-
els in Finnish subjects aged between I 8 and
82. Information on dietary habits was ob-
tamed from personal interviews on the fre-
quency of consumption and the quantity of
certain foods. (Bread, porridges, potatoes,
dried peas, fruit, root and green vegetables,
milk, curdled milk, cheese, butter, eggs,
meat sausages, fish, liver, kidney, blood
dishes, and various beers.) From this infor-
mation the weekly intake of vitamins was
calculated. It is not clear from the reports
how often the subjects were interviewed or
for what period oftime. The method appears
inaccurate for the assessment of nutrient
intake but adequate to show differences in
dietary patterns. As might be expected, soft
foods such as porridge were eaten more fre-
quently by those without teeth (p <0.05)
and hard and fibrous foods less frequently.
These included fruit (p <0.05), raw vegeta-
bles (p <0.06), cheese (p <0.05), meat (p
<0.001), and sausage (p <0.001). Examples
of differences in the frequency of consump-
tion of several foods expressed as the per-
centage of dentulous compared with eden-
tulous who ate the food daily are as follows:
porridge 24 versus 35%; fruit 46 versus 21 %;
meat 51 versus 26%. The tendency to avoid
meat due to lack of teeth was also reported
by Bender and Davies (2 1) in elderly subjects
under the care of health visitors.
In a further study of dietary selection (22)
housebound pensioners were asked whether
they ever ate 12 specified foods chosen to
cover a range of easy to chew to very diffi-
cult. Foods such as nuts, hard biscuits, and
raw celery were progressively more excluded
from the diet of those with poor fitting den-
tures, no lower dentures, and no dentures so
that there was a significant difference in the
range of diet of the latter two categories as
compared with the “better” denture group
(p <0.01). Since it was a pilot survey the
groups were too small to match for relevant
variables such as age, sex, and cultural and
social backgrounds. Similar findings were
obtained in US dental patients and veterans
(23) in Australian men and women (24) in
whom it was found that older patients had
more eating problems than younger ones,
and in elderly US medical patients and out-
patients (25).
A more extensive survey was carried out
in 1967 to 1968 by the UK Department of
Health and Social Security (DHSS) of the
health and nutrition of 700 elderly people
living at home in various rural and urban
parts ofBritain (26). The effects of inefficient
mastication were also reported separately by
Berry (27). Thirteen percent were classified
by geriatricians on a subjective, unmeasured
basis as having inefficient mastication. Food
intake was recorded for 1 wk by the subjects
who were visited at frequent intervals to
quantify their intake diaries which were also
cross-checked by food purchases. They con-
sumed on average 20%, and those over 75
yr 40%, less meat, but not compounded
meat, and the women and older men con-
sumed 10 to 20% fewer calories. However,
these relationships are not necessarily cause
and effect, no account having been taken of
other factors that could influence the differ-
ences in intake such as social class, physical
disability, etc, which may affect both food
intake and dental status separately. To ac-
count for this, 28 men and 25 women with
efficient mastication and mostly older than
75 yr of age were matched with controls of
the same age, sex, and geographical area. To
determine which foods in particular were
consumed less, their consumption of various
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foods was compared, taking into account
the overall reduction of energy intake of
20% in subjects with inefficient mastication.
Consumption oftomatoes, green vegetables,
and raw noncitrus fruits were disproportion-
ately lower (40%). Unfortunately the overall
nutrient intake ofthese matched groups was
not reported.
Neill (28) has published several papers
relating dietary intake to dental function. In
a study to relate the dietary intake of 576
subjects to dental state it was found that
male subjects aged 5 1 to 70 yr wearing den-
tures consumed significantly more calories
than those with their own teeth. The expla-
nation proposed was that inefficient masti-
cation may lead them to select more readily
assimilable carbohydrates and fats. To in-
vestigate the subject further he studied the
dietary intake and masticatory performance
of other groups of elderly people. One was a
group of 53 Chelsea pensioners (29) aged 65
to 93 yr living in a veterans home. Mastica-
tion was assessed by the percentage recovery
of food through a 10-mesh USS sieve after a
standard amount of mastication. Each sub-
ject was asked to chew a 12-mm cube por-
tion of ham using 20 chewing thrusts and
then to spit and rinse into a container. This
was washed through a sieve. Masticatory
performance was expressed as the percentage
of the total mass recovered which passed
through the sieve. Mean scores of edentulous
subjects varied according to the quality of
the dentures: no dentures 7.5; poor dentures
12.7; fair dentures 20. Food intake was es-
timated by dieticians observing food con-
sumed in the dining hall over a 2 day period,
presumably not weighed. In view ofthe error
involved in estimating intake by observa-
tion, their conclusions that subjects with
highest masticatory performance consumed
the largest quantity of each nutrient are per-
haps unwarranted as they are based on small
differences. For example the intakes of sub-
jects with masticatory scores of more than
20, 20 to 10, and less than 10 were as follows:
energy 2495, 2366, 2341 kcal; carbohydrate
263, 234, 217 g; animal protein 63, 58, 58
g; total protein 89, 82, 79 g; and fats 96, 90,
89 g. A definite trend is visible but with the
relatively small number of subjects, (10, 21,
18, the small differences in masticatory
scores, and the extent of variance, the differ-
ences are not great.
Other groups (30) were 40 men and
women living in Old People’s Homes in
Hertfordshire and 50 men and women par-
ticipants in the 1967 to 1968 DHSS survey
(26) of the elderly living at home in Cam-
bridge. Masticatory efficiency was assessed
as before and in addition retention of den-
tures was assessed. Food intake was meas-
ured in the Cambridge subjects by their
keeping a diary offood intake, quantified by
frequent visits of dietary investigators. The
method used in the Old People’s Homes was
not reported and only half of these subjects
took part. In the small numbers examined
no clear trend related dietary intake with
masticatory performance in either Cam-
bridge or Hertfordshire. Neill’s original hy-
pothesis that impaired mastication leads to
the increased selection of easily assimilable
carbohydrates and fats is therefore not borne
out by his subsequent studies.
The diet of edentulous geriatric patients
was analyzed before and after fitting den-
tures, from 4-day records, apparently un-
weighed (3 1). Unfortunately the results are
not expressed in a way that allows the level
of intake of nutrients before and after to be
satisfactorily compared. Absolute values are
not given, only the significance of deviation
from recommended dietary allowances.
However, their statistical analysis shows a
significantly increased intake of energy in
both men and women. This is reflected in
increased intakes of various nutrients but it
is not possible from the data to see whether
individual nutrients were selectively in-
creased. Most of the subjects noted subjec-
tively that they were eating coarser and more
fibrous foods.
Osterberg and Steen (32) used more rig-
orous criteria in their study of 368 elderly
men and women in Sweden. Mastication
was measured by Eichner’s index based on
the extent of contact of posterior teeth. The
dietary history method used had been vali-
dated for protein intake by 24-h urinary
nitrogen outputs. The subjects were classi-
fled by well-defined criteria into adequate or
insufficient intake of one or more of the
following nutrients: protein, calcium, iron,
vitamin A, thiamin, riboflavin, and ascorbic
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acid. A significantly greater proportion of
subjects with poor dentition had intakes of
one or several nutrients below their criteria
for sufficiency. This difference remained
even when confounding factors of school
education, professional education, marital
status, and family income, are taken into
account. The authors recognize that the re-
lationship i not necessarily causal, that bad
dietary practices maintained from earlier in
life could have been a factor both in tooth
loss and in poor nutrient intake.
