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Presented byDr shria dhaonMds 2nd year
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Nutrition : care in edentulous patient
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Terminologies
Nutrition:- the science of how the body utilizes food tomeet requirements for development, growth, repair
and maintenance..utilization of food by living organisms
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Diet:
the total oral intake of substance that furnish nourishmentand calories
Nutrients:are the constituents of food necessary to sustain the normal
functions of the body
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Nutrition in denture wearingpatient
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Enjoyment of food is regarded as an importantdeterminant of an adults quality of life
Loose teeth ,edentulism or ill fitting dentures may
preclude eating favorite foods and limit intake ofessential nutrients conversely affecting the health oforal tissues
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The National Institute on Aging has judged that inthe area of geriatrics, there is a triad, nutrition-health-aging, which cannot be separated and areparts of an integral whole.*
It is felt that malnutrition is the antecedent ofdisease.Since aging is a life process, good nutritionand health practices must be applied throughout
life.Watkin D: Logical bases for action in nutrition and aging. J AmGeriatr Soc
26(5): 193-202, 1978
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Decreased chewing ability ,fear of choking whileeating & irritation of oral mucosa under denturesmay influence food choices of denture wearer
Caf coronaryNutrition status of patient effects the health of oral
tissues and oral tissue adaptation to new denture
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Factors affecting nutritional status of theelderly
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S
Sight
Smell
Teeth
Memory
Ability to move
depression heart disease
lonliness diabetes, osteoporosis etc.
Physiological changes
Nutritional statusof elderly
Economical
changes
Psychological orsocial
changes
Medication or
disease
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Impact Of Dental Status On Food Intake99
Food choices of older adults are closely linked todental status and masticatory efficiency
Loss of teeth often leads adults to select diets that
are lower in nutrient densityWhen compared to dentate individuals edentulous
consume fewer vegetables , less fibre and caroteneand more cholesterol , saturated fat and calories
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Do prostheses affect dietary intake?
The studies to date, because of the way they wereconducted, provide unclear results. Dentures appear
to improve dietary quality somewhat but do notreally compensate for loss of teeth.
Papas et al. (1998a) evaluated the impact of fulldentures and noted lower intake of protein and 19
other nutrients. In a separate population, Papas etal. (1998b) reported that subjects who woredentures consumed more refined carbohydrates,sugar, and dietary cholesterol than their dentatecounterparts.
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Importance of Proper Nutrition1111
Enough intake of essential nutrients to maintain goodhealth..
Carbohydrates
Fat
Protein
Vitamins
Minerals
Water
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Nutritional Importance of Carbohydrates1212
Contributes to 60-70% of total caloric
requirement
Types of Carbohydrates
Simple
candy, sweets, fruit
individual glucose or fructose molecules
Complex
rice, breads, potatoes
Chains of glucose molecules
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Nutritional Importance of Proteins1313
Body building food repair n replacement of
body tissues
fundamental basis of cell structure and its function
10 -15% of total body energy is derived from protein
osmotic pressure, clotting of blood, muscle contraction
Starvationmajor supplier of energy
Types of Amino Acids
Nonessential (14) can be made by body
Essential (8) must be made by body
Sources of Protein
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Nutritional Importance of Fats1414
Provides 9Kcal/g of energy
Lipids contains 15-50% of body energy requirement
Fat is stored in adipose tissue and serve as energyreserve
Protect internal organs, regulate temp, store energy
during starvation
Forms cellular components
Essential Fatty Acids .which body cannotsynthesizefatty acids- linoleic and linolenic acid
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Functions of EFA :
Structural component of biological membrane
Participate in transport and utilization of cholestrol
Prevent fat accumulation
EFA rich food is sunflower oil,cotton seed oil,soyabean oil,meat ,pork and chicken
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deficiency-
-impairment in growth and reproduction
- BMR
- Toad skin (phrynoderma)- scaly dermatitis, hair loss,poor wound healing
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Nutritional importance of vitamins1717
Organic substances that regulate numerous anddiverse physiological processes in the body
Do not contain calories
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Nutritional importance of minerals1818
Inorganic elements found in food that are essentialto life processes
About 25 are essential
Classified as major or trace minerals
Sodium, zinc, iron, fluoride, calcium, phosphorus,magnesium, potassium
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Functions of Water1919
Comprises about 60% of body weight
Chief component of blood plasma
Aids in temperature regulation
Lubricates joints
Shock absorber in eyes, spinal cord
Active participant in many chemical reactions
Helps in excretion
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2020
Age (years) Water (ml/kg bodywt)
Infants Birth- 1 120 -100
children 0 -10 60 - 80
Adolscent 11- 18 41 - 55
Adult 19 - 51 20 -30
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Why do elderly or aging patients have
malnutrition??
