nutrition in etentulous patients
TRANSCRIPT
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ROLE OF NUTRITION IN
MAINTAINANCE OF
ORAL HEALTH OF
EDENTULOUS PATIENTS
Presented ByDr. Kartik R. Morjaria
Post Graduate student
Department Of Prosthodontics
Karnavati School Of Dentistry
Guided ByDr. Dipti S. Shah
Dean, Professor & HOD
Department Of Prosthodontics
Karnavati School of Dentistry
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CONTENTS
1) INTRODUCTION
2) NUTRITION IN PREVENTION AND MANAGEMENT OF
PERIODONTAL DISEASE
3) AGING FACTORS THAT AFFECT NUTRITIONAL STATUS
4) THE IMPACT OF DENTAL STATUS ON FOOD INTAKE
5) GASTRO INTESTINAL FUNCTIONING
6) NUTRITIONAL NEEDS AND STATUS OF ELDERLY
7) FOOD PYRAMID FOR 70+ ADULTS
8) CALCIUM AND BONE HEALTH
9) CLIMATERIC
10) VITAMIN SUPPLEMENTATION
11) DIETARY COUNSELLING OF PATIENTS UNDERGOING
PROSTHODONTIC TREATMENT
12) TRIPHASIC NUTRITIONAL ANALYSIS
13) RISK FACTORS FOR MALNUTRITION IN DENTURE PATIENT
14) NUTRITION GUIDE LINES FOR PROSTHODONTIC PATIENT15) CONCLUSION
INTRODUCTION
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All people have some basic needs of nutritional intake, for
growth, development, maintenance and metabolism. Enjoyment of
food is an important determinant of an adults quality of life. Loose
teeth, edentulousness or ill fitting dentures may preclude eatingfavourite food as well as limit the intake of essential nutrients.
Decreased chewing ability, fear of choking while eating, and
irritation of the oral mucosa when food particles get under dentures
may influence food choices of the denture wearer. Conversely,
affects the health of the oral tissues and the patients adaptation
to the new prosthesis.
In fact, well designed and constructed denture or an implant-
supported prosthesis may prove to be unsatisfactory for a patientbecause of poor tolerance by the underlying tissues and bone. Hence
denture failures can also be due to poorly nourished tissues.
Clinical symptoms of malnutrition are often observed first in
the oral cavity. Because of rapid cell turn over (3-7 days) in the
mouth, a regular balanced intake of essential nutrients is required
for the maintenance of oral epithelium. Inadequate long term
nutrition may result in angular cheilitis, glossitis and slow tissue
healing.
The nutritional status of a denture wearer is influenced by
economic hardship, social isolation, degenerative diseases medication
regimens and dietary supplementation practices.
NUTRITION IN PREVENTION AND MANAGEMENT OF
PERIODONTAL DISEASE
Low Caloric
Intake
UNHEALTHY
ORAL TISSUES
Low nutrients
intake
Diabetes
Alcohol abuse
Medications
Smoking
Xerostomia
Soft Diet
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Nutrition can affect periodontal disease at 3 levels
Contributing to microbial growth in the gingival crevice
Affecting the immunological response to bacterial antigens
Assisting in the repair of connective tissue at the local siteafter injury from plaque and calculus
Nutrition and sulcular epithelium
New cell synthesis
Foliate, B vitamins, protein
Maintain epithelial integrity
Vitamin A
Collagen in basement membrane
Vitamin C, iron. zinc
Nutrition and immune mechanisms
Antibody formation
Protein
Immune cell activity
Protein
Nutrition and the repair process
Connective tissue formation
Protein and Vitamin C
Accelerate wound healing
Zinc
Promoting bone density
Calcium and phosphorus
Effects of food textures on periodontal health
Chewing firm, fibrous foods is beneficial to periodontal health
Increases salivary flow
Promotes a strong periodontal ligament
AGING FACTORS THAT AFFECT NUTRITIONALSTATUS
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PHYSIOLOGIC FACTORS:
Declines in physical and cognitive status often increase withage. For example, decreased lean body mass, particularly muscle
mass (sarcopenia), is common. Muscle mass is a predictor of
strength, mobility, insulin sensitivity and basal metabolic rate. Thus,
with a decline in lean body mass, caloric needs decrease and risk of
falling increases.
