Nutrition And Oral Health.pdf

Best Practice & Research Clinical Gastroenterology Vol. 15, No. 6, pp. 885±896, 2001

doi:10.1053/bega.2001.0247, available online at http://www.idealibrary.com on

4 Nutrition and oral health Ejvind Budtz-Jùrgensen

Dr. Odont

Professor

Jean-Pierre Chung

Dr. Med. Dent

Associate Professor Division of Gerodontology and Removable Prosthodontics, University of Geneva, 19 rue BartheÂlemy-Menn, CH-1205 Geneva, Switzerland

Charles-Henri Rapin

Dr. Med

Professor Policlinic of Geriatrics, University Hospitals of Geneva, 35 Rue des Bains, CH-1205 Geneva, Switzerland Bioethical Center of Montreal, Canada

Reduced chewing function in community-dwelling older people with adequate general health is linked to having fewer than 20 teeth present or to wearing removable dentures. By chewing for longer periods of time or swallowing larger food particles they are normally able to compensate for the impaired function. The masticatory function can be restored by adequate prosthetic therapy, which results in increased activity of the masticatory muscles during chewing and reduces the chewing time and the number of chewing strokes until swallowing. In frail or dependent elderly people undernutrition is prevalent because of health problems, reduced appetite and poor quality of life. Poor oral health and xerostomia are often associated with a reduced body mass index and serum albumin level and the avoidance of dicult-to-chew foods. Maintenance or re-establishment of masticatory function is an integral part of the medical health care of these patients, with the aim of improving their nutritional status and quality of life. Key words: masticatory function; nutrition; oral health; tooth loss; oral health care.

INTRODUCTION Proper nutrition of the elderly is essential both for general and oral health. In this context, oral health and oral comfort are a prerequisite for a good masticatory function and adequate food intake. The preservation of a healthy natural dentition, or the replacement of missing teeth with adequate prosthetic appliances, is essential for masticatory function. A sucient amount of saliva is necessary for the maintenance of oral health and comfort during mastication. Saliva contains minerals such as calcium, phosphate or ¯uoride, which are essential for re-mineralization of surface carious lesions. Saliva also plays a role in the clearance of pathogenic micro-organisms from the mouth. Furthermore, saliva is important in the chewing process, since it plays a role in binding the food fragments together as a coherent bolus that can be swallowed safely, 1521±6918/01/060885‡12 $35.00/00

c 2001 Harcourt Publishers Ltd. *

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without the danger of stray particles entering the respiratory system. As a consequence, the elderly who su€er from xerostomia will have less chewing comfort as the food will tend to stick to the mucosa rather than together. Saliva is also rich in digestive and other enzymes that dissolve the molecules needed in taste perception. Taste and odour perception also play an important role in food intake. Among elderly persons, there is a wide diversity in the sense of smell and odour perception, but the perception threshold is not markedly reduced with age.1 Ageing is associated with a decline in olfactory function resulting in higher odour detection thresholds for both nasal2,3 and retronasal presentation of odours.4 Indeed, impaired or altered taste and smell sensation in older persons is a frequent complication of general disorders such as Alzheimer's or Parkinson's disease, chronic liver or kidney diseases, endocrine disorders and drugs (e.g. drugs for arthritis, hypertension, heart disease or drugs to improve mood or treat epilepsy) as well as oral disorders such as xerostomia, burning mouth syndrome, periodontal disease or halitosis.5,6 ORAL HEALTH STATUS OF THE ELDERLY The prevalence of periodontal disease, caries, tooth loss and edentulousness are the accepted and most important criteria for assessing oral health status. The improved oral health status of the adult population in industrially developed countries will have an important impact on the oral health status of the future elderly.7 Thus, tooth retention in the USA population is projected to increase from 9.0 to 15.6 teeth on average per person between 1990 and 2025 for those aged 75 years or older. The percentage who are edentulous in this age group is expected to decrease from 44% to 22.5%. These trends will have a profound in¯uence on the future need for oral health care, particularly among those who become frail and dependent. On the one hand, there will be a relative decline in the need and demand for the replacement of missing teeth by prosthetic therapy in order to maintain appropriate masticatory function. On the other hand, it will be necessary to implement ecient preventative oral measures in this population in order to maintain dental and oral health. Functionally independent elderly Generally, the periodontal health of the elderly has improved during the last 10±20 years, re¯ecting improvements in oral health attitude and preventative measures. However, in practice 100% are a€ected by gingivitis and 20±30% have at least one deep periodontal pocket requiring complex periodontal therapy.8 In the elderly, the most important risk indicators of periodontal disease are large number of teeth present, low educational level, age and current smoking habits.9 In the elderly, root caries are a major problem due to recession of the gingival tissues. The exposed root surface becomes easily a€ected by caries, particularly in those who have already had caries, who have poor oral hygiene, a low salivary ¯ow rate or who wear removable dentures.8 Root caries are dicult to treat eciently using conventional restorative therapy. However, with proper oral hygiene measures and improvements in diet, active root caries can often be converted into inactive lesions.10 The prevalence of edentulousness in the elderly population is associated with age, female sex, low education, low social class and income level, and living in a rural area.11,12 As mentioned previously, the relative prevalence of edentulousness among older, functionally independent adults is about to decrease drastically. However, due