Factors determine the nutritional status of the
geriatric patient :
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Factors affecting nutritional status of the elderly
Sight
Smell
taste
Teeth
Memory
Ability to move
depression heart disease
lonliness diabetes, osteoporosis etc.
ENERGY INTAKE OR EXPENDITURE DECREASES
HIGHER DEMAND FOR NUTRIENT CONTENT OF DIET
Nutritional statusof elderly
Economical
changes
Psychological orsocial
changes
Medication or
disease
Physiologic changes
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Biological concomitants of the aging process
Reduced taste and smell acuity accompanies aging
The largest study is that by Mattes et al. (1990),
who evaluated 118 patients with taste distortion andtaste loss.
They evaluated that sensory perception of taste
,texture acceptability is rated lowest in completedenture wearers
Ability to sense thirst is reduced,leadingdehydration
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Dry mouth and altered taste decrease PLEASURE ofEating.
Eating habits are those of having large amounts ofcommercially prepared convenience foods.
Such diets are rich in carbohydrates and calories butlow in proteins & vitamins.
With aging lean body mass is replaced by
fat,reducing metabolic rateEnergy needs decline due to reduced basal
metabolism and physical activities
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The onset of chronic disease leads to low physicalactivity
Bone loss is normal part of aging,trabecular bone is
affected first several factors contribute to age related bone loss,
leading to osteoporosis :genetic background
hormonal status bone density
low exersice level
inadequate nutrition
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Dehydration:
Major problem in seniors
Due to sense of thirst is reduced
Water lost by kidneys, intestine , lungs and skin is2500cc/day must be balanced
Kidney function is depressed in elderly ,due to
glomerular leakage
The filteration system of kidney works hard toexcrete toxic additives and preservatives present in
food everyday for years and years
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Kidney must eliminate these toxins if the person hasto survive ,over years kidney damage is cumulative
Dehydration can affect:
Saliva:
Impotant for mastication, food is formed intobolus ,which then swallowed and digested
When salivary flow is low it causes xerostomia ordry mouth
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Causes: physiologic
Menopause
Reduce water intake
Chronic glomerular leakage
psychological
DepressionDisease
DiabetesPernicious anemia , vitamin A and vitamin Bdeficiency
HIV infection and other auto immune diseases
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Clinical symptoms and signs seen by
prosthodontist
skin of the patient is wrinkled with loss of
turgidity is seen
Cornea of the eye is dry,
diminished tear secretion
old patient cry inside
Muscle strength is diminished and facial contourcollapse.
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Clinical symptoms and signs seen by prosthodontist
Oral mucosa is dry ,hot and fragile
Reduced salivary secretion,saliva is thick ,foamy andropey
Gloves sticks to mucosal surface
Materia alba accumulates due to lack of self cleasning
activity
Dorsum of the tongue is fissured*atrophy of filiformpapillae
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Treatment:for patient on medications or radiationtherapy
Salivary substitute should be provided for relief
which includes :Sialogogues: sugar free gums , lozenges candies
If drug is suspected to be the cause consulting with
physician drug can be alternated or dosage can bemodified
.
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In such cases, measurement of a patient's nonstimulatedsalivary flow rates before and after altering their medicationmay be useful in gauging the success of treatment.
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Pilocarpine hydrocholoride and Cevimilinehydrochloride are commonly used drugs for salivarystimulation and produce clinically significantincrease in salivary flow in xerostomic patients
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In severe xerostomic cases, saliva substitutes orsalivary stimulants may be used.To minimizepatient discomfort, soft denture liners can also beused. Often, a combination of treatments may be
required.