Declines in gastric acidity also often occur with age, and may
affect from 10% to 15% of persons over age 60 years. Thishypochlorohydria results from atrophic gastritis and can cause
malabsorption of food-bound vitamin B12. Atrophic gastritis results
in increased levels of bacteria in the stomach and small intestine
that bind the vitamin B12 for their own use and make it unavailable.
Vitamin B12 deficiency, in turn, can result in neuropathy,
megaloblastic anemia, gastrointestinal symptoms, and cognitive
impairment.
Vitamin D deficiency is also common in the elderly for several
reasons : insufficient sun exposure, decline in the skins ability to
synthesize vitamin D from sun, and impaired kidney or liver function
needed to activate vitamin D. Vitamin D synthesis at age 80 years is
half that at age 20 years.
Impairment in the function of the intestinal track secondary toillness, disease, or medications can also result in food maldigestion
and malabsorption. A classic example is the increase in lactase
deficiency found in older individuals. Lactase deficiency results when
the villi of the small intestine secrete too little lactase enzyme to
fully digest the milk sugar, lactose. The resulting pain, bloating,
excessive gas, and nausea lead sufferers to avoid dairy products.
Decrease in intestinal function may also be associated with
increased constipation in older people. The adoption of low-fiber
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diets in response to chewing difficulties and dentures can
exacerbate this condition.
Dehydration, caused by declines in kidney function and totalbody water metabolism, is a major concern in the older population.
Dehydration can be insidious and unrecognized until serious side
effects occur.
Overt deficiency of several vitamins is associated with
neurological and behavioural impairment B1 (thiamin), B2, niacin, B6
(pyridoxine), B12, Foliate, Panthothenic acid, vitamin C and Vitamin E.
PSYCHOSOCIAL FACTORS:
Psychosocial factors may play even greater roles than physical,
medical, and dental issues in determining the health and well-being
of elders. Elders particularly at risk include those living alone, the
physically handicapped with insufficient care, the isolated, those
with chronic disease and restrictive diets, and the oldest old.
Poverty is also a major contributor to malnutrition.
PHARMACOLOGIC FACTORS: MEDICATIONS AND ALCOHOL
Most elders take several prescription and over-the-counter
medications daily. These drugs can interact with food and diet,
sometimes with serious side effects. Declining physiologic functioncan keep drugs in the body for longer periods of time than is
desirable. Drugs can affect the absorption and utilization of some
foods and nutrients, and vice versa.
Prescription drugs are the primary cause of anorexia, nausea,
vomiting, gastrointestinal disturbances, xerostomia, taste loss, and
interference with nutrient absorption and utilization. These
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conditions can lead to nutrient deficiencies, weight loss, and ultimate
malnutrition.
Drugs that exert an effect on taste and appetite
Reduce taste Baclofen, carbamazepine, lincomycin,
penicillamine, phenylbutazone
Alter taste perception Captopril, griseofulvin, lithium carbonate
Metallic taste Ethambutol, gold compounds
Bitter taste Carbamazepine, phenylbutazone
Decreased appetite Anticonvulsants, antineoplastic, carbonic
anhydrase inhibitor, digitalis, estrogens,
flurazepam, indomethacin, lithium salts,
metronidiazole, tetracyclins, thiazides
ORAL FACTORS THAT AFFECT THE DIET AND NUTRITIONAL
STATUS
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Xerostomia:
Xerostomia (dry mouth or hyposalivation) affects almost one in
five older adults. Saliva provides natural protection to the hard and
soft tissues of the oral cavity. When salivary levels decline, teethbecome more susceptible to dental caries. The exposed root
surfaces of teeth are particularly at risk. Xerostomia can also impair
complete denture retention and is associated with increased
periodontal disease, burning or soreness of the oral mucosa, and
difficulties in chewing and swallowing all of which can adversely
affect food selection and contribute to poor nutritional status.