In most of these studies the methods of
dietary estimation by questionnaire are ad-
equate for qualitative evaluation or even
roughly quantitative ifdaily food records are
kept over several days. However, many pa-
pers do not report methodological details
and some calculate with deceiving exacti-
tude nutrient intake based on an inaccurate
method and see trends in very small differ-
ences. In some, nutritional adequacy of the
diet is classified by means that are dubious
by current knowledge such as supposedly
beneficial combinations of food groups.
Dietary habits are greatly affected by so-
cial class and geographical area, which also
affect dental care. Only the 1967 to 1968
DHSS study reported by Berry (27) and to
some extent Osterberg and Steen (32) take
these factors into account. Berry used con-
trol subjects matched for age, sex, and area,
while Osterberg and Steen analyzed their
data considering educational and economic
factors. Several reports (22, 23, 29, 30) were
of housebound or institutionalized pension-
ers and therefore a selected group less rep-
resentative of the elderly than the DHSS
nationwide survey. Although tooth loss
starts early in life all of these studies have
concentrated almost entirely on the elderly.
The nutritional significance of these re-
ported changes in dietary habits related to
tooth loss are the reduction in energy intake
and reduction in specific nutrients of which
the avoided foods may be particularily good
sources. Reduced energy intake may even
be beneficial rather than detrimental to
health as almost half of the adult British
population is obese and the incidence of
obesity increases with age. The obesity situ-
ation is similar in other developed countries.
The specific nutrients and dietary factors
that are likely to be reduced are vitamin C,
vitamin A precursors, folic acid, and readily
assimilable iron and fiber. Some of these
reductions may be compensated for by other
items in the diet. Only accurate dietary rec-
ords, preferably weighed, could estimate the
overall effect of these dietary changes on
nutrient intake. For this purpose only the
1967 to 1968 DHSS nutrition survey re-
ported by Berry is satisfactory. Reductions
in intake do not necessarily mean deficien-
cies. Some studies have measured serum
vitamin levels and clinical parameters of
nutritional status in edentulous subjects.
However, no studies have looked specifically
at the fiber content oftheir diets, despite the
frequent statement that coarse, fibrous foods
are avoided. In view of the accumulating
evidence ofthe beneficial role ofdietary fiber
in the control of obesity, diabetes, divertic-
ulitis, cancer, and other diseases of affluence
this is an important omission. No doubt this
is partly due to the lack of data on the fiber
content offoods but not entirely as no report
has mentioned the health aspects of fiber.
Gastrointestinal disturbances
Although the edentulous tend to eat soft
foods, they do often eat food requiring mas-
tication which are then less well chewed.
Several authors have reported gastrointes-
tinal disturbances caused by inadequate
chewing. Acute intestinal blockage has al-
ready been discussed: chronic gastrointes-
tinal irritation has also been studied in hu-
man case reports and in animal experiments.
Rodriguez-Olleros (33) reviewed 3684
medical histories from which were chosen
those with severe dental deficiency number-
ing 168. The total number of cases of pri-
mary gastritis was 299 of which 83 were
toothless. Therefore almost 50% of the
toothless had primary gastritis compared
with only 6% of those with relatively effi-
cient mastication. No account was taken of
age which is an important factor in such
studies because tooth loss is closely related
to age. However, antecedents likely to pro-
duce gastritis such as excessive alcohol or
caffeine consumption were taken into ac-
count and the proportion was the same in
the two groups.
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His conclusion that tooth loss was an im-
portant cause ofgastritis did not correspond
with experimental work in the rat (34, 35)
and the contradiction led Mumma and
Quinton (36) to conduct a similar but much
smaller study, controlling for age and length
of stay in hospital. Efficiency of mastication
was compared against records ofgastric dis-
tress (including anorexia, epigastric distress,
nausea, and vomiting). Their results are less
convincing. The authors conclude that mas-
ticatory efficiency had some influence on
gastric distress as a combination of two or
more symptoms occurred more frequently
in the inefficient (14%) than in the efficient
(5%) masticators. However, comparing sub-
jects with one or more symptoms the con-
clusion can be reversed as the equivalent
figures are 20 and 25%.
A report from a South African work col-
ony (37) is frequently quoted but is not
scientifically sound. The author bases his
conclusion, that gastrointestinal disorders
were due to lack of teeth, on the fact that
after fitting dentures to 33 edentulous men
who complained of abdominal pains after
meals “they did not complain subse-
quently.” Of the 33, 26 had been admitted
for drunkenness and “it could not be estab-
lished whether the fitting of dentures or the
total abstention from alcohol cured the al-
leged complaint.”
No evidence was found in 53 army pen-
sioners in a residential home of a relation-
ship between masticatory performance and
gastrointestinal symptoms of chronic gastri-
tis (29). However, 30% of patients with he-
reditary malformation of the jaws were re-
ported to suffer from gastric and intestinal
disorders (38).
Some studies have attempted to explain
the mechanisms connecting mastication
with gastrointestinal irritation. It has been
postulated that gastric ulceration may be
related to bile reflux. On this basis Malhotra
(39-42) investigated the higher incidence of
peptic ulcer in Southern compared to North-
ern Indians. His hypothesis that ulceration
is related to lack of mastication is based on
the fact that the diet of North Indians, with
a low incidence of peptic ulceration, consists
largely of wheat chappatis which require
more chewing than the rice-based diet of the
south where peptic ulceration is much more
common. The diets are, however, different
in other respects that are not considered in
the early papers (39, 40) but are in the later
papers (41, 42) including fat, fiber, and spice
content. Both fiber and spice have been pro-
posed to correlate with peptic ulceration
Malhotra suggests that the amount of
chewing required and the constituents of the
diet both have an effect on bile excretion
and he attempted to separate these two fac-
tors. Fecal and urinary urobilinogen were
used in his studies as indirect indices of the
amount ofbile entering the duodenal lumen,
as urobilinogen excretion depends primarily
on the amount of bilirubin entering the in-
testine. When the diet of subjects was
changed from chappati to rice type, fecal
urobilinogen excretion doubled and urinary
excretion quintupled. When the rice diet was
deliberately chewed fecal urobilinogen ex-
cretion was reduced by 30%. The paper does
not report changes in urinary urobilinogen.
The explanation proposed is that chewing
produces more saliva with greater buffering
capacity that would reduce the effects of HCI
as the most potent stimulus for gallbladder
evacuation. Alternatively the mucus content
of the saliva might prevent stimuli for the
release ofcholecystokinin from reaching the
receptors. The hypothesis is that when the
flow rate ofbile is decreased, it is held longer
in the gallbladder where it loses alkilinity
and therefore the ability to damage the mu-
Boccardo and Betancor (44), working on
the hypothesis that it is gastric acidity that
causes peptic ulceration, compared gastric
secretion in dentate and edentulous subjects
after subcutaneous injections of histamine.
Volume and acidity of secretion before and
after histamine stimulation was greater by at
least 35% in subjects whose teeth had been
recently extracted (1 5 to 30 days previously).
However, such differences were less marked
in subjects with chronic loss of occlusion.