Saliva substitutes containing thickening agents forlonger relief and increased moistening and
lubrication of the oral surfaces have been developed.These are available as solutions, sprays or gels
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contents:
carboxymethylcellulose, electrolytes and flavoringagents eg wet mouth (ICPA Health Products Ltd),
aqwet (Cipla Ltd)Main problem is to deliver this substitute constantly
into patients mouth without affecting his normalroutine. Where all treatment modalities have proven
unsuccessful, the incorporation of artificial salivaryreservoir in dentures, has been proposed
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Dentures incorporating metal bases may exhibitimproved accuracy of fit and effective wettingcontributing to better retention Metal basedprosthesis are also easier to clean and have less
plaque accumulation.
Patients wearing implant supported denturesreport improved oral comfort and function when
compared with conventional, mucosa-supportedprosthesis.Removable prosthodontic therapy and xerostomia. Treatment considerations. JosephJ Massad, David R Cagna Dent Today June 2002 ,vol. 21, Issue 6, 80-7.
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Patient treatment for physiologic changes
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Milk is also proposed as salivary substitute ,aids inlubrication, pleasure eating , buffering action
Additional recommendation: breverages producing
more saliva-water with slice of lemon,lemonadeDiet planning
Patient is advised for bound water intake in form ofsoups as they are more effectively absorbed byintestine and carried to tissue cell by vascularsystem
Vegetable fibres are strongly hydrophilic and also
softens the feces for elderly patient
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Dentifrices:
Biotene and Oralbalance products are availableover-the-counter from Laclede, Inc. (These are
antixerostomia dentifrices that contain threesalivary enzymes, lactoperoxidase, glucose oxidaseand lysozyme, specifically formulated to activateintra-oral bacterial systems
Currently available formulations include:
Biotene Dry Mouth Toothpaste
Biotene Gentle Mouthwash
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Calcium deficiency and bone loss4242
Bone loss is normal part ofaging that effects maxilla and
mandible
Sites where trabecular bone ismore prominent like alveolar
bone ,Vertebrae ,Wrist
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Thus, increase bone loss leads to a condition calledas osteoporosis
Osteoporosis causes weak bones., bones looses
mineral calcium. They become fragile and breakeasily.
Fracture usually at hip , spine and wrist
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How can we evaluate???
Dentist is the first to detect
Trabecular bone is source of calcium used tomeet tissue calcium needs
Alveolar bone loss precedes loss of calciumfrom the vertebrae and long bones
In a Study done by , Wical & Swoope in 1974,They found that there was a positivecorrelation between LOW CALCIUM intake,
calcium phosphorus imbalance & severe ridge
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How to get enough calcium everyday??
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Treatment:
Dietary calcium intake is critical
Major source of calcium-are milk cheese ,
yogurt,green broccoli, salmon and sardines.Turnips ,calcium fortified fruit juices.
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Advice patient to drink 3 or 4 glasses of low fat milkeveryday
Eat 5- 7 oz of cheese every day
Adequate intake of Vitamin D is alsorecommended,as it ennhances calcium resorption inintestine
Daily dose of 10g is recommendedSources : fish fish liver oil, egg yolk,sunlight
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In lactate intorlant individuals-calcium supplementsare recommended
Osteoporotic individuals:
Calcium supplements includeCalcium carbonate - 40% Elemental Calcium
Calcium citrate - Absorbed BETTER by Older
women
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Protein deficiency4949
In elderly protein depletion of body source is seen asdecrease in body mass
Muscles account for 45% of body mass which drops
to 27% in old patientRecommended requirement adult-0.8-1.0 g/kg
body wt.
How will we identify it??Reduction in muscle mass is more conspicous in
muscles of mastication
There is marked decrease in muscle strength andbulk
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Treatment: for physiologic factor:
Patient is advised for mutual supplementationie.,cereals,wheat and rice along with pulses like
bengal gram ,2-3 servings of 1 cup (cooked)Other good source is meat ,fish-which can be
advised 2-3 oz
2 eggs per day
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Vitamin and mineral deficiency5151
RECOMMENDED DIETARY ALLOWANCE (RDA)
Represents quantity of nutrients advised daily
Vitamin C:
RDA for ascorbic acid is 500mg/day
Synthesize collagen ,basic structure of tendons andpdl
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How will we evaluate??