Oral infectious conditions:Periodontal disease also increases with age and maybe
exacerbated with systemic disease
Sense of taste and smell:
Although the olfactory system is generally well preserved with
age, age-related changes in taste and smell may alter food choice
and decrease diet quality in some people. Factors contributing to
this report decreased function may include health disorders,
medications, oral hygiene, denture use, and smoking.
Effects of dentures on taste and swallowing:
A full upper denture can have an impact on taste and swallowing
ability. The hard palate contains taste buds, so taste sensitivity may
be reduced when an upper denture covers the hard palate. It also
becomes difficult to determine the location of food in the mouthwhen the upper palate is covered. As a result, swallowing can be
poorly coordinated and dentures can become a major contributing
factor to deaths from choking.
THE IMPACT OF DENTAL STATUS ON FOOD INTAKE
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1) The food choices of older adults are closely linked to
dental status and masticatory efficiency.
2) The loss of teeth often leads adults to select soft diet;
soft foods are often lower in nutrient density and fiber.3) An individuals masticatory ability is mainly determined by
age, oral motor function, adequate saliva and the number of
occluding pairs of teeth in the mouth.
4) There is general agreement that the masticatory
function of denture wearer is greatly inferior to person with
intact dentition. Denture wearer must complete a greater
number of chewing strokes to prepare food for swallowing.
5) In a study of the united states, department ofagriculture human nutrition research center Boston the
nutrition intake of those who had one (or) two complete
dentures was about 20% lower than that of the dentate
subjects.
6) Studies in Finland showed that the wearing of dentures
for several years, improved the quality of their diet.
7) The condition of an individuals denture also may influence
food selection.
When old complete dentures with poor retention were replaced
with new dentures the masticatory performance of the patients
improved.
The use of osseointegrated implants also increased the chewing
ability and varieties of foods were eaten.
8) The comfort of wearing dentures is dependent on the
lubricating ability of saliva in the mouth. If the oral mucosa isdry, chewing is difficult, denture retention is compromised and
mucosal soreness (or) ulcerations develop.
Salivary flow facilitates mastication, formation of food bolus
and swallowing.
9) Xerostomia may contribute to geriatric malnutrition.
Xerostomia (dry mouth) is a clinical manifestation of salivary
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gland dysfunction. Causes of xerostomia may be use of
medication, therapeutic radiation to the head and neck,
diabetes, depression, alcoholism, pernicious anemia, menopause,
vit A or vit B complex deficiency.10) Milk has been proposed as saliva substitute; milk not only
aids in lubricating the tissues, but also has a buffering capacity.
As dry mouth may result in inadequate nutritional intake, the use
of milk serves as saliva substitute and also an excellent source
of nutrients.
GASTRO INTESTINAL FUNCTIONING
Little research exists on the effect of tooth loss on
gastrointestinal functioning.
The purpose of mastication is to reduce food particles in size,
so that they can be swallowed and to increase the surface area of
food exposed to digestive juices and enzymes. Individuals with poor
masticatory ability often swallow large pieces of food.
When a denture covers the upper palate, it is difficult to
detect the location of food in the mouth. Adults with such dentures
are at a greater risk of having a large piece of food (or) a bone
lodged in the air or food passage, which may cause death.
NUTRITIONAL NEEDS OF ELDERLY
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1) The nutrient needs of older persons vary depending on health
status and level of physical activity. So it is difficult to
generalize about energy, vitamin and mineral requirements
appropriate for all older adults.2) Depending on body metabolism an individual may need more (or)
less of nutrients than proposed in the required daily
allowances.
3) Energy needs decline with age because of decrease in basal
metabolism and decreased physical activity. With aging lean
body mass is replaced by fat, this leads to a decrease in
metabolic rate.
4) Cross sectional surveys showed that the average energyconsumption of 65 74 yrs old men 1800 k cal, Women 1300
k cal.
This is lower than RDA for adults 51 65 yrs
Men 2300 k cal
Women 1900 k cal
5) Complex carbohydrate should be the mainstay of elderly diet.Important component of complex carbohydrate is fibre which
promotes normal bowel function, may reduce serum cholesterol
and is thought to prevent diverticular disease, and
haemorrhoids.