Only total acid in the nonstimulated gastric
secretions was greater by 25% in the eden-
Although Sognnaes (34, 35) did not show
that tooth loss was an important factor in
gastritis in the rat, several experimental an-
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imal studies have demonstrated disturb-
ances of the digestive system. In rats, scle-
rosis and dystrophy of the pancreas were
reported (45) after dental extraction, increas-
ing with time after extraction. In pigs, cereal
particle size has a marked effect on the in-
cidence of gastric ulceration, the finer the
grinding the greater the frequency of ulcers
in the esophageal region of the stomach and
the more fluid the stomach contents (46).
One hypothesis suggests that ulceration is
due to acid and pepsin which could be trans-
ported more easily to the esophageal region,
another that it may be due to duodenal
regurgitation. This evidence runs contrary
to the idea that poor mastication causes
gastric ulceration.
The human studies point toward a link
between gastrointestinal irritation and tooth
loss; however, no study exists in which other
known related factors have been carefully
controlled. The most stringent from this
point of view is that of Rodriguez-Olleros
(33). In addition the large number of sub-
jects makes the conclusion relating gastritis
to tooth loss the most convincing. Animal
experiments provide conflicting evidence.
Altered digestion and absorption of
If inadequate chewing is associated with
gastrointestinal irritation, as some evidence
suggests, then the digestion of food and ab-
sorption of nutrients could be altered. This
has been studied in several species of animals
and in man. The human work is mainly
from the first halfofthis century. Van Oefele
(47) and other workers in Germany found
that when mastication was impaired higher
residues of starch, protein, and fat were
found in the feces.
In humans, the classic study was Farrell’s
(48). Volunteers swallowed two small cotton
bags tied together, one of which contained
about 1 g of masticated food and the other
the same food before mastication. The bags
were subsequently removed from the feces
and weighed. The 29 foods tested were class-
ified into three groups according to the ef-
fects of mastication on their residue. Some
foods were better digested with mastication,
others were just as well digested without
mastication. The experiment was extended
to subjects with poor masticatory efficiency
due to loss of teeth and it was found that
even the slightest degree of mastication was
enough to ensure maximal digestion. This
study is often quoted to show that mastica-
tion is not important for digestion. However,
the quantity of foods used in the experiment
was only 1 g and so one would not expect
great differences due to mastication, either
from the physical aspect ofgrinding or from
more complete mixing with saliva.
Sognnaes (49) quotes the work of Becker
(1927) on one 32-yr-old woman in normal
health except for very defective teeth. Anal-
yses ofexcreta showed no marked difference
in the degree of food utilization before teeth
were removed, after removal and wound
healing, and when dentures were inserted.
He concludes that modern food requires
little mastication and the gastrointestinal
tract can compensate for no chewing. An
alternative interpretation ofthis report could
be that defective teeth, edentulous jaws, and
newly inserted artificial teeth are equally
However, further evidence that chewing
is unnecessary for digestion was quoted from
Seppa (1929). He examined the absorption
of ordinary foods after poor, normal, and
prolonged mastication. The absorption was
reported to be about the same except for
bacon which was considerably better di-
gested after prolonged chewing.
In the early years of this century the im-
portance of proper mastication was widely
advocated. fletcher was such a proponent
that very thorough mastication was de-
scnbed as Fletcherizing. To clarify the con-
flict between the observation that all high
protein feeding animals bolt their food and
the then current advocacy of Fletcherizing.
Foster and Hawk (50) studied the utilization
of protein in a uniform diet under different
degrees of chewing in two young men over
periods of 4 to 7 days. The nitrogen content
ofthe food, feces, and urine were measured.
Less than 2% difference was shown in the
apparent or real (corrected for metabolic
nitrogen losses in feces from digestive juices
and epithelium) digestibility of food nitro-
gen.Most of the limited evidence in humans
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therefore suggests that the degree of masti-
cation is not important for digestion at least
in young, healthy subjects.
In animals the evidence is less harmoni-
ous. Sognnaes (34) demonstrated a large fall
in masticatory efficiency in rats with maxil-
lary molars removed and fed a diet of 60%
coarsely ground corn. The size of particles
in the stomach and feces was increased.
However, there was no significant change in
growth rate or general health and it was
concluded that the rats must have compen-
sated for the lower digestibility either by
eating more or selecting a larger proportion
of finer parts of the diet.
Other animal experiments have shown
that impaired mastication leads to reduced
weight gain. Kapur and Okubo (5 1) pro-
posed that lack of oral gratification from
mastication could alter both food intake and
the secretion of digestive enzymes. They
tested the hypothesis on 4- and 12-month-
old rats from which all posterior teeth were
removed or which were sham operated.
They were fed whole cracked corn ad libi-
tum. Differences in food intake and weight
gain were significant only in the older males.
Despite greater food intake of the experi-
mental group weight was lost, not gained. A
greater percentage of coarse food particles
was also found in the gastrointestinal tract
of the experimental animals. From these
observations the authors conclude that
digestion is impaired. Another factor, how-
ever, may be increased metabolism due to
the trauma of total molar extraction which
was presumably greater than the trauma of
the sham operation. The difference in weight
gain from presurgery to 1 3 or 17 wk post-
surgery between the experimental and con-
trol groups ofolder rats was about 30 g. This
might reasonably be lost postsurgery in rats
which at 12 months must weigh in the order
of 300 g. Catch-up growth would occur in
most animals after recovery; however, pos-
sibly the older male rats were unable to
recover to the same extent. We can conclude
therefore that the effect oftooth loss in most
of these animals was negligible except in the
older males. The effect was not to reduce
food intake but possibly to impair digestion
although increased metabolism cannot be
ruled out.
Further experiments (52) on the influence
of particle size showed no significant differ-
ence between male or female experimental
(molarless) and control rats in the intake of
whole cracked corn but the body weights of
the molarless male rats were substantially
lower than controls. Females showed no dif-
ference in body weight. Weight recovery oc-
curred in the experimental male group when
pulverized corn was substituted. This was
accompanied by a temporary sharp increase
in food intake in both groups, but was
greater in the experimental than control
group. The catch-up in growth could have
been related to either the increased intake
or to increased digestibility ofthe pulverized
diet in the molarless rats. The author takes
these results to suggest the clinical impor-
tance of impaired mastication in affecting
digestibilty, particularly in underdeveloped
countries and undernourished groups. How-
ever, we question the comparability of this
cracked corn diet to human eating habits
where the staple is invariably well cooked.
Furthermore even in these extreme expen-
mental conditions most rats were unaffected
by impaired mastication; only the old and
males losing weight, and this weight loss
could be due partly to raised metabolism
from trauma as well as to impaired diges-
Gyimesi and Zelles (53) fed young rats on
various combinations of solid or pulpy food
ad libitum or pair fed. The body weight of
the control group compared with the molar-
less group was 16% greater on the pulpy diet
despite a 15% lower food consumption (per
unit body weight) and 23% greater on the
solid diet of which consumption was twice
that of the molarless rats. Even when the
dietary intake was equal, whether solid or
pulpy, the control rats grew faster than the
molarless rats, indicating either impaired
digestion or higher posttrauma metabolism
in the molarless rats. The reported measure-
ments were made at the end of the 8th wk
after extraction which was probably enough
time for recovery from trauma in young rats.
In pigs, which are poor masticators, cereal
particles of small size are better digested and
give better growth and food conversion effi-
ciency than large particles, according to sev-
eral reports reviewed by Lawrence (46).