Slow healing of wounds ,after extraction
Hypermobility of teeth
Edematous oral mucosa
Tender & bleeding gingiva
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Treatment
Dietary sources includes CITRUS fruits, peppers,melons, KIWI fruit, mangos, papaya & strawberry
Advised dosage is 1 orange,1/2 grapefruit or cupfruit juice ,2-4 serving /day for 5 days
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Vitamin B complex:
Folic acid plays an important role in cell division &RBC formation inadequate intake of folate may resultin anemia
How will we evaluate???
Clinical symptoms of sour or metallic taste
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Lips: chelosis
angular stomatitis
inflammation
Tongue:
edema
magenta tongue
atrophy of filiform pappila
burning sensation
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Treatment:
Dietary sources include Oranges , Cantaloupe,Broccoli, asparagus & dried beans
Recommended 1 cup cooked dry beans 2-3 servings/day for 10 days
i l
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minerals
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Sodium
Regulates balance of body fluids
Nerve function
Acid base balance
Blood pressure
Deficiency..
Headache
Weakness, cramps
Inc fluid retention in body
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Zinc
Reqd for digestion n metabolism
Wound healing
Tissue growth
Reproduction
Deficiency leads to:
Retarded growth
Taste/smell alteration
Dec immune function
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Iron
Growth
Immune system health
Hb formation
Deficiency:
Anemia
Loss of weight
Gastric disturbances
Pallor
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Phosphorus
Formation of bones n teeth
Metabolism
Muscle activity
Acid base balance
Deficiency:
Weakness, loss of appetite
Retarded growth
Porous bone
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Minerals and vitamins are in small amount areessential to issue health
Many patients can be benefited from dietary
correction and combined with nutritionalsupplements
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It is often difficult ,based on visual inspection or aninterview ,to identify patient need of nutritional care
Patient should be carefully screened
Providing nutrition care for edentulous patiententails following steps
1. obtain nutritional history,record of food intake over3-5 days
2 .Evaluate diet,assess nutritional risk
3.Teach about components of diet ,that will supoortoral mucosa ,bone health and total body health
.Hel atient to establish oals
St
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Step 1
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St
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Step 2
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When record is obtained ,nutrient analysis is obtainedby either
on a computer with dietary analysis software
Or the reported foods can be classified into 5 basictype described on food pyramid guide
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Step 3
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Step 3
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The relationship of diet to the health of oral tissue andpatients diet evaluation is done
Start with a positive note
Explain about bone health and calcium relatonshipUse food guide pyramid as a visual tool to educate
patient
Step 4
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Step 4
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Small changes can be incorporated to patients dietwithin the patients budget
A diet precription can be made for the patient
The result of diet assessment should always recordedImportant detail:advicepatient to reduce the daily fat
intake to 20-35% of total calories
Evidence of link between dietary intake offat,cholestrol and occurrence of hyperlipidemias
Dietary counseling for Denture wearers
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Helping new denture wearers learn to chew
Diet for the first day after denture insertion : full-liquid diet
Vegetable fruit group: juices Bread cereal group: gruels cooked in milk or water
Milk group: in any form, : pasteurized milk,
Meat group:meat broths or soups
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Diet for the 2nd and 3rd day after denture insertion:pureed diet to soft diet
Bread/cereal group-cooked cereals, milk, toast andsoften bread, puffed rice
Vegetable group- juices, well cooked carrots, greenbeans, mashed potatoes, creamed vegetablesFruitgroup- well-cooked fruits (no seeds), juices
Meat group- soft boil eggs, chopped beef, ground liver,chicken or beef in sauce
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Diet for the fourth day and later: soft diet to regulardiet as tolerated
As soon as sore spots are healed, firmer foods can beeaten
Best to cut food into small pieces
Success of dentures-manage sandwiches and salads ofraw fruit and vegetables
conclusion
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conclusion
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Edentulous patients are particularly vulnerable tocompromised nutritional health , dietary guidance isan integral part of treatment of denture wearingpatient
bibliography
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bibliography
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Prosthodontic treatment for edentulous patients
zarb and Bolender;12th edi. Nutrition in clinical dentistry Nizel n Papas;3rd edi
Essential of complete denture prosthodontic
Sheldon Wrinkler;2nd edSyllabus of complete denture Chales Heartwell
Textbook of Biochemistry Satyanarayan
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THANK YOU