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to demographic changes the absolute number of edentulous elderly people will remain high in industrialized countries. Based on objective criteria the quality of existing dentures is clinically poor, but complaints regarding comfort or oral pain are rare.13 Thus, patients tend to wear old dentures that ®t poorly, but they are rarely motivated to seek and bene®t from prosthodontic treatment. Frail or functionally dependent elderly In the frail or functionally dependent elderly, oral health status is profoundly in¯uenced by the patient's medical problems, drug history and their psychosocial situation. The functionally dependent elderly living in an institution make up about 5% of the population over the age of 65 years, but it is projected that some 20% of persons over 65 will spend at least a part of their life in nursing homes.14 The frail elderly constitute about 20% of the elderly. They have partial loss of independence and more serious medical or emotional problems. The majority are able to live in the community with support services, but they can only visit a dental oce if helped. The oral health status of individuals living in nursing homes has been well documented.15±18 These studies have indicated that frail and dependent individuals tend to have only a few functional teeth left and their oral health status is generally poor. The oral problems of particular importance are a high prevalence of root-surface caries, the presence of root remnants, poor oral hygiene and the presence of very old ill-®tting dentures. The poor oral hygiene is the major problem, since this may give rise to dental emergencies and an elevated risk of aspiration pneumonia.19,20 Impaired manual dexterity combined with cognitive deterioration makes it dicult for these residents to carry out oral self-care. Therefore, they must rely on caregivers' help for their daily oral hygiene. However, sta€ members are often overworked and give low priority to oral hygiene compared with other tasks. Furthermore, sta€ are often uninformed about proper oral hygiene techniques.21,22 The extent to which the poor oral health status in the frail and dependent elderly may be an important factor in predisposing them to proteocaloric undernutrition will be discussed later in this chapter. NUTRITION INTAKES AND ORAL HEALTH It is important for older individuals to be able to comminute food during mastication and to prepare the ingested food for swallowing and further processing in the digestive tract (Table 1). However, many factors other than masticatory function per se are essential for good nutritional status in the elderly. Thus, medical problems, socioeconomic situation and dietary habits have an in¯uence on dietary selection and nutritional intakes. Masticatory function Adequate dental/prosthetic status and muscle function are essential for masticatory function. With age there is a signi®cant decrease in the cross-sectional area and the density of the masticatory muscles.23 This reduction is most important in edentulous individuals throughout the age spectrum compared with those who have natural teeth left. These observations are consistent with general age-related changes of muscle tissue in the body as a whole and may be a contributing factor to the reduction of masticatory force with age.24 Thus, retention of teeth or rebuilding the dentition by tooth or

