Changes in nutrient needs occur due to both physiologic and functional changes in the natural course of aging. Energy requirements decrease progressively with age [19]. This is due to normal changes in body composition reflected in loss of skeletal muscle mass accompanied by gains in both total and visceral body fat mass [19]. Associated diminishing energy requirements can also make it difficult for the aging adult to meet increased vitamin and mineral needs [20]. Calcium and Vitamin D requirements that support bone health in aging are discussed further in Chapter 16. Vitamin B12 needs may be compromised in older adults if malabsorption or inadequate dietary intake is present [20] (See Chapter 1, Table 3.3 for a list of recommended dietary sources of Vitamin B12). A deficiency of this B vitamin is manifested as macrocytic anemia and presents with neurological and sensory symptoms [20, 21]. An excessive intake of Folic Acid, available in most fortified foods, can mask a Vitamin B12 deficiency in the older adult [8, 21, 22]. Diets adequate in dietary fiber, high quality protein, and antioxidants derived from fruits, vegetables, legumes, and grains contribute to successful aging [8]. Age-specific recommendations for both macro and micronutrients can be found in the Appendix.
Dentate Status Affects Diet and Nutrition
Fifty-three percent of adults aged 25–44 and 29% of adults aged 45–64 had a full set of permanent teeth (excluding third molars) according to results of the National Health and Nutrition Examination Survey (NHANES) conducted in 2009–2010 [23]. The prevalence of complete tooth retention was significantly higher among adults aged 45–64 living above the poverty level compared with those living in poverty [23]. Complete tooth loss was significantly higher among adults aged 65–74 with one in four adults over 65 having lost all their teeth [23]. Fifteen percent of adults aged 65–74 and 22% of adults aged 75 and greater were edentulous in 2009–2010 [23]. The prevalence of complete tooth loss was more than twice as high for those living at or below 100% of the federal poverty level (34%), compared with those living above the poverty level (13%). For adults aged 75 and over, there was no significant difference in the prevalence of edentulism; differences observed by race and ethnicity status were not statistically significant [23].
In older adults, caries and its sequellae, along with periodontal disease, are the most common reasons cited by dental professionals for tooth loss [24]. Although the percentage of older adults with removable dentures (approximately 44% of those aged 75 or older) is not increasing, as the population of older adults increases in number, so do the total number with removable dentures [25]. Removable prostheses—ranging from overdentures, complete dentures, implant-supported dentures, or removable partial dentures are used to replace natural teeth in individuals with tooth loss [26]. Subsequently, changes in mastication of foods and alterations in taste and salivary flow occur that may lead to alterations in dietary choices possibly influencing nutritional intake and dietary quality [26–28]. Studies designed to determine the success rate of the variety of possible dental prostheses relative to these alterations remain equivocal and subject to further study [27, 28].
Masticatory Ability
Research consistently has demonstrated that reduced chewing efficiency is associated with decreasing numbers of teeth, removable partial dentures as compared with a similar number of natural teeth, and complete dentures as compared with natural dentition [29]. The number of natural teeth and their function, particularly that of the posterior teeth; the occlusal force or functional tooth units; salivary flow; and oral motor function or muscle strength are thought to be the most accurate indicators of masticatory or chewing ability [30]. Aging is associated with changes in oral architecture and possible muscle weakness; however, the literature suggests that dental impairment rather than age is a major determinant of masticatory performance [31–33].
Changes in dentition can have a profound impact on perceived and actual ability to eat, although perceived chewing efficiency seems to be a more likely determinant of food acceptance than measured function based on chewing strokes required for swallowing, a methodology used as a gold standard in masticatory studies [34]. According to a systematic review of the literature, chewing ability seems to be sufficient with at least 21 teeth and significantly impaired when greater than seven teeth are missing, however, the number of functional tooth units appear to be a critical factor [35]. Reviews addressing comparisons of types of removable prostheses relative to chewing ability reported contradictory results, but there has been an overall slight improvement with implant-supported dentures noted in the literature [36, 37]. Awad et al. studying patients 65 years and older fitted with either implant-supported overdentures or traditional complete dentures, suggested that neither treatment had a more positive effect on nutritional status at 6 and 12 months posttreatment, but that those patients wearing overdentures were significantly more likely to eat fresh, whole fruits and vegetables [38, 39].
Sensory Perception
Taste of foods depends on both the structure of the food’s chemical composition and the binding to the 28 taste receptors expressed on the surface of the tongue [40]. Reports of declining taste function among aging adults leading to changes in food selection have been noted in the literature. However, this may be associated with other conditions such as age-related diseases and health status rather than aging per se [41]. Medications, smoking, lack of tongue cleaning, dental diseases and oral infections and lesions, salivary gland dysfunction, and poorly fitting dentures can alter both senses of taste and smell [42].
