A randomized clinical trial comparing the efficacy of mandibular implant-supported overdentures and conventional dentures in diabetic patients. Part IV: Comparisons of dietary intake

Teeth Rehabilitation and Nutritional Influence on Diabetic Patients: A Review

Diabetes mellitus (DM) is a globally prevalent endocrine and metabolic disorder characterized by hyperglycemia. Its complications significantly impact both the quality and longevity of the patient's life with a substantial burden on the healthcare system. Missing teeth make individuals more susceptible to malnutrition compared to those with functional teeth. This is especially true for people with diabetes, as the condition is closely linked to both oral health and food intake. Natural teeth loss can significantly reduce an individual's ability to chew food, leading to a decrease in the quality and quantity of their nutrition. Prosthodontics is a dental specialty that replaces missing teeth with artificial ones. Replacing missing teeth may prevent the risk of malnutrition due to decreased ability to chew. Good oral health is important for overall health, especially for those with conditions such as diabetes. Artificial teeth replacement may improve nutrition intake by improving chewing ability. Therefore, the ultimate objective of rehabilitating a patient's oral cavity is to replace the shape and function in terms of chewing performance to a degree that is as close to normal as feasible. The purpose of this review is to explore the literature showing the link between natural teeth loss and nutrition in individuals with DM, with a special focus on prosthodontic management. Several oral complications occur in diabetic patients specifically teeth loss, which in turn affects mastication function. This in turn cause malnutrition and affect glucose level. It is imperative for healthcare providers to take an interdisciplinary approach in order to improve the dental and nutritional status and overall well-being of DM patients.

Development of patient-centric eating advice for complete denture wearers

BACKGROUND

Edentulous people eat less healthily, and wearing dentures impairs eating function and enjoyment.

OBJECTIVE

To apply a sequential approach to integrate scientific evidence, and patient and professional experience to co-develop intervention to support better eating with dentures.

METHODS

Focus groups, two with purposive samples of patients and two with dental professionals, explored experiences and opinions about advice on eating with complete dentures. Findings were distilled with evidence from the literature to underpinned concepts for eating interventions. User engagement informed prioritisation of ideas and led to the development of a leaflet on eating with dentures.

RESULTS

Patients receive no advice on what they can realistically expect when eating with dentures, and professionals lacked confidence to provide eating advice. Patients did not think dentists a credible provider of eating advice, feeling peer support more appropriate and offering numerous strategies for eating with dentures. Concepts for eating intervention included a patient leaflet, Web-based eating interventions, patient support blogs, waiting room videos and improved nutrition training for dental professionals. User feedback informed prioritisation of ideas, leading to the development of a leaflet on eating with dentures. Justified by the data, the leaflet focused on patient-generated tips for overcoming the functional limitations of eating with dentures, and unobtrusive healthier eating advice. Face validity with users confirmed acceptability.

CONCLUSION

A systematic and rigorous integration of scientific evidence, expert experience and patient input has developed a patient-centric, evidence-based approach to a patent leaflet on eating with dentures that, based on initial face validity, is likely to be well received.

Eating Advice for People Who Wear Dentures: A Scoping Review

Objective: A scoping review of available advice to address eating problems experienced by people who wear dentures was conducted in accordance with the PRISMA statement. The objective was to identify and map type, volume, and content of the available eating advice. Methods: Medline, CINAHL, and grey literature databases and Google were searched. Relevant content pertaining to study type, peer-review vs. grey literature, country of origin, advice content, and methods to evaluate effectiveness was mapped. Results: Of the 4591 records identified from peer-reviewed literature, 56 full papers underwent duplicate screening, resulting in 26 papers (from Germany (n = 1), Europe (n = 1), India (n = 2), Japan (n = 7), UK (n = 6), USA (n = 6), or other (n = 3)) being included in the review. These yielded 18 different items of relevant eating advice. Of the 258 screened websites, 63 were included, yielding 30 different items of eating advice. The most-cited advice was to eat soft food and avoid hard and sticky food, cut food into bite-sized pieces, and chew on both sides of the mouth and chew slowly and thoroughly. The identified advice was not supported by reference to peer-reviewed evidence. Advice included some conflicting messages and some advice was non-compliant with authoritative nutritional advice (e.g., avoid red meat, take a vitamin supplement). Conclusion: There is support for providing eating advice at the time of denture provision. A broad range of advice based on clinical experience to support people who wear dentures to overcome the functional limitations exists. However, the efficacy of this advice in improving diet and eating experience has not been tested.