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The apparently contradictory observation
that in dogs, meat is more completely di-
gested when fed in large lumps than when
finely ground is surprising (54). Precise fig-
ures are not given but interpretation of a
chart indicates a residue of about 5% from
meat in lumps compared with about 10%
when ground. As part of research for a low
residue diet these studies were performed in
six dogs deprived ofa colon and the amount
of residue measured after digestion of var-
ious foods. Ground meat leaves the stomach
almost unaltered and the intestine may be
less able to digest it completely, whereas
lumps are held in the stomach and the prod-
ucts ofgastric digestion are expelled in small
lots into the intestine.
From the human and animal evidence it
appears that mastication does not have an
important role in the digestion ofmost foods
by most people and most animals. The ex-
ceptions may be for uncooked fibrous foods
such as cereals. In the human diet cereals
are almost always cooked but the digestibil-
ity of other fibrous foods eaten raw may be
impaired. In animals it was the older one
that adapted least well to impaired mastica-
tion or increased particle size. The probabil-
ity is that poor mastication is of importance
to humans only where normal digestive ca-
pacity is impaired. This may be the case
particularly in older people.
Effects on nutritional status and general
The reductions in body weight on expen-
mental diets in molarless animals are of
doubtful significance for humans because of
our wide range of food choice and tech-
niques of food preparation. Several human
studies have reported serum vitamin levels
in experimental conditions, and indices of
nutritional status in surveys of edentulous
Makila’s studies (1 8-20) on edentulous
subjects in Finland compared with controls
found no significant trends in weight change.
As might be expected from changes in food
choice described earlier, the significant dif-
ferences in blood values were lower serum
ascorbic acid values in edentulous compared
to control subjects and a greater proportion
(24% females and 37% males) of edentulous
subjects with Hb values less than 12.5
g/lOO ml than controls (13% females and
19% males).
In the 1967 to 1968 DHSS study of elderly
people throughout Britain, reported by
Berry (27), no relationship was found be-
tween masticatory efficiency and Hb levels
in a small sample (53) matched with controls
of the same age, sex, and geographical area.
However, in the whole sample (700) Hb
levels were related to the amount of meat
consumed. The levels of Hb measured were
unlikely to be associated with ill effects. The
group from the whole sample with ineffi-
cient mastication did, however, show a
higher prevalence of underweight (Quetelet
index wt/ht2) and leanness (low skinfold
thickness). These results are concordant with
the 20% lower energy intake of the subjects
with inefficient mastication.
However, these differences in adiposity
were not confirmed by Elwood and Bates
(55) nor were there significant differences in
serum folic acid and thiamin between effi-
cient and inefficient masticators. Only in the
female toothless subjects were Hb and hem-
atocnt significantly lower but the differences
were small (Hb 12.7 versus 13.3, hematocrit
39.6 versus 4 1 .8). These surveys were con-
ducted to obtain an unbiased sample of el-
derly people from mining valleys (300 and
150 subjects) and a town (250 subjects) in
South Wales.
Other studies were based on less rigorous
sampling methods. Setyaadmadja (56) con-
cluded that elderly edentulous subjects had
significantly more health complaints than
those with teeth. This was based on the
results of a self-administered health ques-
tionnaire from “presumably” healthy female
subjects. The edentulous and dentate in the
age group 55 to 66 yr were compared for the
number of symptoms and signs of ill health
reported. However, the numbers of subjects
were small (23 edentulous versus nine den-
tate) and their backgrounds unreported. The
results were further analyzed by age group
comparing the dental state ofthose with high
scores against those with low scores. In all
but one age group the subjects with many
health problems had fewer teeth than those
with few health problems but the differences
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were significant only in the 55 to 66 yr age
Another report (57) compared the mci-
dence ofpoor occlusion in 460 consecutively
selected patients of a nutrition clinic in Bir-
mingham, AL, with patients of private den-
tal practitioners, patients in a dental school
clinic, and in a cross-sectional survey of the
general population. The fact that the per-
centage edentulous was higher, by as much
as 40% in age groups over 35 yr, in the
nutrition clinic population was taken by the
authors as evidence supporting the hypoth-
esis ofa relationship between impaired mas-
tication and general nutritive failure. Such a
conclusion is unfounded in view of the se-
lection bias.
Further evidence for the association of
edentulousness with undernutrition comes
from the 1972 to 1973 British DHSS survey
of nutrition and health in old age (58) on a
sample of 365 people over 65 yr living at
home in rural and urban areas throughout
Britain. Assessment ofnutritional status was
based on 7-day weighed dietary intake rec-
ords and clinical signs supported by labora-
tory determinations. Twenty-six people were
diagnosed as malnourished. Undernutrition
was associated with various medical and so-
cial conditions. Of these endentulousness
showed a significant correlation with under-
nutriton. In the malnourished group a
higher proportion of the edentulous never
wore dentures when eating (23%) than in
the well-nourished group (5%). Again no
cause and effect can be claimed for these
Nutritional status should give the overall
picture of the effects of mastication on the
several components offood assimilation that
we have reviewed: food choice, gastrointes-
tinal disturbances, digestion, and absorp-
tion. Studies of nutritional status and gen-
eral health are few and far between and most
do not adequately separate mastication from
other social and health factors that influence
food consumption. The evidence for body
weight loss is conflicting. The most positive
evidence is for reduced Hb and ascorbate
Most studies have concluded that tooth
loss in humans and animals has significant
effects on nutritional status, health, gastroin-
testinal disturbances, and digestion. How-
ever, in dissecting closely the reports the
evidence is much weaker than it would ap-
pear. The main weaknesses are that 1)most
human studies have not been carefully con-
trolled for social and health factors that af-
feet food choice and nutrition, 2) the
method of dietary assessment is often poor
or unreported, and 3) extrapolation from
animal studies is not necessarily relevant in
view of our greater flexibility in choosing
and preparing different foods. On the other
hand, human experiments in digestion re-
lated to mastication have been mainly on
young and healthy subjects, whereas the sig-
nificance of improper mastication is more
likely to be where there is some impairment
in the function of the gastrointestinal tract
which would then be less able to cope with
the extra burden of inadequately chewed
food. However, even in the studies of nutri-
tional status which have been mainly in old
people in whom there is a greater chance of
deficient digestive function, well-sampled
studies reveal some but no very striking
differences between those with efficient and
inefficient mastication. Although it is con-
sistently reported that fibrous foods are
avoided, no study has been made of dietary
fiber intake related to tooth loss. This is an
important omission in view of recent evi-
dence relating dietary fiber to health.
It would, however, be wrong to conclude
from the paucity of well-controlled studies
that tooth loss is of no importance: it does
alter food choice reducing the consumption
of meat and fresh fruit and vegetables, re-
sulting in lower Hb and serum vitamin C
levels; total energy consumption may be re-
duced; it appears to be related to gastritis
and therefore discomfort it not impaired
digestion and absorption; it may affect diges-
tion if uncooked fibrous foods are eaten or
if gastrointestinal function is impaired. The
additional burden of poor chewing is there-
fore likely to be ofsignificance to health and
nutrition only in conjunction with other risk
factors. The most serious effect is the in-
creased risk ofdeath by choking on improp-
erly chewed food. The technical measures of
physiological function that we have dis-
cussed also completely ignore the depriva-
by guest on July 12, 2011www.ajcn.orgDownloaded from
tion experienced by those with severe tooth
loss from the aesthetic and sensual aspects
of food, which is one of the great pleasures
oflife. El
1. Todd JE, Whitworth A. Adult dental health in
Scotland in 1972. London: HMSO, 1974.