888 E. Budtz-Jùrgensen et al Table 1. Oral and general conditions with an impact on masticatory function and alimentation in older individuals. Tooth loss Quality of dental prostheses Masticatory muscles Strength Neuromuscular function Salivary gland dysfunction and xerostomia Smell and taste perception Modi®ed threshold Modi®ed perception Dietary habits Socio-economic factors General health status

implant supported prostheses are means by which masticatory muscle mass and function can be maintained in older individuals.25 With regard to a qualitative evaluation of the masticatory function, two ideas are of importance: (i) masticatory ability, which is the individual's self-assessed masticatory function and (ii) masticatory eciency or performance, which is an objective assessment of masticatory function carried out either by fractional sieving to separate out food particles after chewing, or by counts of the number of chewing strokes before swallowing.26 In order to evaluate the masticatory ability, questionnaires are administered that contain questions relating to chewing function, speci®c questions relating to the types of food that are dicult to chew, and questions relating to swallowing and oral comfort (Table 1).27±29 Studies on masticatory ability indicate that elderly people with reduced dentition are, to a large extent, able to compensate for tooth loss, either by chewing on the side where most teeth are left, by chewing longer, or by swallowing larger food particles. With regard to the masticatory ability, studies show that removable partial or complete dentures are a poor substitute for natural teeth. Those who have more than 20 natural teeth left report no chewing problems. In edentulous people wearing complete dentures, a considerable improvement in masticatory ability can be obtained by the placement of implants to retain the dentures.30 Elderly people who are comfortable with their prosthetic restorations replacing posterior tooth loss, generally indicate an unimpaired masticatory ability.31 Thus, acceptance and oral comfort with the prosthetic appliance are more important for masticatory ability than the number of teeth replaced by the prosthesis. It is noteworthy that complaints related to loss of appetite and xerostomia often coincide with poor masticatory ability.29 In this situation, a poor general health condition may be the principal cause of loss of appetite, xerostomia and the perceived masticatory ability, and may re¯ect poor general oral comfort. Chewing eciency, or the rate of breakdown of food during mastication, is clearly correlated to features of the dentition, such as number of posterior teeth and the quality of the occlusal relationships.32 For any particular type of food there is an optimum number of chews.33 Chewing is continued until the food fragments bind together as a coherent bolus that can be swallowed safely. If chewing is carried out for too long, excess saliva will weaken the cohesive forces and allow the bolus to fall apart. Poor masticatory function is usually compensated for by using a greater number of chewing strokes prior to swallowing.34,35 This means that elderly people with severely

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reduced dentition, where the missing teeth have not been replaced by a prosthesis, need more time to ®nish their meal. This is a particular problem if the stimulated salivary ¯ow rate is reduced, which can increase chewing time by up to 100%.36 Therefore, preservation of natural occlusal tooth contacts is important in maintaining masticatory function. With increased retention of natural teeth among `new elderly', the need for preventive measures and dental care will increase so as to prevent tooth loss. For those who are partially or totally dependent, the carers will have to assume the daily oral hygiene care for these individuals. When posterior teeth are lost, they can be replaced by ®xed or removable partial dentures if the patient expresses a demand for rehabilitation. Treatment of edentulous patients with implant-supported ®xed or removable dentures is an excellent option to treatment with conventional complete dentures, since both the masticatory ability and eciency will be better.37 Saliva plays an important role in the masticatory process by acting as a lubricant and by binding the chewed food together. There is a reduction of the non-stimulated salivary ¯ow rate with age; however, there is no evidence that the functional or stimulated salivary ¯ow rate is reduced with age.38 But, older people su€er from more diseases and consume more medications than younger people. In elderly people there are three main causes of salivary hypofunction or xerostomia (Table 2): dehydration, damage to the salivary glands, or interference with the neural transmission initiating salivary secretion.39,40 In frail and dependent elderly, dehydration is frequently associated with insucient water intake, renal water loss associated with diabetes mellitus, or protein±calorie undernutrition. Thus, there exists a certain relationship between reduced salivary ¯ow rate, impaired masticatory function, loss of appetite and clinical evidence of undernutrition.41 Since salivary ¯ow is stimulated during normal masticatory function, a decrease in the function of the masticatory muscles may induce atrophy of the salivary glands and reduce synthesis and secretion of saliva.39 Thus, appropriate masticatory function is important for proper alimentation, maintenance of the salivary ¯ow and the overall quality of life for the elderly. Table 2. Causes of salivary gland hypofunction. Dehydration Impaired water intake Loss of water through the skin Blood loss Diarrhoea Renal water loss Protein±caloric undernutrition Damage to the salivary gland Irradiation to the head and neck region Autoimmune diseases (e.g. SjoÈgren's syndrome) HIV Ageing Interference with neural transmission Medications Autonomic dysfunction Conditions a€ecting the central nervous system (e.g. Alzheimer's disease) Psychogenic disorders (e.g. depression, anxiety) Trauma Decreased masticatory function Source: Adapted from Sreebny39 and Fisher & Ship.40