Since the 1950s, oral health care professionals (OHCPs) have recognized that taste sensitivity is reduced when an upper denture covers the hard palate which contains taste receptors, making it difficult for a person to determine the location of food in the mouth and thus making swallowing less well coordinated [43–45]. Unusual odor perception and risk of choking are additional conditions that may accompany altered taste perception among older adults [46].
Salivary Flow, Digestion, and Gastrointestinal Function
A decline in salivary flow is associated with reduced masticatory performance in older adults [47]. The estimated prevalence of perceived dry mouth ranges from 20 to 40% in most community dwelling older adults, with a higher prevalence reported in women than men [48]. Although use of select medications is associated with decreased salivary flow, aging per se is not [49]. Adequate saliva plays a significant role in bolus formation of food suitable for swallowing and in retention, stability, and tissue protection of removable dentures [30].
The chewing of foods is important for the initiation of food digestion. Tosello demonstrated that subjects with “a natural set of teeth” had significantly less gastrointestinal pathology than did partially edentulous subjects [50]. Heartburn, chronic cough, hoarseness, asthma, and idiopathic pulmonary fibrosis have all been associated with gastroesophageal reflux disease (GERD), leading to possible dental erosion, taste alterations, chronic duodenal ulcers, and vomiting [51]. GERD in older adults is a common symptom of the aging gut, particularly in those individuals with an increased susceptibility to gastrointestinal complications of comorbid illnesses [52].
Diet Quality, Nutritional Status, Aging, and Oral Health
Aging of the population, together with prolonged retention of teeth, has brought new challenges to OHCPs. In the past, oral care for the elderly was restricted to provision of restorations or partial or complete dentures, but now patients who are older adults are presenting with ongoing dental caries or other oral infectious diseases, failed restorations, and comorbid diseases such as type 2 diabetes mellitus, peptic ulcers, and CVD [53]. These problems may be associated with masticatory, salivary, and olfactory functions and possibly associated pain, reflected in changes in general health, dietary quality, nutritional status, and quality of life [53, 54]. When adults aged 60–71 years in Australia responded to a survey to assess compliance with dietary guidelines in relation to fiber, sugar, fat, and salt reported diminished chewing efficiency, it was associated with lower compliance with those guidelines, reflecting risk behaviors that impact health status [55].
Declining oral health status in older adults has been shown to adversely affect dietary intake and subsequently nutritional status. Deterioration in diet quality due to lack of adherence to dietary guidelines for management of some chronic diseases including diabetes and gastritis may lead to exacerbation of the diseases and negatively impact systemic health [53, 56].
Malnutrition and Nutritional Status
Oral health is associated with malnutrition in older adults [56]. However, malnutrition is independently a complex and multifactorial condition usually representing low quality food intake, possibly reduced food intake, and associated with other concurrent negative systemic health conditions [57]. It may alter homeostasis which can lead to oral disease progression, reduced resistance to oral biological infectious agents, and compromised tissue healing capacity [7]. Evidence that suggests this independent association between malnutrition and oral health requires extensive examination in future research [57].
Study participants 70 years and older when screened using the Mini-Nutritional Assessment were dissatisfied with their gingival (“gum”) health and at risk of malnutrition [58]. Specifically, those who were edentulous were at higher nutritional risk due to insufficient energy intakes and deficits in vitamins and micronutrients than those with teeth [58]. Frail edentulous elders in a Swiss study presented with malnutrition as measured by low serum albumin and weight loss associated with not wearing their dentures due to their ill-fitting condition [59]. An insufficient number of functional tooth units associated with inadequate intake of vitamin C, calcium, riboflavin, and zinc, explained a further association with poor oral health status in noninstitutionalized older adults in Brazil [60]. In the US, data from NHANES revealed lower serum beta carotene, folate, and vitamin C levels in individuals with the most impaired dentition compared to those with a functional dentition [61].
Food Choices and Dietary Patterns and Quality
Aging is associated with possible declines of physiological and cognitive functions that contribute to overall health [62]; nutrition is considered a major determinant of successful aging [62]. Food choices and dietary patterns in combination, as compared to intake of individual nutrients, reflect the total diet and represent targets for change that may improve the influence of diet and nutrition on both oral and general health outcomes of older adults. Two dietary patterns, ranging from healthful to lower quality, were identified based on analysis of 24 hours dietary recalls from over 400 older adults in a study on aging [62]. Using the Healthy Eating Index-2005 scores for analysis, a more healthful dietary pattern was considered a stronger predictor of diet quality [62]. It included higher intakes of fruits, vegetables, whole grains, nuts, legumes, and dairy, and was associated with lower energy density and higher intakes of fiber, folate, vitamins C and B6, calcium, iron, magnesium, and zinc [62]. The alternative pattern of lower quality was depicted as diets low in produce (fruits, vegetables, etc.), and high in sweet foods, high in saturated fat, and low in dietary fiber and vitamins [62].