2. Gray P0, Todd JE, Slack GL, Bulman JS. Adult
dental health in England and Wales in 1968. Lon-
don: HMSO, 1970.
3. Todd JE, Walker AM. Adult dental health. England
and Wales in 1978. London: HMSO, 1980.
4. H#{226}kansson.Dental care habits, attitude towards
dental health and dental status among 20-60 year
old individuals in Sweden. Bokforlaget Dialog
5. Yurkstas AA, Emerson WH. Dietary selections of
persons with natural and artificial teeth. J Pros
Dent l964;l4:93l-4.
6. Miller DS. Prevalence of nutritional problems in
the world. Proc Nutr Soc l979;38:197-205.
7. Eller WC, Haugen RK. Food asphyxiation-restau-
rant rescue. N Engl J Med l973;289:81-2.
8. Anderson DL. Death from improper mastication.
Int Dent J l977;27:349-54.
9. Wengraf C. Pharyngo-oesophageal foreign bodies
in denture wearers. Dent Pract l969;19:281-2.
10. Ray ES, Vinson PP. 584 foreign bodies removed
from the oesophagus. A statistical study. Va Med
Mon l958;85:6l-4.
11. Heath MJ. Intestinal obstruction due to ingestion
of food bolus. Med Sci Law 1980;20: 108-9.
12. Statistics Canada 1965-1974: Causes of death,
provinces by sex and Canada by sex and age. Ot-
tawa: Information Canada.
13. Graham 5, Dayal H, Rohrer T, et al. Dentition,
diet, tobacco and alcohol in the epidemiology of
oral cancer. J Nat Cancer Inst 1977;59:l6ll-l8.
14. Barone JV. Nutrition ofedentulous patients. J Pros
Dent 1965;l5:804-9.
15. Hobson W, Pemberton J. The health ofthe elderly
at home. London: Butterworth, 1955.
16. Davidson CS, Livermore J, Anderson P. Kauf-
mann S. The nutrition of a group of apparently
healthy aging persons. Am J Clin Nutr 1962;
10:18 1-99.
17. M#{228}kil#{228}E. The part played by the dentition in the
utilization of trace nutrients in food. Suom Ham-
maslaak Toim l965;6l:l22-33.
18. M#{228}kil#{228}E. Effects of complete dentures on the
dietary habits and serum thiamine, riboflavin and
ascorbic acid levels in edentulous persons. Suom
Hammaslaak Toim l968;64: 107-52.
19. M#{228}kil#{228}E. Protein consumption and intake of es-
sential amino acids, niacin and calcium before and
after wearing complete dentures. Suom Hammas-
laak Toim 1969;65:125-33.
20. M#{228}kil#{228}E. Effects of complete dentures on dietary
intake and serum levels of pantothenic acid, folic
acid and iron in edentulous persons. Suom Ham-
maslaak Toim l969;65:299-3I 1.
21. Bender AE, Davies L. Milk consumption in the
elderly. Geriat Prac 1968;5:331.
22. Heath MR. Dietary selection by elderly persons
related to dental state. Br Dent J l972;l 32:145-8.
23. Anderson E. Eating patterns before and after den-
tures. J Am Diet Assoc 197 l;58:42l-6.
24. Ettinger RL. Diet, nutrition and masticatory ability
in a group ofelderly edentulous patients. Aust Dent
J 1973;Feb:l2-l9.
25. Hartsook E. Food selection, dietary adequacy, and
related dental problems of patients with dental
prostheses. J Prosthet Dent 1974;32:32-40.
26. DHSS. Report on health and social subjects no 3.
Anutrition survey of the elderly. London: HMSO,
27. Berry WTC. Mastication, food and nutrition. Dent
Pract 1972;22:249-53.
28. Neill DJ. Studies of tooth contact in complete
dentures. Br Dent J l967;123:369-78.
29. Neill DJ, Phillips HIB. The masticatory perform-
ance, dental state and dietary intake of a group of
elderly army pensioners. Br Dent J l970;128:58l-
30. Neill DJ, Phillips HIB. The masticatory perform-
ance and dietary intake of elderly edentulous pa-
tients. Dent Pract 1972;22:384-9.
31. Baxter JC, Nutrition and the geriatric edentulous
patient. Care Dent 1981;l:259-6l.
32. Osterberg T, Steen B. Relationship between dental
state and dietary intake in 70 year old males and
females in Goteborg, Sweden: a population study.
J Oral Rehab l982;9:509-2l.
33. Rodriguez-Olleros A. Gastritis in the toothless. Rev
Gastroenterol 1947; 14:180-5.
34. Sognnaes RF. Studies on masticatory efficiency:II
Masticatory efficiency ofrats. Am J Orthodont Oral
Sur l94l;27 Oralg Surg Sect:383-8.
35. Sognnaes RF. Studies on masticatory efficiency:IV
Mastication and experimental rat caries. Am J Or-
thodont Oral Surg l941;27 Oral Surg Sect:552-6.
36. Mumma RD, Quinton K. Effect of masticatory
efficiency on the occurrence of gastric distress. J
Dent Res l970;49:69-74.
37. Ockerse T. The incidence ofgastrointestinal disor-
ders in edentulous inmates in a work colony. S Afr
Med J 1956;30:l 188-9.
38. Wictorin I, Hillerstrom K, Sorensen S. Biological
and psycho-social factors in patients with malfor-
mation of the jaws. Scand J Plast Recon Surg
1969;3: I 38-49.
39. Malhotra SL. Effect of patterns of eating and ant-
acids on faecal urobilinogen excretion. Gut
1968;9:38-4 1.
40. Maihotra SL. Effect of diet on faecal and urobili-
nogen excretion and its possible relationship to the
pathogenisis of peptic ulceration. Gut l968;9: 183-
41. Malhotra SL. New approaches to the pathogenesis
of peptic ulcer based on the protective action of
saliva, with special reference to roughage, vegetable
fibre and fermented milk products. Med Hy-
potheses l978;4:l-14.
42. Malhotra SL. A comparison of unrefined wheat
by guest on July 12, 2011www.ajcn.orgDownloaded from
and rice diets in the management ofduodenal ulcer.
Postgrad Med J l978;54:6-9.
43. Burkitt DP, Trowel HC, eds. Refined carbohydrate
foods and disease. Some implications of dietary
fibre. London: Academic Press, 1975.
44. Boccardo JJ, and Betancor E. Comportamiento
secretomotor gastrica ante la insuficiencia masti-
coria. Rev Dental (San Salv) 1972;19:25-32.
45. Panchoka VP, Enekhnovich VA, Zamureiko Al.
Morphological changes ofthe pancreas in rats after
dental extraction. Stomatologiia (Mosk) 1975;
46. Lawrence TLJ. A review of some effects on health
and performance of variations in the physical form
ofthe diet ofthe growing pig. 1) Cereal processing.
Vet Rec l972;15:67-70.
47. Von Oefele F. Deutsche Zahn. Wochenschrift
l9Ol;4:330-l. In: Neill DJ. The relationship be-
tween masticatory performance and diet. Proc Roy
Soc Med 1973;66:lO-ll.
48. Farrell JH. The effect of mastication on the diges-
tion of food. BrDentJ l956;lOO:l49-55.