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Dietary habits and nutritional status of older adults Nutritional factors have a great impact on health versus disease late in life. Estimates indicate that one-third to one-half of health problems in elderly individuals are a direct or indirect consequence of nutritional de®ciency.42 The prevalence of undernutrition is not very high in independent-living older adults (5±8%), but it may reach signi®cant levels (30±60%) among those who live in nursing homes, are homebound, or are hospitalized.43 In addition to social, psychological and biological factors, age-related undernutrition is associated with culturally mediated in¯uences leading to dietary restrictions and poor nutrition in old age.44,45 Sociomedical factors such as housing and living conditions, economic situation, loneliness and subjective health perception may in¯uence diet and nutrition.41,46 Some health-related behaviours also may have a negative e€ect on nutrition e.g. alcohol consumption, use of tobacco products and reduced motor activity. Indeed, subjects who age successfully have better eating behaviours and better general health status than those who age unsuccessfully.47 Whereas the dietary intake and nutritional state of community-dwelling older adults in perhaps not always ideal, many reports have been published pointing to the fact that severe undernutrition among the hospitalized elderly and elderly in long-term care facilities is associated with increased morbidity and mortality.45,48±50 Following hospital discharge, undernutrition predisposes the patient to increased morbidity and mortality. However, such complications can often be reduced simply by providing nutritional support. Can undernutrition in nursing home residents be prevented? Many factors in¯uence undernutrition, including general health status, cognitive status, degree of immobility, anorectic medication and the ability to chew and swallow. There are no proven optimal strategies to normalize nutrition in the elderly or to improve long-term clinical outcomes and quality of life; however, a better meal environment as well as dietary supplements my be bene®cial.51,52 The extent to which oral status / improvement of oral status may in¯uence dietary habits and nutritional status is considered below. NUTRITIONAL STATUS AND MASTICATORY FUNCTION Four factors are related to dietary selection and the nutritional status of older individuals: general health, socioeconomic status, dietary habits and oral health status. These factors are inter-related, which means that the cause of under- or malnutrition is normally multifactorial. Community-dwelling elderly Is a good masticatory function important for food intake and digestion? This question has been elucidated by two classical studies.53,54 In the study by Baxter53, the nutritional intake in three groups of community-dwelling elderly was compared: wearers of complete maxillary and mandibular dentures, wearers of complete maxillary and partial mandibular dentures replacing posterior tooth loss and dentate individuals with at least 20 functional teeth. Whereas the intake of certain nutrients varied signi®cantly from the recommended allowances, the variations were not related to the subjects' age or dental status. In the study by Farrell54, chewed and non-chewed food, placed in small sacks, was swallowed by healthy adult individuals. After having passed the digestive system the degree of digestion of the food was examined. The