Pairs of natural teeth rather than use of dental prosthesis are associated with nutritional status in older adults: A cross-sectional study

OBJECTIVE

To evaluate the association between pairs of natural teeth and nutritional status among older adults.

METHODS

This cross-sectional study evaluated a total of 569 home-dwelling adults from two southern Brazilian cities aged ≥60 years. Present teeth were counted, and pairs of natural teeth were defined as antagonistic teeth. Nutritional status was assessed using Mini Nutritional Assessment. Sociodemographic, behavioral, medical and dental history were collected. Sample was dichotomized into well-nourished and at nutritional risk (including at risk of malnutrition and malnourished). Multiple multivariate models were performed considering different categorizations of pairs of natural teeth.

RESULTS

For each number of present teeth, a decrease of 1.8 % in the prevalence ratio (PR) for nutritional risk was detected (p = 0.040). For each pair of natural teeth, there was 4.4 % decrease in PR for nutritional risk (95 % confidence interval [95 % CI]: 0.917 - 0.997). No statistically significant association was found for pairs of natural anterior teeth (p = 0.222). For pairs of natural premolar, molar and posterior teeth, reductions of 15.4 %, 22.8 % and 11.5 %, respectively, in PR for nutritional risk were observed (p < 0.05). The presence of at least two pairs of natural molars or three pairs of natural posterior teeth was significantly associated with nutritional risk (p < 0.05).

CONCLUSION

Older adults with fewer teeth or pairs of natural teeth, especially posterior teeth, presented poorer nutritional status.

CLINICAL SIGNIFICANCE

Demonstrating threshold correlation between natural teeth and nutrition, data showed significant association between at least two pairs of natural molars or three pairs of natural posterior teeth and lower nutritional status.

Do implant-supported prostheses affect bioavailability of nutrients of complete and partially edentulous patients? A systematic review with meta-analysis

BACKGROUND & AIMS

Debate still exists about the impact of dental implant-supported prostheses on nutritional status of partially and complete edentulous patients. This review aims to answer the focused question: "Do complete and partial edentulous patients, using implant-supported prostheses, present better nutritional and masticatory functions when compared to those using conventional rehabilitations?". A possible cause-effect relationship between masticatory improvements and nutritional gain was also evaluated.

METHODS

Literature search included 6 databases (PubMed/Medline, Embase, LILACS, Scopus, Web of Science, and The Cochrane Library - CENTRAL), grey literature (Google Scholar, Proquest Dissertations and Thesis and Open Grey databases) and manual search (last update June 2020), without language, publication time and follow-up restrictions. We included only studies evaluating both masticatory and nutritional outcomes. The PICO question comprised complete and partial edentulous patients (Population), submitted to implant-supported prostheses (Intervention), in comparison to conventional dental prosthetic rehabilitation, evaluating masticatory function and nutrition parameters (outcomes). Risk of bias was assessed by using Cochrane Collaboration's tool (randomized clinical trials), Joanna Briggs Institute critical appraisal checklist (paired clinical trials), and Meta-Analysis of Statistics Assessment and Review Instrument" (JBI - MAStARI) critical appraisal tools (cohort studies). All meta-analyses were conducted at 5% level of significance. This report followed the PRISMA guidelines. (Review registration PROSPERO - CRD42019135744).

RESULTS

We identified 1199 articles while searching databases. Fourteen articles met eligibility criteria, including 817 prostheses installed in 660 patients (mean age = 66.8 years-old). Patients wearing implant overdentures (IOD) presented better masticatory function in comparison to conventional complete denture (CD) wearers (p < 0.05). However, bioavailability of several nutrients remained within the same range, except for serum folate that was lower in IOD patients after 6 (mean difference 3.51 nmol/L; p = 0.01) and 12 months of rehabilitation (mean difference 3.69 nmol/L; p = 0.003). When comparing the effects of CD and IOD rehabilitations along time (for the same patient), serum albumin and vitamin B12 levels also decreased for both groups after 12 months-follow-up, but still within the reference range. The additional retention of the implants did not interfere in body weight, but reduced the risk of malnutrition (using the Mini Nutritional Assessment). Implant-supported partial prostheses also improved mastication in comparison to the conventional ones, increasing short-term daily intake of carbohydrates, protein, calcium, fiber, and iron, whereas decreasing the consumption of cholesterol. However, no long-term changes on bioavailability of most nutrients were observed, expect for a slight increase in ferritin and cholinesterase, and a small reduction in folate and Vitamin A.