49. Sognnaes RF. Studies on masticatory efficiencies: I
Review of the literature. Am J Orthodont Oral Surg
194 1;27 Oral Surg Sect:309-l2.
50. Foster LF, Hawk PB. Gastro-intestinal studies. VII.
The utilization ofingested protein as influenced by
undermastication (bolting) and overmastication
(Fletcherizing) J Am Chem Soc I 9 1 5;37: 1347-59.
51. Kapur KK, Okubo J. Effect of impaired mastica-
tion on the health of rats. J Dent Res l970;49:61-
52. Kapur KK. Influence of ingested food particle size
on body weight of rats. JDent Res l974;53:422-6.
53. Gyimesi J, ZelIes T. Effect ofremoval ofmolars on
weight increase and food intake in albino rat. J
Dent Res 1972;5 1:897-9.
54. Childrey JH, Alvarez WC, Mann FC. Digestion:
efficiency with various foods and under various
conditions. Arch Intern Med l930;46:36l-74.
55. Elwood PC, Bates JF. Dentition and nutrition.
Dent Pract 1972;22:427-9.
56. Setyaamadja ATSH, Cheraskin E, Ringsdorf WM,
Barrett RA. Predictive prosthodontics, general
health status and edentulousness. J Prosthet Dent
1969; May:475-9.
57. Greene HI, Dreizen 5, Spies TD. A clinical survey
of the incidence of impaired masticatory function
in patients of a nutrition clinic. J Am Diet Assoc
l949;39:56 1-71.
58. DHSS report on health and social subjects. 16.
Nutrition and health in old age. London: HMSO,
by guest on July 12, 2011www.ajcn.orgDownloaded from
... The aim of this thesis is to explore relationships of varied dentition status and diet, nutrition and nutritional status in the U.S. adult population aged 25 years and older utilizing national data from the third National Health (Geissler & Bates, 1984) This statement concludes a sentinel critical review of the literature on the nutritional effects of tooth loss by Geissler andBates in 1984. Geissler andBates (1984) describe serious weaknesses in the study designs used by researchers who had tried to make the case that complete tooth loss or ill fitting dentures caused people to avoid nutritious foods which in turn resulted in lower intake of important nutrients and lower levels of the nutrients in the blood. ...
... The aim of this thesis is to explore relationships of varied dentition status and diet, nutrition and nutritional status in the U.S. adult population aged 25 years and older utilizing national data from the third National Health (Geissler & Bates, 1984) This statement concludes a sentinel critical review of the literature on the nutritional effects of tooth loss by Geissler andBates in 1984. Geissler andBates (1984) describe serious weaknesses in the study designs used by researchers who had tried to make the case that complete tooth loss or ill fitting dentures caused people to avoid nutritious foods which in turn resulted in lower intake of important nutrients and lower levels of the nutrients in the blood. ...
... xplore relationships of varied dentition status and diet, nutrition and nutritional status in the U.S. adult population aged 25 years and older utilizing national data from the third National Health (Geissler & Bates, 1984) This statement concludes a sentinel critical review of the literature on the nutritional effects of tooth loss by Geissler andBates in 1984. Geissler andBates (1984) describe serious weaknesses in the study designs used by researchers who had tried to make the case that complete tooth loss or ill fitting dentures caused people to avoid nutritious foods which in turn resulted in lower intake of important nutrients and lower levels of the nutrients in the blood. Many faults were noted in t ...
The hypothesis of this study was that dental status significantly affects diet, nutrition and nutritional status in U.S.A. adults. The objectives were to test whether significant relationships existed between numbers of teeth, of occluding pairs of teeth (OPs) and of posterior occluding pairs of teeth (POPs) amongst (1) those with a solely natural dentition and (2) those who had a dentition with a combination of replaced and natural teeth. In addition, to test whether complete denture wearers differed from fully dentate adults in relation to diet, nutrition and nutritional status. Data were for adults 25 years and older (n=12,243) from the third U.S.A. National Health and Nutrition Examination Survey (NHANES III) 1988-1994, which used a stratified, multi-staged probability sample of the United States non institutionalized civilian population. The population had a full dental examination and dietary analysis and an assessment of blood analytes and anthropometric measures. Findings of multivariate analyses indicated that complete denture wearers had lower (1) consumption of most foods (2) dietary fibre and (3) levels of blood analytes than did the fully dentate. Significant relationships existed between numbers of teeth (and OPs and POPs) and most of the nutrition related outcomes amongst people with only natural teeth. Among people who had both natural and replaced teeth there were some differences in diet, nutrition and nutritional status between those with low numbers of teeth, OPs or POPs (whether natural or replaced) compared to fully dentate adults. On the other hand, there were few associations between diet and dental status in the rehabilitated group with more than 20 teeth. An inverse relationship was found between dental status and Body Mass Index across all typologies.
... Several studies showed an impact of dental status on modifications in food behavior (Geissler and Bates, 1984;Brodeur et al., 1993;Joshipura et al., 1996;Kagawa et al., 2013). Geissler and Bates (1984) demonstrated in their review that tooth loss was related to a reduced consumption of meat, fresh fruit and vegetables based on the results of a nutrition survey in the British elderly population. ...
... Several studies showed an impact of dental status on modifications in food behavior (Geissler and Bates, 1984;Brodeur et al., 1993;Joshipura et al., 1996;Kagawa et al., 2013). Geissler and Bates (1984) demonstrated in their review that tooth loss was related to a reduced consumption of meat, fresh fruit and vegetables based on the results of a nutrition survey in the British elderly population. These results go in line with the ones of Joshipura et al. (1996) who demonstrated that participants with less teeth consumed less vegetables in terms of frequency. ...
... En effet, certains auteurs ont montré que la perception de la texture mais également la perception des flaveurs pouvaient être perturbés avec le déclin de la capacité masticatoire (Manly et al., 1952;Burdach and Doty, 1987;Duffy et al., 1999;Veyrune and Mioche, 2000;Nalcaci and Baran, 2008). De plus, des études ont montré que la perte de dents ou le port de dentier pouvait affecter le comportement alimentaire (Geissler and Bates, 1984;Brodeur et al., 1993;Joshipura et al., 1996;Kagawa et al., 2013). En effet, la plupart des études ont mis en évidence le fait qu'un mauvais état bucco-dentaire était lié à une diminution d'apports en nutriments par rapport à une population en bonne santé bucco-dentaire (Ernest, 1993;Sahyoun et al., 2003;Hung et al., 2005;Yoshihara et al., 2005;Cousson et al., 2012). ...
Context. In human, oral food intake is the ultimate stage of food supply chain and the beginning of food disintegration and the digestion process. During aging, the oral health changes and sometimes eating food can be a real challenge as food can be hard to masticate, humidify or swallow.Objective. The aim of the present study is to determine which oral factors (salivary, dental, tongue strength) have an impact on physiological – ability to form a food bolus – and psychological – pleasure to eat – dimensions of food oral processing in order to select culinary techniques and help elderlies maintaining an appropriate protein intake in spite of the occurrence of poor oral health.Material and method. Resting and stimulated salivary flow, oral status, the ability to form a food bolus, the pleasure induced by food consumption and the nutritional status were measured on 108 elderly people (65-92 years old, living at home, with no acute pathology at the time of the study). In parallel, culinary technics that aimed at improving meat texture were developed and evaluated throughout physical measurements and oral comfort assessment by the elderly volunteers.Results and conclusion. Multivariate analysis highlighted the fact that oral factors (salivary, dental, muscular) play different roles in food oral processing and eating behavior in elderly people. Moreover, the assessment of oral comfort on the culinary technics showed that some technics improve significantly meat tenderness and juiciness. Those results will help the development of food offer tailored to elderly people with or without oral health impairments.