6) Fats contribute about 33% of total calories in an adult diet
Fats Cause heart diseases, obesity, certain cancers, so adults
are advised to maintain their dietary fat intake at 20% to 35%
of total calories.7) The protein intake of denture wearers is lower than that of
dentate adults, but is often adequate.
8) Oral symptoms of malnutrition are usually due to lack of
vitamin B-complex, vit C, iron and protein.
Nutrient lacking Oral symptoms
1) Protein Decreased salivary flow,
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enlarged parotid glands
2) Vit B- complex, iron, protein Lips :
Chelosis Angular stomatitis
Angular scars
Inflammation
Tongue :
Edema
Magenta tongue
Atrophy of filiformpapillae
Burning sensation
Soreness
Pale, bald
3) Vit C Edematous oral mucosa
Tender gingiva
Spontaneous bleeding of
gingival Haemorrhages in
interdental papillae
9) Heavy smokers, alcohol abusers, or persons with high aspirin
intake have a higher daily requirement of vit C.
Vit c Ascorbic acid plays a role in collagen synthesis
(essential for wound healing)
10) Deficiency of thiamine, niacin, pyridoxine, folate (vit-B) and
ascorbic acid are commonly seen in alcoholics.
11) Osteopenia in males, may be due to chronic alcohol intake.
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(PALMER CA. GERODONTIC NUTRITION AND DIETARY COUNSELING FOR
PROSTHODONTIC PATIENTS. DENT CLIN N AM 2003; 47:355-71)
In general, the food guide pyramid for healthy older adults is
narrower than the original pyramid, recognizing that seniors usually
need less energy and therefore usually eat less.
The bread, cereal, rice and pasta group forms the base of the
original food guide pyramid. But the pyramid for older adults isbased on at least eight-ounce glasses of water each day. The
emphasis on fluids is due to older adults reduced sense of thirst
that can lead to drinking less fluid. This two-quart daily fluid intake
can include juice, milk and non-caffeinated soft drinks and
beverages, as well as water. However, alcohol and drinks containing
caffeine can cause the body to lose fluids and become dehydrated.
Dehydration can make kidney function and constipation worse.
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Another key difference from the original food guide pyramid is
the flag at the top to indicate a recommendation for the dietary
supplements calcium, vitamin D and vitamin B-12. These supplements
are sometimes recommended because older adults eat less and donot absorb and process nutrients as efficiently as younger people.
Total calcium intake each day should be 1200-1400 milligrams,
which is the equivalent of three servings of calcium-rich dairy
products (such as milk, hard cheese or yogurt). Supplements, such as
calcium citrate and calcium carbonate are available to make up the
difference.
Daily vitamin D intake should be 600 international units (IUs),which is equivalent to three 8-ounce glasses of milk. Sunlight
provides vitamin D, too, but many seniors often have limited
exposure to it, thereby requiring a supplement if their milk intake is
less than the three glasses.
Seniors do not easily absorb vitamin B-12. Fortified breakfast
cereal can help as it contains vitamin B-12 in a form that the body
will absorb. A total of 2.4 micrograms is recommended each day.Taking a multivitamin for seniors will ensure an adequate intake of
both vitamin D and B-12.
Another difference for the pyramid for seniors is the addition
of a fiber icon (f+). Fiber comes from many sources, including
whole fruits and vegetables, whole grains and legumes. Fiber is very
important because it helps prevent constipation, hemorrhoids and
diverticulosis (inflammation of small pockets lining the intestines). Itis also associated with lower cholesterol levels, and a reduced risk of
heart disease and cancer. A total of 20-30 grams of fiber is
recommended each day for optimal health. Eating the recommended
number of servings of foods that contain fiber will usually provide
that intake.
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CALCIUM AND BONE HEALTH
Bone loss is a normal part of aging that affects the maxilla andmandible, as well as the spine and long bones skeletal sites where
trabecular bone is more prominent than cortical bone, are affected
first (alveolar bone, vertebrae, wrist, and neck of femur)
Several factors are thought to contribute to age related bone loss
that leads to osteoporosis:-
Genetic back ground
Hormonal status Bone density at maturity
Disturbance in bone remodeling process
Low exercise level
Inadequate nutrition
Low calcium intake throughout life is a contributor to
osteoporosis.