Dietary studies examining dietary quality for all adults, including older adults, reported similar findings when dietary data were reviewed relative to oral health status [63–65]. The Department of Veterans Affairs Longitudinal Aging Study with 625 community dwelling men age 65 and older reported that an adequate intake of good to excellent sources of total fiber was linked with lower risk of alveolar bone loss progression associated with periodontal disease [63]. Edentulous participants in the United Kingdom Low Income Diet and Nutrition Survey consumed lower intakes of fruits and vegetables compared to their dentate counterparts even after the data were controlled for lack of means to acquire these foods [64]. After controlling data for socioeconomic factors, less than 1% of adults with tooth loss (0–10 teeth remaining) participating in a North Carolina study met recommended intakes for total vegetables, dark green and orange vegetables, energy from solid fat, alcohol, and added sugar compared to those adults with greater than 10 teeth [65]. Adults with fewer than 28 natural teeth reported significantly lower intakes of foods such as carrots and salads, as well as total dietary fiber in the US [61].
Aging affects both hard and soft oral tissues; negative oral tissue changes can cause pain, difficulty in speaking, mastication, swallowing, and poor dietary intake, in addition to aesthetical considerations leading to anxiety and depression [66]. The interactions among nutrition, dietary patterns, and oral health play a significant role in successful aging and the possible decreased risk of oral health difficulties over time.
Dietary Guidance
Prior to receiving dental care to improve oral health, individuals may have developed poor dietary habits associated with tooth loss, poor occlusion, oral infection, and other pathological conditions [67, 68]. Dietary choices, including avoidance of foods that are difficult to chew or cause pain or irritation can lead to the possible avoidance of fruits, vegetables, whole grains, and nuts that contribute to a healthy diet. The consistency, temperature, and dryness of foods have been associated with food-avoidance behaviors of people with either conventional dentures or implant-retained overdentures as well as those with pain and discomfort [25, 26]. Food modifications including steaming and moistening foods, as well as altering consistency by chopping or pureeing to various consistencies, can accommodate temporary oral discomfort and act as a transitional step to improving the dietary quality in an effort to achieve or maintain dietary guidelines associated with successful aging [26].
Patient satisfaction with oral health care, empowerment to achieve a quality diet and adaptation to changes in oral health status due to the insertion of an oral prosthesis are enhanced when OHCPs include suggestions for dietary strategies to help discourage avoidance of foods important in healthful dietary patterns [25, 69, 70]. Table 3.2 lists questions to guide OHCPs when interviewing adult dental patients about oral health conditions associated with dietary behaviors. Table 3.3 provides suggestions for modifications of dietary choices to support oral adherence to dietary recommendations and support of oral and general health status.
Table 3.2
Questions to guide dietary interview of adult patient
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1.
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Is it more comfortable to chew small pieces of chicken or ground beef than to chew pieces of meat?
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2.
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Do you prefer to eat softer foods rather than harder, crusty foods?
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3.
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Are you comfortable chewing foods with nuts and seeds?
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4.
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Is it necessary to add juice, sauce, or gravy to your food or to soak your food before you eat?
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5.
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Can you eat fresh fruits and vegetables that you enjoy with ease?
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6.
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Is it necessary to drink liquids when you eat to help you either chew or swallow?
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7.
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Do you experience excessive coughing or choking when you swallow foods?
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8.
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Does your mouth feel dry most of the time?
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9.
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Do you experience an unusual or different taste when you eat certain foods?
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10.
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Have you gained or lost weight in the past few months?
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Answers can be explored further and correlated with suggestions for dietary modifications listed in Table 3.3
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Table 3.3
Modifications of dietary choices to support oral adherence to dietary recommendations for adults with special needs associated with oral conditions
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Food choices to accommodate need for
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Dairy
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Meat, fish, eggs, and meat alternative
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Fruits and vegetables
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Grains and cereals
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Other
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|---|---|---|---|---|---|
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Soft or liquid alternatives
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Low-fat milk and milk drinks
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Broths, soups, low-fat or Nonfat egg nogs, or custards
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Juices, nectars, sauces, gelatins
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Cooked cereals/grains soaked in liquid
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Moderate use of fats and oils
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Low-fat yogurt and cottage cheese
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Baked, poached and broiled fish, chicken, or turkey
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Pureed, mashed, canned, and cooked fruits/vegetables
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Mash potatoes
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Avoid excessive use of sugars and sweeteners
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High protein breakfast drinks
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Tofu, lentils, soybeans, eggs
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Avoid seeds and peels
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Soft breads without crust
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Ensure daily intake of water
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|
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Low-fat spreadable cheese products
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Avoid nuts and nut butter or spreads
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Add crackers to soups or stews
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|||
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Impaired taste issues
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Enriched milk products in favorite flavors
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Use spices seasonings and herbs to enhance flavor
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Combine juices and purees with meats and other foods
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Enriched and fortified breads such as whole grain
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Seasonings, flavoring agents, and herbs to be used as desired
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