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results showed that chewed and non-chewed food was digested to the same degree and suggested that masticatory function was not important for nutrition. This may be true for healthy individuals, but the situation is quite di€erent for elderly individuals. Indeed, a high incidence of digestive complaints was observed in individuals with a poor dental status.55 Since prosthetic therapy reduced the symptoms signi®cantly, it was concluded that poor masticatory function may give rise to digestive symptoms. The reason for the digestive problems could be that subjects with inadequate dentition tended to swallow larger food particles.56 Several more recent studies have indicated that oral health status may have implications for dietary intakes.57±60 Thus, elderly persons wearing complete dentures tended to have lower intakes of protein and vitamin A and C and a lower intake of dicult-to-chew food items, such as roots, vegetables, fruits and meat, than those with natural dentition. Similarly, elderly individuals having a compromised dentition or wearing complete dentures consumed lower levels of proteins and ®bre, as well as nutrients such as thiamine, iron, folic acid, vitamin A and carotene.57 In two recent Swedish studies, subjective chewing problems were associated with poor dental status, de®cient dietary intakes, negative socioeconomic conditions and self-reported general health problems.46,61 Appollonio et al62 studied the in¯uence of dental health status on dietary intake, morbidity and survival rate during a 6-year period in a cohort of 1200 community-dwelling subjects, 70±75 years old living in Brescia, Italy. They found that subjects with inadequate natural dentition and not wearing dentures had lower intakes of vitamins, proteins and calories, and a higher morbidity and mortality rate than did subjects with adequate natural dentition or edentulous subjects wearing dentures in both jaws. The authors concluded that a functionally inadequate dental status has a negative impact on the dietary intake of community-dwelling elderly adults, and that the use of dentures can counteract this e€ect and is associated with a more satisfactory dietary intake. These ®ndings were supported in two other studies of independent-living elderly people, showing that the nutritional quality of the diet fell as the number of teeth declined.59,63 Residents in long-term care facilities About 60% of residents living in long-term care facilities su€er from undernutrition, with the major causes being general medical problems, reduced appetite and poor quality of life.64 However, oral problems such as poor oral hygiene, xerostomia and the inability to chew are common in frail older adults. Indeed, these are the best predictors of signi®cant involuntary weight loss.65 In one study, the relationship between general health, oral health and undernutrition was examined in 324 residents in a long-term care facility.66 Their functional status was evaluated using the Barthel index and their nutritional status using the Body Mass Index (BMI) and serum albumin concentration. It was found that serum albumin level and BMI were reduced in dentate individuals, whose oral function was compromised by having fewer than six occluding teeth, mobile teeth or four or more retained roots, and in the edentulous elderly who did not wear dentures or who wore dentures with defective bases. Using the Mini Nutritional Assessment, lower scores were observed in edentulous subjects without any or with just one complete denture, than in edentulous subjects with two dentures or dentate subjects with or without partial dentures.67 In this study, those with a more compromised dental situation reported eating more mashed food. Certain associations have been demonstrated between undernutrition, as indicated by anthropometric measures, and serum albumin level on the one hand, and loss of

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appetite, reduced stimulated salivary ¯ow rate and impaired masticatory function on the other.36,41,68 Thus, there was a signi®cant association between low salivary ¯ow rate and low serum albumin levels, whereas the number of masticatory movements until swallowing a standard biscuit was increased in patients with low skinfold thickness. It has also been reported that patients with complaints related to xerostomia report diculties in chewing and that they tend to avoid the intake of crunchy food such as vegetables, dry food such as bread, or sticky food such as peanut butter.69 In addition to problems with eating, xerostomia may also be a negative factor with respect to the ability of elderly people to communicate and participate in social interaction.70 ORAL HEALTH CARE Today, primary oral health care for disabled elderly people living in institutionalized or non-institutionalized settings is poorly developed, even in the highly industrialized and rich Western countries. The reason may be that dental and oral diseases are not perceived as conditions that are likely to have a negative e€ect on general health and the quality of life of old people. This was supported by a recent study of the attitude of institutional sta€ regarding oral health problems.19 Thus, the management of the nursing homes was unaware of the oral health situation of the residents, the carers were poorly informed to understand and take care of the residents' oral and dental health and there was poor communication between the nursing home and the dentist living in the area. Furthermore, domiciliary dental care services need to be developed by improving pre- and post-doctoral training programmes and by establishing a realistic remuneration for dental teams providing this care.71,72 The planning of dental and prosthetic care and treatment for frail or dependent older adults in long-term care facilities requires knowledge about the patient's oral and general health status, as well as information about the existing dental service, including the sta€'s attitude toward dental care.73 Therefore, the dentist should be integrated into the health care team and it is also important to include the family in any decisionmaking. When planning prosthodontic therapy for frail or dependent elderly people in order to restore or improve masticatory function, the following issues should be addressed: . The treatment plan should be realistic, taking into consideration the resident's physical and mental situation as well as their present oral health status. . It is important to consider whether the resident has a perceived need and expressed demand. . The dentist should consider the cost±bene®t ratios; that is, the bene®t from the treatment in terms of improved oral function and quality of life should always be greater than the mental anguish, physical pain and discomfort experienced during treatment.