CONCLUSION

Current evidence indicates significant masticatory improvements for dental fixed implant-supported prostheses in comparison to conventional removable prostheses. However, bioavailability remained stable for most of the nutrients, especially for complete edentulous patients. These results indicate the importance of a multidisciplinary approach during oral rehabilitation (nutrient specialist), in order to enhance food choices and promote health benefits to the patients.

Implant-Supported Prosthetic Therapy of an Edentulous Patient: Clinical and Technical Aspects

The purpose of this article is to show how to implement an implant-supported prosthetic overdenture using a digital workflow. Esthetic previewing using a specific software, guided-surgery, construction of the prosthesis, and the esthetic finalization are described in this article. Patients suffering from severe loss of bone and soft tissue volume could benefit from the construction of an overdenture prosthesis as a feasible therapeutic choice for functional and esthetic issues of the patient.

Masticatory Function with Implant-supported Overdentures

The type of attachment that is used in implant-supported mandibular overdentures may influence the retention and stability of the prosthesis and, thus, masticatory function. In this within-subject cross-over clinical trial, we examined the hypothesis that greater retention and stability of the overdenture improve the masticatory function. Eighteen edentulous subjects received 2 oral implants, a new overdenture, and, successively, 3 different suprastructure modalities: magnet, ball, and bar-clip. Masticatory performance, masticatory efficiency, and swallowing threshold were measured. The masticatory function significantly improved after implant treatment with each of the 3 attachments. We observed small differences in masticatory function among the 3 attachment types: slightly better masticatory performance with ball and bar-clip than with magnet attachments. The number of chewing cycles until swallowing hardly decreased after implant treatment. We conclude that significantly better masticatory performance, combined with a slightly smaller number of chewing cycles after implant treatment, results in smaller food particles being swallowed.

Does a mandibular overdenture improve nutrient intake and markers of nutritional status better than conventional complete denture? A systematic review and meta-analysis

OBJECTIVES

The need for denture treatment in public health will increase as the population ages. However, the impact of dentures on nutrition, particularly overdenture treatment, remains unclear although the physical and psychological effects are known. We investigated whether treatment with a mandibular implant supported overdenture improves nutrient intake and markers of nutritional status better than a conventional complete denture in edentulous patients.

DESIGN

Systematic review and meta-analysis.

METHODS

Medline, EMBASE and the Cochrane Central Register of Controlled Trials were searched for eligible studies published up to April 2016. We included studies which compared the treatment effect of an overdenture to conventional denture on nutrition, in which primary outcomes included changes in intake of macronutrients and/or micronutrients and/or indicators of nutritional status. Two reviewers independently evaluated eligible studies and assessed the risk of bias. We used a fixed effects model to estimate the weighted mean difference (WMD) and 95% CI for change in body mass index (BMI), albumin and serum vitamin B12 between overdenture and conventional denture 6 months after treatment.

RESULTS

Of 108 eligible studies, 8 studies involving 901 participants were included in the narrative appraisal. Four studies reported changes in markers of nutritional status and nutrient intake after treatment with a prosthetic, regardless of type. In a meta-analysis of 322 participants aged 65 years or older from three studies, pooled analysis suggested no significant difference in change in BMI between an overdenture and conventional denture 6 months after treatment (WMD=-0.18 kg/m(2) (95% CI -0.52 to 0.16)), and no significant difference in change in albumin or vitamin B12 between the two treatments.

CONCLUSIONS

The modifying effect of overdenture treatment on nutritional status might be limited. Further studies are needed to evaluate the effectiveness and efficacy of denture treatments.

Standardizing the evaluation criteria on treatment outcomes of mandibular implant overdentures: a systematic review

PURPOSE

The aim of this review was to analyze the evaluation criteria on mandibular implant overdentures through a systematic review and suggest standardized evaluation criteria.

MATERIALS AND METHODS

A systematic literature search was conducted by PubMed search strategy and hand-searching of relevant journals from included studies considering inclusion and exclusion criteria. Randomized clinical trials (RCT) and clinical trial studies comparing attachment systems on mandibular implant overdentures until December, 2011 were selected. Twenty nine studies were finally selected and the data about evaluation methods were collected.

RESULTS

Evaluation criteria could be classified into 4 groups (implant survival, peri-implant tissue evaluation, prosthetic evaluation, and patient satisfaction). Among 29 studies, 21 studies presented implant survival rate, while any studies reporting implant failure did not present cumulative implant survival rate. Seventeen studies evaluating peri-implant tissue status presented following items as evaluation criteria; marginal bone level (14), plaque Index (13), probing depth (8), bleeding index (8), attachment gingiva level (8), gingival index (6), amount of keratinized gingiva (1). Eighteen studies evaluating prosthetic maintenance and complication also presented following items as evaluation criteria; loose matrix (17), female detachment (15), denture fracture (15), denture relining (14), abutment fracture (14), abutment screw loosening (11), and occlusal adjustment (9). Atypical questionnaire (9), Visual analog scales (VAS) (4), and Oral Health Impact Profile (OHIP) (1) were used as the format of criteria to evaluate patients satisfaction in 14 studies.