... 41 Nonetheless, we cannot exclude the possibility that other dietary factors, such as intake of fruit, vegetables, and protein, that are known to be affected by tooth loss and difficulty in chewing, could affect nutrient intake, and therefore be responsible, indirectly, for the observed relationship between poor oral health and decline in physical function; these factors should be examined in future studies. 39,42 In the current study, periodontal pocket depth (a measure of current periodontal disease) was associated with decline in chair stand and gait speed in the BRHS cohort. In support of these findings, periodontal disease has been associated with decline in grip strength 21 and physical frailty in later life. ...
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Background Poor oral health could be associated with changes in musculoskeletal health over time. This aim of this study was to investigate the longitudinal relationship between oral health and decline in physical function in later life. Methods We did a prospective analysis of two cohorts of older adults (aged 70 years or older) including men from the British Regional Heart Study (BRHS; n=612), and men and women from the Health, Aging and Body Composition (Health ABC) Study (n=1572), followed up for about 8 years. Data were available for clinical or self-reported oral health measures, muscle (grip) strength, and physical performance (chair stand and gait speed). ANCOVA models were used to assess the association between oral health and follow-up physical function scores. Multivariate logistic regression models were used to examine the associations between oral health and decline in physical function over the follow-up period. In the BRHS, changes in oral health and physical function were also assessed. All models were adjusted for relevant sociodemographic, behavioural, and health-related factors. Findings In the BRHS, complete tooth loss and difficulty eating were associated with weaker grip strength at followup, and periodontal status was associated with decline in gait speed. In the Health ABC Study, complete tooth loss, poor self-rated oral health, and the presence of one oral health problem were associated with slower gait speed at follow-up. In both studies, dry mouth was associated with declines in physical function. In the BRHS, deterioration of dentition (tooth loss) over the follow-up period was associated with decline in chair stand speed (adjusted odds ratio 2·34 [95% CI 1·20–4·46]), as was deterioration in difficulty eating (2·41 [1·04–5·60]). Interpretation Oral health problems are associated with poorer physical function and greater decline in physical function in older adults, and could be an indicator of individuals at risk of reduced physical capacity and subsequent frailty and disability in later life. Funding The Dunhill Medical Trust and the US National Institutes of Health—National Institute of Dental and Craniofacial Research.
... A study on the gender issues and oral health in the elderly found that elderly men had a higher percentage of filled teeth and denture wear compared to elderly women (4). There are several studies to prove that tooth loss affects dietary intake, mastication and the nutritional status of individuals (5). The level of edentulousness and denture needs of the rural elderly are higher than those of the urban elderly (6). ...
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The objectives of this study were to evaluate the prevalence of edentulousness, patient's perception on dietary changes resulting from tooth loss and to identify the disparity between actual and patient perceived need to replace missing teeth in an elderly rural population in south India. A cross sectional study using the systematic cluster sampling method was used to select the study sample of 150 elderly men and women. Data were collected using questionnaires and oral examination. The data were statistically analyzed using chi square test and pearson correlation. 15.6% of the rural elderly were completely edentulous and 54.7% were partially edentulous. Observed differences in distribution between the sampled elderly age groups were found to be statistically significant. Although 70.3% of the evaluated elderly actually required prosthodontic treatment, only 14.4% perceived the need to replace missing teeth. A small percentage of the elderly (18%) perceived a severe change in their diets due to tooth loss. Thirty three percent of them perceived a moderate change and 28% felt that there were no dietary changes because of tooth loss. It is essential to identify feasible strategies to provide primary dental health education and treatment to all rural elderly in the future. We suggest community dental health services as a general health need of the elderly rather than a special health need of the community.
... There are local and systemic sequelae to tooth loss [5,6]. Local complications of tooth loss can result in aesthetic and functional complications [7,8]. ...
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(1) Background: Tooth loss is an important component of the global burden of oral disease, greatly reducing the quality of life of those affected. Tooth loss can also affect diet and subsequent incidences of lifestyle diseases, such as hypertension and metabolic syndromes. This study aimed to evaluate the oral health-related quality of life (OHRQoL) score using the oral impacts on daily performance (OIDP) index in relation to tooth loss patterns among adults. (2) Methods: From 2014 to 2016, a cross-sectional study was conducted on adults living in Bellville South, Cape Town, South Africa. The OHRQoL measure was used to evaluate the impact of tooth loss. (3) Results: A total of 1615 participants were included, and 143 (8.85%) had at least one impact (OIDP > 0). Males were less likely to experience at least one impact compared to the females, OR=0.6, 95% C.I.: 0.385 to 0.942, p = 0.026. Those participants who did not seek dental help due to financial constraints were 6.54 (4.49 to 9.54) times more likely to experience at least one impact, p < 0.001. (4) Conclusions: Tooth loss did not impact the OHRQoL of these subjects. There was no difference in the reported odds for participants experiencing at least one oral impact with the loss of their four anterior teeth, the loss of their posterior occlusal pairs, or the loss of their other teeth.
... Although incidence of edentulism has been reported to decline 4 , gradual tooth loss continues and presents influential determinant of poor OHRQoL among elderly people 3 . It is also known from the literature that oral health issues have the great impact not only on the well-being and social activities of people 5 , but also on chewing efficacy and nutritional intake 6 11 . In fact, patients need to function with prosthesis, thus their final evaluation should be considered paramount. ...
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Background/Aim. Oral health disorders are crucial regarding general health and quality of life of the elders. The aim of this cross-sectional study was to evaluate the long-term clinical and patient-centered outcomes of dental implants, placed in partially and fully edentulous people older than 65 years. Methods. A total of 38 participants with an overall number of 168 implants were selected and underwent clinical and radiological examination. The implant survival rate, implant failure rate and other complications were recorded and analyzed. All participants agreed to respond to the Oral Health Impact Profile-14 (OHIP-14) questionnaire and another questionnaires on the Visual Analog Scale (VAS) related to their experiences and satisfaction with the overall implant treatment. Univariate and multivariate regression models were used to verify the relation between the OHIP score and the VAS questionnaires? items. Results. The implant survival rate was 94.3%. The number of implants without any complication was 73.2% (123), while biological and technical ones occurred in 17.3% (29) and 9.5% (16) implants, respectively. Regarding quality of life, significant difference was found only between those who wear fixed and removable restauration (p = 0.001). The multivariate regression model showed that the degree of satisfaction with shape and size of dentures was significantly associated with lower OHIP scores, indicating a better quality of life. Conclusion. Ac-cording to the results obtained, it can be concluded that dental implant therapy in elderly people can be considered as predictable long-term treatment option regarding high implant survival rate, minimal complications and significantly better quality of life found in the group with fixed dentures.
... Whilst food choices can be affected by a range of factors, including social, demographic, sensory, economic, cultural and behavioural, the ability to bite and chew is also important [31]. Impaired masticatory efficiency has also been shown to be associated with reduced nutrient intake, poor nutritional status and subsequent health [32][33][34][35] (Fig. 6.4). ...