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CLIMACTERIC
Climacteric is a period in both males and females, when an
important change in bodily function occurs.
In females this period is termed menopause and in males it is
called andropause.
The glandular functional changes have varying effects
1) Generalized osteoporosis reduction in bone mass with pain,
deformity (or) pathologic fracture.
2) Burning palate, burning tongue etc.
Resorption of alveolar ridge is a wide spread problem.
A greater degree of residual ridge resorption is seen in women
than in men.
Bone loss is accelerated in the first 6 months after tooth
extraction and resorption is greater in the mandible than maxilla.
Dietary calcium is critical to maintaining the body skeleton.
Calcium intake by older adults will not restore the bone, but
will improve calcium balance and slow the rate of bone loss.
Denture patients with excessive ridge resorption report lower
calcium intake.
Recommended daily allowance RDA (1997)
Age (yr) Calcium (
g) Vitamin D (
g)31 50 1000 5
51 70 1200 10
> 70 1200 15
To receive 1000 to 1200 g of calcium, adults must drink 3 or
4 glasses of low fat milk / day.
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VITAMIN SUPPLEMENTATION
Based on nutrient deficiency in denture patients, it may be
reasonable to prescribe a low- dose multivitamin diet.For nutrients to be present in proper ratio, to one another a
multivitamin mineral supplement is preferable to single nutrient
tablets.
The use of megadose vitamin in elderly is of great concern because
with a high dose of a vitamin, it no longer functions as a vitamin but
becomes a chemical with pharmacological activity.
1) Mega doses of vit-D, can disturb calcium metabolism leading to
calcification of soft tissues.
2) High doses of retinol, accelerates bone resorption increasing
the risk of hip fracture.
3) Mega doses of Vit-C can induce copper deficiency anaemia.
4) High intake of Niacin flushing, headache, itching skin
5) High intake of Vit B6 peripheral neuropathies
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DIETARY COUNSELLING OF PATIENTS UNDERGOING
PROSTHODONTIC TREATMENT1) The main objective of diet counseling for patients undergoing
prosthodontic care is to correct imbalances in nutrient intakethat interfere with body and oral health.
2) The quality of a denture wearing patients diet can be
improved with nutrition counseling.
3) Elderly population over 70 years of age is more likely to have
poor diets, and nutrition risk increases with advancing age.
4) Maintenance of oral epithelium, rapid cell turnover in the
mouth, requires a regular balanced intake of essential
nutrients.5) To lower the rate of alveolar ridge resorption, increased
intake of calcium and vitamins is required.
Dietary evaluation and counseling should be included in
prosthodontic treatment, if patient has any of the following physical
or social conditions.
Medical Conditions
Greater than 75 yrs of age Low income
Little social contact
Involuntary weight loss
Daily use of multiple drugs
Need for assistance with daily self-care
Providing nutrition care for the denture wearing patient entails the
following steps :-1) Obtain a nutrition history and an accurate record of food
intake over a 3-5 day period.
2) Evaluate the diet, assess nutritional risk
3) Teach about the components of a diet that will support the
oral mucosa, bone health and total body health.
4) Guidance in the establishment of goals to improve the diet
5) Follow up.
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ASSESSING THE NUTRITIONAL STATUS
TRIPHASIC NUTRITIONAL ANALYSIS(BANDODKAR K.A., ARAS M. NUTRITION FOR GERIATRIC
DENTURE PATIENTS. JIPS 2006; 6, 1:22-28)
PHASE 1
The first phase must be used to screen all patients and consists of
obtaining information from a medical-social history, screening for
clinical signs of deficiency, conducting selected anthropological
measurements and assessing the adequacy of dietary intake.
Qualitative dietary assessment
The purpose of the dietary assessment is to determine what an
individual is eating now, what he or she has eaten in the past and
recent changes in the diet. A questionnaire has been developed to
identify older individuals with nutritional problems.
This questionnaire may be administered by health care professionalsand applied in both inpatient and outpatient settings.
If potential nutritional problems are detected, based on any of
these parameters, the nutritional evaluation should progress to
phase II. However, if at the conclusion of phase I, enough
information is available to ensure a rational basis for therapy, the
nutritional assessment should be terminated and approximatedietary counseling instituted.