CONCLUSION

For evaluation of implant overdenture, it is necessary to include cumulative survival rate for implant evaluation. It is suggested that peri-implant tissue evaluation criteria include marginal bone level, plaque index, bleeding index, probing depth, and attached gingiva level. It is also suggested that prosthetic evaluation criteria include loose matrix, female detachment, denture fracture, denture relining, abutment fracture, abutment screw loosening, and occlusal adjustment. Finally standardized criteria like OHIP-EDENT or VAS are required for patient satisfaction.

Do implant overdentures improve dietary intake? A randomized clinical trial

People wearing mandibular two-implant overdentures (IOD) chew food with less difficulty than those wearing conventional complete dentures (CD). However, there is still controversy over whether or not this results in better dietary intake. In this randomized clinical trials (RCT), the amounts of total dietary fiber (TDF), macronutrients, 9 micronutrients, and energy in diets consumed by persons with IOD and CD were compared. Male and female edentate patients ≥ 65 yrs (n = 255) were randomly divided into 2 groups and assigned to receive a maxillary CD and either a mandibular IOD or a CD. One year following prosthesis delivery, 217 participants (CD = 114, IOD = 103) reported the food and quantities they consumed to a registered dietician through a standard 24-hour dietary recall method. The mean and median values of TDF, macro- and micronutrients, and energy consumed by both groups were calculated and compared analytically. No significant between-group differences were found (ps > .05). Despite quality-of-life benefits from IODs, this adequately powered study reveals no evidence of nutritional advantages for independently living medically healthy edentate elders wearing two-implant mandibular overdentures over those wearing conventional complete dentures in their dietary intake at one year following prosthesis delivery.

A critical review of diabetes, glycemic control, and dental implant therapy

OBJECTIVES

To systematically examine the evidence guiding the use of implant therapy relative to glycemic control for patients with diabetes and to consider the potential for both implant therapy to support diabetes management and hyperglycemia to compromise implant integration.

MATERIAL AND METHODS

A systematic approach was used to identify and review clinical investigations directly assessing implant survival or failure for patients with diabetes. A MEDLINE (PubMED) database search identified potential articles for inclusion using the search strategy: (dental implants OR oral implants) AND (diabetes OR diabetic). Inclusion in this review required longitudinal assessments including at least 10 patients, with included articles assessed relative to documentation of glycemic status for patients.

RESULTS

Although the initial search identified 129 publications, this was reduced to 16, for inclusion. Reported implant failure rates for diabetic patients ranged from 0% to 14.3%. The identification and reporting of glycemic control was insufficient or lacking in 13 of the 16 studies with 11 of these enrolling only patients deemed as having acceptable glycemic control, limiting interpretation of findings relative to glycemic control. Three of the 16 studies having interpretable information on glycemic control failed to demonstrate a significant relationship between glycemic control and implant failure, with failure rates ranging from 0% to 2.9%.

CONCLUSIONS

Clinical evidence is lacking for the association of glycemic control with implant failure while support is emerging for implant therapy in diabetes patients with appropriate accommodations for delays in implant integration based on glycemic control. The role for implants to improve oral function in diabetes management and the effects of hyperglycemia on implant integration remain to be determined.

Implant overdentures and nutrition: a randomized controlled trial

We conducted a randomized clinical trial to determine whether providing simple mandibular implant overdentures (IODs) to elderly individuals would give them a significantly better nutritional profile than those who receive complete dentures (CDs). Two hundred fifty-five edentate patients > 65 yrs were randomly assigned to receive maxillary CDs and mandibular IODs (n = 128) or CDs (n = 127). Six-month and one-year post-treatment outcomes were blood plasma levels of homocysteine (tHcy), vitamin B12, vitamin B6, albumin, serum folate, and C-reactive protein concentrations, as well as dietary intake. The association between treatment and tHcy levels was not statistically significant. A decline of folate from baseline values in both study groups, as well as those of vitamins B6 and B12 and albumin, was observed. Significant between-group differences were detected in food preparation and in the individuals' ability to chew a variety of foods. This study suggests that implant overdentures do not have a more positive effect on the nutritional state of elderly edentate individuals at 6 and 12 mos post-treatment than new complete dentures. However, those wearing IODs are significantly more likely to take in their nutrients through fresh, whole fruits and vegetables.