If the resident's life expectancy is limited, palliative treatments are generally indicated. However, if the life expectancy is several years, a more comprehensive treatment may be indicated including extraction of now useless teeth and the implementation of preventive measures to avoid the need for future extractions. Necessary prosthetic therapy should take place immediately and not be postponed until a time when the resident may be unable to co-operate. The caregiver's role in supporting the resident in maintaining daily oral hygiene is fundamental for the outcome of prosthetic or restorative treatment. This means that if

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Practice points . impaired or altered taste and smell sensation in older persons is a frequent complication of general disorders . elderly individuals with a poor general health status frequently have poor oral health . masticatory function in elderly individuals depends on the number of remaining teeth, the quality of prosthetic restorations, masticatory muscle mass and function and the salivary ¯ow rate . assessment of masticatory ability and chewing eciency should be an integral part of the nutritional assessment of elderly individuals

Research agenda . the in¯uence of oral health on nutrition and general health needs to be de®ned . appropriate policies to improve and maintain oral health in frail and dependent elderly people need to be developed . appropriate routines to improve or maintain oral health in frail and dependent elderly have to be implemented

appropriate oral hygiene cannot be maintained, only palliative care should be carried out. It is, therefore, very important that the caregivers are motivated and trained to provide the necessary follow-up care to restorative and prosthetic therapy in order for the patient to bene®t from such therapy. SUMMARY In healthy older individuals the intake of nutrients and energy is, by and large, satisfactory. Furthermore, masticatory function is likely to improve if missing teeth are replaced by conventional or implant-based prosthodontics.74 In those with an impaired masticatory function, the food choices may be limited and the oral comfort and quality of life rather poor without necessarily giving rise to a de®cient nutritional status. In frail and dependent elderly people the situation is quite di€erent, since they are often a€ected by proteocaloric undernutrition. Therefore, maintenance or reestablishment of a proper masticatory function should be considered as an integral part of the medical health care for these individuals. Indeed, oral comfort and appropriate masticatory function and nutrition are important for the quality of life of elderly people.75 The relative importance of oral health and masticatory function compared with general health and socioeconomic status as factors predisposing for undernutrition is not known. REFERENCES 1. Griep MI, Verleye G, Franck AH et al. Variation in nutrient intake with dental status, age and odour perception. European Journal of Clinical Nutrition 1996; 50: 816±825. 2. Doty RL, Shaman P, Applebaum SL et al. Smell identi®cation ability: changes with age. Science 1984; 226: 1441±1443.