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QUESTIONNAIRE
Q. NO. QUESTION SCORE1 I have an illness or condition that made me change
the kind and/or amount of food I eat.
2
2 I eat fewer than 2 meals a day 3
3 I eat few fruits, vegetables or milk products 2
4 I have three or more glasses of beer, liquor or wine
per day
2
5 I have tooth or mouth problems that make itdifficult for me to eat
2
6 I dont always have enough money to buy the food I
need
4
7 I eat alone most of the times 1
8 I take three or more different prescribed or over-
the-counter drugs a day
1
9 Without wanting to, I have lost or gained 10 poundsin the last six months
2
10 I am not always able to shop, cook and/or feed
myself
2
SCORES
TOTAL SCORE NUTRITIONAL RISK
0-2 Good nutritional health
3-5 Moderate nutritional risk
> 6 High nutritional risk
PHASE II
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When the parameters described here indicate the existence of a
nutritional problem, more information should be accumulated. A
semi-quantitative dietary analysis and routine blood chemistry
should be undertaken.
Semi-quantitative dietary analysis
At this level of evaluation, dietary intake is assessed using more
quantitative means. Nutrients in all foods and beverages consumed
during a 3 to 5 day period are calculated using Food Composition
Tables or computer-assisted nutrient analysis programs.
Average caloric and nutrient intakes can be quantitated and
compared with norms. The services of a registered dietician, serving
as a consultant, are invaluable at this level of assessment.
Biochemical assessment
Common automated blood tests are also useful in providing more
definitive information regarding the nutritional status of patients.
However, most indices fall within standard ranges for young adults
and many of the parameters are affected by an age related decline
in renal function and body water, as well as the effects of drugs and
chronic disease.
PHASE III
The final phase of the analysis is reserved for more complex
nutritional problems and should be accomplished under the direction
of a physician. The analysis in this phase includes comprehensive
nutritional biochemical assays of blood, urine and tissues, as well as
tests of metabolic and endocrine function.
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RISK FACTORS FOR MALNUTRITION IN DENTURE
PATIENT
1) Unplanned weight gain or loss of > 10 lb, in the last 6 months.2) Undergoing chemotherapy or radiation therapy
3) Poor dentition or ill fitting prosthesis
4) Oral lesions glossitis, chelosis or burning tongue
5) Severely resorbed mandibular ridge
6) Alcohol or drug abuse
7) Eating less than 2 meals / day
NUTRITION GUIDE LINES FOR PROSTHODONTIC
PATIENT1) Eat a variety of diet
2) Build diet around complex carbohydrate, fruits, vegetables
whole grams and cereals.
3) Eat atleast 5 servings of fruit and vegetables daily.4) Select fish, poultry, meat (or) dried peas and beans every day
5) Consume 4 servings of calcium rich foods daily.
6) Limit intake of bakery products high in fat and simple sugars.
7) Limit intake of prepared and processed foods high in sodium
and fat
8) Consume 8 glasses of water daily, juice or milk daily.
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CONCLUSION
The success of complete denture prosthesis is mainly
influenced by the mucosal condition of the denture bearing areas.
Many denture failures are the result of nutritional deficiencies.Good health and nutrition of older patients are necessary for the
successful wearing of dentures.
So the patient has to be well nourished and consume a well
balanced diet. Dietary guidance based on assessment of the
edentulous patient nutrition history and diet should be an integral
part of comprehensive prosthodontic treatment.
REFERENCES
PROSTHODONTIC TREATMENT OF EDENTULOUS
PATIENTS BOUCHERS 12TH EDITION
ESSENTIALS OF COMPLETE DENTURE PROSTHODONTICS
- SHELDON WINKLER BANDODKAR K.A., ARAS M. NUTRITION FOR GERIATRIC
DENTURE PATIENTS. JIPS 2006; 6, 1:22-28
PALMER CA. GERODONTIC NUTRITION AND DIETARY
COUNSELING FOR PROSTHODONTIC PATIENTS. DENT
CLIN N AM 2003; 47:355-71