Impact of facial form on the relationship between conventional or implant-assisted mandibular dentures and masticatory function

STATEMENT OF PROBLEM

It is not clear if the interaction of craniofacial form with type of prosthetic restoration (conventional or implant-assisted) is related to masticatory function in complete denture patients.

PURPOSE

The purpose of this study was to investigate the relationships among facial form, skeletal class, alveolar residual ridge heights and masticatory function in subjects treated with implant-assisted or conventional mandibular dentures with lateral cephalometric evaluation.

MATERIAL AND METHODS

Data from a previously reported randomized controlled clinical trial were accessed to compare treatment success rates, functional and perceptual outcomes, dietary intake, and craniofacial relationships between mandibular complete dentures and implant overdentures in edentulous diabetic subjects. Evaluation of the digitized post-insertion lateral cephalometric radiographs provided measures of facial form (mesocephalic "medium", brachycephalic "broad and square", dolichocephalic "vertical and long"), skeletal class (Class I, Class II, Class III), and alveolar ridge height (mm), which were compared to results of standardized masticatory tests as evaluated using MANOVA and REGW post-hoc evaluation (α=.05).

RESULTS

Masticatory performance on the preferred side was slightly reduced in the dolichocephalic group, compared to brachycephalic and mesocephalic groups (P=.085). Swallowing threshold performance was significantly less in skeletal Class II subjects compared to Class I (P=.034). Maxillary residual alveolar ridge height was significantly less in the brachycephalic group compared to the dolichocephalic group (P<.001). No differences in mandibular ridge height were seen associated with facial form or skeletal class groups.

CONCLUSIONS

Facial form may be related to masticatory function with conventional and implant-assisted mandibular dentures, but larger controlled studies are needed to confirm this relationship. Alveolar ridge height is reduced in edentulous subjects with a brachycephalic facial form.

Overdenture with immediate load: mastication and nutrition

Lower conventional complete dentures were converted to overdentures retained by two implants with an immediately loaded bar-clip system (n 16). The masticatory performance test was carried out using 'Optocal' after forty chewing strokes. Nutritional condition was evaluated by means of a Mini-Nutritional-Assessment questionnaire. No individual was classified as malnourished. The masticatory performance test demonstrated a statistically significant difference before conversion (baseline) and 3 and 6 months after conversion of the lower conventional complete denture to an implant-retained overdenture (paired-samples t test; P < 0·05). A statistically significant difference before and after 6 months of conversion for nutritional condition (Wilcoxon test; P < 0·05) was also observed. The association between masticatory performance and nutritional assessment demonstrated that a statistically significant difference between masticatory performance of the subgroups classified at baseline as nourished (22·43 %) and those at risk of malnutrition (3·9 %) was only evidenced before conversion (P = 0·006). After the conversion from a lower conventional complete denture to an implant-retained overdenture, at 3 months, the risk of malnutrition and nourished at baseline did not present significant differences in masticatory performance. Nonetheless, the mean masticatory performance potential was 19·86 and 31·98 % for subgroups classified at baseline as at risk of malnutrition and nourished, respectively (P = 0·187). The results before conversion were less favourable for masticatory performance and nutritional condition. The increased retention of the mandibular prosthesis allowed improvement in masticatory performance and nutritional condition.

Impact of implant support for mandibular dentures on satisfaction, oral and general health-related quality of life: a meta-analysis of randomized-controlled trials

OBJECTIVES

The aim of this study was to examine systematically the data published on the efficacy of mandibular implant-retained overdentures from the patient's perspective.

MATERIAL AND METHODS

Medline, Embase, The Cochrane Central Register of Controlled Trials and The Cochrane Systematic Reviews Database were searched and complemented by hand searching. All randomized-controlled trials published in English or French up to April 2007 were included, in which conventional dentures and mandibular implant overdentures in adult edentulous individuals were compared. The outcomes of interest were patient satisfaction, oral and general health-related quality of life. Random effects models were used to pool the effect sizes (ES) of all included studies.