894 E. Budtz-Jùrgensen et al 3. Schi€man SS, Moss J & Erickson RP. Thresholds of food odors in the elderly. Experimental Ageing Research 1976; 2: 389±398. 4. Stevens JC & Cain WS. Smelling via the mouth: e€ect of ageing. Perceptive Psychophysiology 1986; 40: 142±146. 5. Winkler S, Garg AK, Mekayarajjananouth T et al. Depressed taste and smell in geriatric patients. Journal of the American Dental Association 1999; 130: 1759±1765. 6. Grushka M & Sessle B. Taste dysfunction in burning mouth syndrome. Gerodontics 1988; 4: 256±258. 7. Thompson GW & Kreisel PSJ. The impact of the demographics of aging and the edentulous condition on dental care services. Journal of Prosthetic Dentistry 1998; 79: 56±59. 8. Katz RV, Neely AL & Morse DE. The epidemiology of oral diseases in older adults. In Holm-Pedersen P & LoÈe B (eds) Textbook of Geriatric Dentistry, 2nd edn, pp 263±301. Copenhagen: Munksgaard, 1996. 9. Locker D & Leake JL. Risk indicators and risk factors for periodontal disease experience in older adults living independently in Ontario, Canada. Journal of Dental Research 1993; 72: 9±17. 10. Fejerskov O, Luan WM, Nyvad B et al. Active and inactive root surface caries lesions in a selected group of 60- to 80-year-old Danes. Caries Research 1991; 25: 385±391. 11. Palmqvist S, SoÈderfeldt B & Arnbjerg D. Explanatory models for total edentulousness, presence of removable dentures and complete dental arches in a Swedish population. Acta Odontologica Scandinavica 1992; 50: 133±139. 12. Takala L, Utriainen P & Alanen P. Incidence of edentulousness, reasons for full clearance, and health status of teeth before extractions in rural Finland. Community Dentistry and Oral Epidemiology 1994; 22: 254±257. 13. Mojon P & MacEntee MI. Discrepancy between need for prosthodontic treatment and complaints in an elderly edentulous population. Community Dentistry and Oral Epidemiology 1992; 20: 48±52. 14. Henry RG & Ceridan B. Delivering dental care to nursing home and homebound patients. Dental Clinics of North America 1994; 38: 537±551. 15. Berkey DB. Meaning and value of oral health for older persons: research ®ndings and clinical care implications. A reactor's note. Gerodontology 1996; 13: 90±93. 16. Kiyak HA, Grayston MN & Crinean CL. Oral health problems and needs of nursing home residents. Community Dentistry and Oral Epidemiology 1993; 21: 49±52. 17. Vigild M. Dental caries and the need for treatment among institutionalized elderly. Community Dentistry and Oral Epidemiology 1989; 17: 102±105. *18. Budtz-Jùrgensen E, Mojon P, Roehrich N et al. Caries prevalence and associated predisposing conditions in recently hospitalized elderly persons. Acta Odontologica Scandinavica 1996; 54: 251±256. 19. Scannapieco FA, Papandonatos GD & Dunford RG. Associations between oral conditions and respiratory disease in a national sample survey population. Annals of Periodontology 1998; 3: 252±256. 20. Mojon P, Budtz-Jùrgensen E, Michel JP et al. Oral health and history of respiratory tract infections in frail institutionalized elders. Gerodontology 1997; 14: 9±16. 21. Eadie DR & Schou L. An exploratory study of barriers to promoting oral hygiene through carers of elderly people. Community Dental Health 1992; 9: 343±348. 22. Chung JP, Mojon P & Budtz-Jùrgensen E. Dental care of elderly in nursing homes: perceptions of managers, nurses, and physicians. Special Care in Dentistry 2000; 20: 12±17. 23. Newton JP, Yemm R, Abel RW et al. Changes in human jaw muscles with age and dental state. Gerodontology 1993; 10: 16±22. 24. Bakke M, Holm B, Jensen BL et al. Unilateral isometric bite force in 68-year-old women and men related to occlusal factors. Scandinavian Journal of Dental Research 1990; 98: 149±158. 25. Lindquist LV & Carlsson GE. Changes in masticatory function in complete denture wearers after insertion of bridges on osseointegrated implants in the lower jaw. Advances in Biomaterials 1982; 4: 151±155. 26. Gunne HSJ. Masticatory eciency. A new method for determination of the breakdown of masticated test material. Acta Odontologica Scandinavica 1983; 41: 271±276. 27. Slagter AP. Mastication, food consistency and dental state, 1992. PhD Thesis: University of Utrecht. 28. Witter DJ, De Haan AFJ, KaÈyser AF et al. A 6-year follow-up study of oral function in shortened dental arches. Part II: Craniomandibular dysfunction and oral comfort. Journal of Oral Rehabilitation 1994; 21: 353±366. 29. Dormenval V, Mojon P & Budtz-Jùrgensen E. Associations between self-assessed masticatory ability, nutritional status, prosthetic status and salivary ¯ow rate in hospitalized elders. Oral Diseases 1999; 5: 32±38. 30. Harle TJ & Anderson JD. Patient satisfaction with implant-supported prostheses. International Journal of Prosthodontics 1993; 6: 153±162. 31. Budtz-Jùrgensen E, Isidor F & Karring R. Cantilevered ®xed partial dentures in a geriatric population: preliminary report. Journal of Prosthetic Dentistry 1985; 54: 467±473.

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