Nowadays, many people retain their natural teeth until late in life as a result of the large success of preventive strategies. However, there is still a very high prevalence of edentulism and partial edentulism especially in elderly patients, and many of these patients are provided with inadequate dental prostheses. In addition, many elderly citizens suffer from systemic diseases leading to increased drug prescription with age. This may have direct or indirect negative effects on the health and integrity of oral tissues like teeth, mucosa or muscles. There is growing evidence that a close interaction between the general medical condition and oral health exists. From a dental point of view, the chewing ability and capacity and its interaction with the nutritional status seem to be especially important. For example, complete denture wearers present a significant oral disability, which often leads to a gradual deterioration of their individual dietary habits. The improvement of maximum bite force and chewing efficiency may be an important prerequisite for an adequate nutrition. Those functional parameters can often be improved by providing functional dental prostheses or by stabilizing complete dentures with endosseous implants. Nevertheless, an improvement of the nutritional status can only be achieved through a close collaboration with dieticians or clinical nutritionists.
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Background Dental prostheses, which aim to replace missing teeth and to restore patients’ appearance and oral functions, should be biomimetic and thus adopt the occlusal morphology and three-dimensional (3D) position of healthy natural teeth. Since the teeth of an individual subject are controlled by the same set of genes (genotype) and are exposed to mostly identical oral environment (phenotype), the occlusal morphology and 3D position of teeth of an individual patient are inter-related. It is hypothesized that artificial intelligence (AI) can automate the design of single-tooth dental prostheses after learning the features of the remaining dentition. Materials and methods This article describes the protocol of a prospective experimental study, which aims to train and to validate the AI system for design of single molar dental prostheses. Maxillary and mandibular dentate teeth models will be collected and digitized from at least 250 volunteers. The ( original ) digitized maxillary teeth models will be duplicated and processed by removal of right maxillary first molars (FDI tooth 16). Teeth models will be randomly divided into training and validation sets. At least 200 training sets of the original and the processed digitalized teeth models will be input into 3D Generative Adversarial Network (GAN) for training. Among the validation sets, tooth 16 will be generated by AI on 50 processed models and the morphology and 3D position of AI-generated tooth will be compared to that of the natural tooth in the original maxillary teeth model. The use of different GAN algorithms and the need of antagonist mandibular teeth model will be investigated. Results will be reported following the CONSORT-AI.
Statement of problem Tooth loss directly affects mastication, cognitive function, and oral health-related quality of life (OHRQoL). Complete dentures (CDs) and removable partial dentures (RPDs) represent a common oral rehabilitation approach. However, studies addressing the impact of removable dentures on replacing missing teeth are lacking. Purpose The purpose of this clinical study was to evaluate whether the OHRQoL, the jaw function limitation (JFL), and the masticatory efficiency of CD and RPD wearers are similar to those of patients with natural teeth and to evaluate whether wearing removable dentures can predict an effect on the OHRQoL, JFL, and masticatory efficiency of their wearers. Material and methods The Oral Health Impact Profile (OHIP-14) questionnaire and the JFL scale were used to measure OHRQoL and JFL. Masticatory efficiency was analyzed by using a subjective color-mixing index for the chewing gum bolus and shape index and an objective colorimetric analysis by using a software program ViewGum. Data were analyzed with Kruskal-Wallis and post hoc Dunn tests, followed by multiple linear regression (α=.05). Results The results from OHIP-14 evidenced that both denture groups presented a low impact on OHRQoL. JFL was higher for all denture wearers. For the subjective color-mixing analysis, the control and RPD groups presented better masticatory efficiency than CD wearers. Colorimetric analysis evidenced better masticatory efficiency for the control group, who differed from the CD and RPD groups. Wearing RPDs was a predictor of impaired JFL and OHRQoL, and the use of CDs was a predictor of impaired JFL and masticatory efficiency. Conclusions Despite being rehabilitated, CD and RPD wearers still had impaired OHRQoL, JFL, and masticatory efficiency. Also, the use of these prostheses can predict a negative effect on these 3 variables.
Résumé Le vieillissement s’accompagne fréquemment d’une baisse d’appétit et de la prise alimentaire, ce qui prédispose la personne âgée à une perte de poids et augmente le risque de dénutrition. Une des raisons physiologiques expliquant cette baisse de prise alimentaire est la forte dégradation de l’état buccodentaire du sujet âgé rendant l’acte alimentaire douloureux. Face à l’enjeu considérable que représente la dénutrition en matière de qualité de vie et de santé publique, il est essentiel de développer une offre alimentaire répondant aux besoins nutritionnels des personnes âgées tout en satisfaisant leurs plaisirs à manger. Dans ce contexte, l’objectif de cet article est de présenter un panorama des résultats obtenus dans le cadre du projet d’ANR AlimaSSenS dont l’objectif fut, via une approche interdisciplinaire et systémique centrée sur les processus en bouche et la formation du bol alimentaire, le développement d’aliments de bonne qualité nutritionnelle et adaptés aux capacités orales des personnes âgées.
The food preference of subjects with natural dentitions was compared with the food items selected by subjects wearing dentures. Results indicated that denture patients tended to avoid foods that were difficult to chew, such as meats, raw vegetables, sandwiches, and salads. Patients with natural teeth ate less cheese, processed fruit, fish, raw fruit, eggs, cereals, bread, and cooked vegetables.
Interview and dental examination data were gathered on 584 males with cancer of the oral cavity and on 1,222 control patients with nonneoplastic diseases at Roswell Park Memorial Institute, Buffalo, New York. No dietary characteristics distinguished cancer patients from controls. However, a higher risk of developing oral cancer was associated with heavy smoking, heavy drinking, and poor dentition. When controlled for the other factors, each factor carried a higher risk. Moreover, heavy smokers and heavy drinkers with poor dentition and males with all three traits had a substantially higher risk than would have been expected, if the traits were considered additively. The risk for males with all three traits was 7.7 times that of men with none of these traits.
Changes in body weight were induced by varying particle size of the same food fed to old male rats with impaired masticatory function. Ingestion of coarse particles for ten weeks produced continuous gradual weight losses. Feeding of pulverized food resulted in significant weight recovery.
This article has no abstract; the first 100 words appear below. IT has been 10 years since Haugen¹ demonstrated that sudden deaths during meals — falsely labeled "heart attacks" — are usually due to choking on a large piece of meat. Four years earlier Helpern² was surprised to learn how often the physician, deluded by the suddenness of death, did not suspect choking and attributed death to coronary thrombosis. Though accurately described in numerous lay publications, this lethal emergency has received scanty recognition in the medical literature. This neglect may explain why a physician in a restaurant recently tried desperately and unsuccessfully to give a choking victim mouth-to-mouth resuscitation, which is . . . Source Information From the Department of Pathology. Holy Cross Hospital, Fort Lauderdale, Fla. (address reprint requests to Dr. Ellerat 4701 N. Federal Highway, Fort Lauderdale, Fla. 33308).
Many edentulous patients are “sick patients.” Often, geriatric considerations are involved, as well as obesity and postmenopausal problems. These patients have deficient tissues on which to build dentures.One of the most important factors of a satisfactory prosthetic service is the nutrition of the patient. Dietary supplements and specific diets were suggested to maintain the nutritional health of edentulous patients throughout the course of their treatment for prosthetic restorations.