RESULTS

Ten publications of seven randomized-controlled trials were identified and eight were included in the meta-analysis. When compared with mandibular conventional dentures, implant overdentures were rated to be more satisfactory at a clinically relevant level [pooled ES 0.80, z=3.56, 95% confidence intervals (CI) 0.36-1.24, P=0.0004], but a statistical heterogeneity was found (chi(2)=31.63, df=5, P<0.00001, I(2)=84%). The pooled ES for oral health quality of life was -0.41 (z=1.31, 95% CI, -1.02 to 0.20; P=0.19, chi(2)=11.53, df=2, P<0.003, I(2)=83%). There was a lack of evidence to show the impact of mandibular implant overdenture on perceived general health.

CONCLUSIONS

Our findings suggest that, although mandibular implant-retained overdentures may be more satisfying for edentulous patients than new conventional dentures, the magnitude of the effect is still uncertain. There is a need for additional evidence including cost-effectiveness analyses on the impact of mandibular implant overdentures and conventional dentures.

Perceived chewing ability and intake of fruit and vegetables

Edentulous individuals have reduced chewing ability and lower fruit and vegetable consumption compared with dentate individuals. It has been suggested that the two are causally related. However, psychosocial factors such as attitude, self-identity, and knowledge of recommendations are predictive of intake in non-edentulous persons. The aims of this study were to: determine if perceived chewing ability was predictive of fruit and vegetable intake; explore the predictive ability of knowledge, attitude, and self-identity; and compare intake between edentulous and dentate individuals. Full denture-wearing (N = 79) and dentate persons (N = 52) completed a three-day food diary. Perceived chewing ability, sociodemographic, and psychosocial factors were assessed via self-administered questionnaire. The dentate persons consumed significantly more fruit and vegetables, but differences were not significant when juices were excluded. Perceived chewing ability explained approximately 4% variance in intake. Attitude, self-identity, and knowledge explained a further approximately 20%. If the diet of denture-wearers is to be improved, psychosocial factors, as well as perceived chewing ability, must be addressed.

Influence of denture improvement on the nutritional status and quality of life of geriatric patients

Recent research suggests that there is a correlation between nutrition, oral health, dietary habits, patients' satisfaction and their socio-economic status. However, the dependent and independent variables have remained unclear.

OBJECTIVE

This exploratory interventional study aimed to identify the impact of denture improvement on the nutritional status as well as the oral health-related quality of life in geriatric patients.

MATERIALS AND METHODS

Forty-seven patients who were capable of feeding themselves (minimum age: 60 years) and with dentures requiring repair or replacement were selected from a random sample of 100 residents of two nursing homes. Before and 6 months after the dentures were optimised a Mini Nutritional Assessment (MNA) and a masticatory function test were carried out. Nutritional markers (pre-albumin, serum albumin, zinc) were determined and an OHIP-G14 (Oral Health Impact Profile, German version) was recorded in order to determine the effect of the optimised oral situation on the patient's nutritional status and oral health-related quality of life.

RESULTS

Despite the highly significant improvement in masticatory ability after the optimisation of the dentures, no general improvement regarding the nutritional status was observed since the albumin, zinc and MNA values remained unchanged and pre-albumin even decreased.

CONCLUSION

Since masticatory ability and masticatory efficiency are not the only factors affecting this, prosthetic measures alone apparently cannot effect a lasting improvement in nutritional status as masticatory ability and masticatory efficiency are not the only factors of influence. Nutrition is not only a matter of masticatory function, but also depends on other influencing factors (e.g. habits, taste and cultural customs as well as financial and organisational aspects).

Dental implants. A role in geriatric dentistry for the general practice?

BACKGROUND

In the general population, the use of dental implants has become a management strategy for replacing missing teeth. As part of the treatment plan for the aging population, general dentists should consider this treatment modality in their practices.

OVERVIEW

This study reviews specific issues concerning the aging population and tooth replacement therapies. Older people often desire to replace missing teeth, but they have complex medical, social, economic and resource issues that must be accounted for in their treatment plan. Dentists need to give careful attention to the patient-based assessment, diagnostic criteria and diagnostic steps to help the patient and family understand the strengths and challenges of each type of tooth replacement therapy. The author emphasizes the importance of careful evaluation and assessment of fixed versus removable implant-retained prostheses in the aging population.

CONCLUSIONS AND CLINICAL IMPLICATIONS

For many general dentists, dental implants have become an increasingly common treatment option for missing dentition. With the population becoming increasingly older worldwide, the general dentist will be confronted with patients who have complex medical and social histories who desire tooth replacement therapy. The rational delivery of this oral health care will assist in providing a high quality of life for these patients.

Bone associated with implants in diabetic and insulin-treated rats

OBJECTIVES

Diabetes is an increasingly prevalent disease with oral health manifestations. While diabetes clearly has an affect on bone, its impact on the healing of bone associated with dental implants is not completely understood. The purpose of this study was to measure bone response to implants in uncontrolled and insulin-controlled diabetic rats.

MATERIAL AND METHODS

One hundred and fifty-two rats were divided into control, diabetic, and insulin groups. Rats received streptozotocin (65 mg/kg) to induce diabetes; animals in the insulin group also received a subcutaneous slow-release insulin implant. Titanium alloy implants (1.5 x 8 mm) were placed in the proximal tibiae of animals. Implants were harvested at 2, 7, 14, and 24 days and examined histologically. Bone or bone-like tissue adjacent to implants was quantified as a percent. Data were compared using a two-way analysis is variance (ANOVA) with time and treatment as primary independent factors.

RESULTS

Time and treatment were significant factors in predicting bone response to implants (P<0.0001). Mean bone volume peaked at day 7 and decreased over time to day 24. Mean bone volume percent at 2, 7, 14, and 24 days (+/-SD) was 8.2 (+/-8), 22.9 (+/-8), 18.8 (+/-10), and 14.9 (+/-9), respectively. Mean total bone volume percent (adjusted for day) for control, diabetic, and insulin groups (+/-SD) was 12.4 (+/-9), 22.6 (+/-10), and 17 (+/-7), respectively. Bone volume adjacent to implants in diabetic rats was significantly greater than controls (P<0.05). Diabetic animals treated with insulin were not statistically different from controls.

CONCLUSIONS

Induction of diabetes with STZ is associated with increased bone response compared with controls. This response was mediated by treatment with insulin.

Impact of Human Genome Project on treatment of frail and edentulous patients*

OBJECTIVE

Because of ongoing increases in life expectancy and deferment of edentulousness to older age, dentists are facing a different challenge to satisfy elderly denture wearers with a higher prevalence of chronic diseases. This discussion introduces the Human Genome databases as novel and powerful resources to re-examine the core problems experienced by frail and edentulous patients.

BACKGROUND

Recent studies demonstrated that mandibular implant overdentures do not necessarily increase masticatory function, perception and satisfaction in denture wearers with adequate edentulous residual ridges. It has been demonstrated that the rate of edentulous residual ridge resorption significantly varies among individuals. The prognosis and cost-effectiveness of denture treatment, with or without implants, may largely depend on how the edentulous ridge is maintained. However, reliable clinical methods permitting dentists to predict the long-term health of the edentulous residual ridge are lacking.

MATERIALS AND METHODS

With the completion of the Human Genome Project, the genomic sequence database from this multinational consortium will provide a unique resource to determine the genetic basis of similarity and diversity of humans.

RESULTS

One base pair in every 100 to 300 base pairs of the genome sequence varies among humans, suggesting that genetic diagnosis using the single nucleotide polymorphisms (SNPs) may provide a novel opportunity to differentiate our edentulous patients.

CONCLUSIONS

Future dental service for the elderly will require a personalized care paradigm, using highly sensitive diagnostic technology such as SNP genomic analysis, for recommending the treatment with greatest potential benefit.

Association of edentulism and diet and nutrition in US adults

Dental status and its relationship to diet and nutritional status have been little explored. In this study of a representative sample of the US civilian, non-institutionalized population (NHANES III), we predicted that the intake of nutritious foods, dietary fiber, and levels of biochemical analytes would be lower, even after adjusting for potential social and behavioral factors, among those who were edentulous and wore complete dentures than for those who had all their natural teeth. Multivariate analyses indicated that intake of carrots and tossed salads among denture-wearers was, respectively, 2.1 and 1.5 times less than for the fully dentate (p < 0.0001), and dietary fiber intake was 1.2 times less (p < 0.05). Serum levels of beta carotene (9.8 microg/dL), folate (4.7 ng/dL), and vitamin C (0.87 mg/dL) were also lower among denture-wearers (p < 0.05). Intakes of some nutrient-rich foods and beta carotene, folate, and vitamin C serum levels were significantly lower in denture-wearers.

The effects of mandibular two-implant overdentures on nutrition in elderly edentulous individuals

It is unclear whether mandibular implant overdentures improve the nutritional state of edentulous patients better than conventional dentures. In a randomized clinical trial, we tested for post-treatment differences in nutritional status between patients with mandibular two-implant retained overdentures and those with conventional complete dentures. Edentulous subjects (ages 65-75 yrs) received two-implant mandibular overdentures (IOD, n = 30) or conventional dentures (CD, n = 30). Measures of nutritional state were gathered before and 6 mos after treatment. Significant improvements in anthropometric parameters were detected in the IOD but not in the CD group, for percent body fat (p = 0.011) and skin-fold thickness at the biceps, subscapularis, and abdomen (p < 0.05), with significant decreases in waist circumference (p < 0.0001) and waist-hip ratio (p = 0.001). Significant increases were seen in concentrations of serum albumin (p = 0.015), hemoglobin (p = 0.01), and B12 (p = 0.01). No significant between-group differences were found. These results suggest that low-cost IOD treatment may improve the nutritional state of edentulous people.

Nutrition as a mediator in the relation between oral and systemic disease: associations between specific measures of adult oral health and nutrition outcomes

Recent associations between oral health and systemic disease have led to renewed interest in the mouth and its contribution to health outcomes. Many pathways for this relationship have been postulated, among them the potential mediating role of nutrition. The link between various nutrients and systemic disease has been established, but relatively little work has been done in relating oral conditions with nutrition. We searched MEDLINE, from 1966 to July, 2001, to identify articles relating specific oral measures to nutrition outcomes. We included original articles written in English with a sample size greater than 30 that used objective oral health measures. We reviewed a total of 56 articles. Only a small proportion of these studies were methodologically sound. Although many studies were small and cross-sectional, the literature suggests that tooth loss affects dietary quality and nutrient intake in a manner that may increase the risk for several systemic diseases. The impact of tooth loss on diet may be only partially compensated for by prostheses. To date, there is little information relating periodontal disease and oral pain and nutrition. A few studies suggest poorer nutrition among individuals with xerostomia and altered taste. Further, impaired dentition may contribute to weight change, depending on age and other population characteristics. There is a paucity of well-designed studies addressing oral health and nutrition. Before we can acquire a better understanding of how nutrition and oral health interrelate, however, more studies will be required to confirm these associations-preferably longitudinal studies with larger sample sizes and better control of important confounders.

Influence of impaired mastication on nutrition

It has been suggested that people who suffer from impaired masticatory function may adapt food consistency to their oral status (which may lead to deficient nutrient intake) or rely on the digestive system to compensate for the lack of oral preparation of food (which may increase the likelihood of digestive diseases and decrease gut absorption). Masticatory deficiency thus may be detrimental to health. This article reviews evidence of the effects of masticatory deficiency on nutrition. The selection of relevant literature was based on Medline queries using the following key words: mastication, nutrition, digestion, diet, and disease risk. Earlier work not listed in Medline but related to the subject also was reviewed. Only publications available in English were selected for inclusion. It is difficult to draw conclusions from many of the reviewed studies due to issues related to study design, confounding variables, and the subjective nature of the measurements. In particular, data supporting a link between masticatory function and deficient dietary intake often are based on relatively weak correlations and cannot confer a causal relationship.

Dietary intake in edentulous subjects with good and poor quality complete dentures

STATEMENT OF PROBLEM

Previous studies in complete denture wearers evaluated the relationship between diet and measures of chewing, yet only isolated nutrient intake was considered. This limited information makes the assessment of overall diet quality and the planning of interventions difficult.

PURPOSE

This study investigated the relationship of complete denture quality to masticatory performance, perceived ability to chew, and diet quality as measured by the Healthy Eating Index (HEI), an overall diet quality index.

MATERIAL AND METHOD

The study population comprised 54 complete denture wearers. Data were obtained from clinical examinations, masticatory performance measurements, and 2 non-consecutive 24-hour dietary recalls. (Masticatory performance data were not collected for 9 subjects because of time constraints, patient fatigue, or patient refusal. Statistical analysis showed no significant effect of their absence on the reported findings.) Based on a composite rating scale, subjects were divided into 3 denture quality groups described as good, medium, and poor. The outcome variables were the HEI and its components, plus selected nutrient and non-nutrient intake. Explanatory variables were quality of complete dentures, masticatory performance, and reported chewing ability. Data were analyzed with Kruskal-Wallis tests, Mann-Whitney U-tests, and Fisher exact tests. Because a large number of dietary components were examined, results were considered significant at alpha=.01.

RESULTS

Masticatory performance and perceived ability to chew were unrelated to diet quality. The good quality denture group had significantly better masticatory performance than the medium and poor quality groups, but the median HEI scores and dietary intakes were not significantly different among these 3 groups. Milk, vegetable, fruit, and grain intake scores were mainly responsible for the low overall HEI scores.

CONCLUSION

In the population evaluated, complete denture quality, food comminution capacity, and perceived chewing ability were not related to diet quality. The majority of subjects had deficient diets regardless of the technical quality of their dentures.