NUTRITION AND DIETETICS IN GERIATRIC PATIENTS (1).pptx

NUTRITION AND DIETETICS

1. NUTRITION AND DIETETICS IN GERIATRIC PATIENTS PRESENTED BY: DR. RENUKA DANGE 1 ST YEAR RESIDENT DEPT OF PROSTHODONTICS AND CROWN & BRIDGE GOVT DENTAL COLLEGE & HOSPITAL, JAMNAGAR. GUIDED BY: DR. SANJAY LAGDIVE HEAD AND PROFESSOR, DEPT OF PROSTHODONTICS AND CROWN & BRIDGE GOVT DENTAL COLLEGE & HOSPITAL, JAMNAGAR.

2. CONTENTS Introduction Need for discussion Definitions Factors Contributing To Nutritional Problems In The Elderly Changes In The Oral Status Of The Elderly Geriatric Nutrition Assessing Nutritional Status Prosthodontic Considerations Of Nutrition Dietary Counseling Of Prosthodontic patients Dietary Suggestions For Denture Wearers Diet After Denture Insertion Conclusion

3. INTRODUCTION A geriatric patient is not specifically age-defined but rather characterized by a high degree of frailty and multiple active diseases which become more common in the age group above 80 years. It is the main aim of geriatric medicine to optimize functional status of the older person and to ensure best possible quality of life.

4. With age, physical changes bring about loss in function thus, appropriate diet and nutrition will be needed to support geriatric patients in order to slow down the development of chronic disease preventing disability. NEED FOR DISCUSSING NUTRITION AND DIETETICS Eleanor D. Schlenker , Joyce Gilbert. William’s Essentials of Nutrition and Diet Therapy, 11 th edition. Elsevier Inc. ; 2015.

5. The number of people older than 65 years in India is 8 percent i.e. over 80 million and expected to reach 12 percent by 2025. Pendyala G., Joshi S., & Choudhary , S. The ageing nation. Indian journal of community medicine : official publication of Indian Association of Preventive & Social Medicine, 2014. 39(1), 3–7.

6. United Nations. 2019. World Population Aging Report. Available from: https://www.un.org/en/development/desa/population/publications/pdf/ageing/WorldPopulationAgeing2019-Report (Accessed 18th November 2021)

7. Definitions Nutrition Nutrition can be defined as the sum of the processes by which an individual takes in and utilizes food. (FDI) Nutritional status Nutritional status is defined as the “health condition of an individual as influenced by his intake and utilization of nutrients determined from the correlation of information from physical, biochemical, clinical and dietary studies. ( Nizel AE, Papas AS. Nutrition in clinical dentistry)   Abraham E Nizel , Athena. S. Papas. Nutrition in clinical dentistry. 3 rd ed. USA: W. B. Saunders Company;1989

8. Diet Diet can be defined as the type and amount of food eaten daily by an individual. (FDI) BMR (Basal metabolic rate) BMR is defined as the number of kilocalories expended by the organism per square meter of body surface area per hour. (K cal / msq ./ hour). ( Nizel AE, Papas AS. Nutrition in clinical dentistry) Abraham E Nizel , Athena. S. Papas. Nutrition in clinical dentistry. 3 rd ed. USA: W. B. Saunders Company;1989

9. Geriatrics The branch of medicine that treats all problems peculiar to the aging patients, including the clinical problems of senescence and senility. GPT-9 Gerodontics /Geriodontics The treatment of dental problem in aged or aging person. GPT-9 Gerodontology The study of the dentition and dental problems in aged or aging person. GPT-9

10. Factors contributing to nutritional problems in the elderly: 1.  Physiologic changes associated with aging. 2.  Psychosocial aspects 3.  Pharmacological factors 4.  Economic factors Hickson M. Malnutrition and ageing. Postgraduate medical journal. 2006 Jan 1;82(963):2-8.

11. Causes of malnutrition in the elderly: I] Primary causes 1. Ignorance of balanced diet. 2. Inadequate income 3. Social isolation 4. Physical disability 5. Mental disorders II] Secondary causes 1. Alcoholism 2. Increased use of drugs 3. Edentulism Abraham E Nizel , Athena. S. Papas. Nutrition in clinical dentistry. 3 rd ed. USA: W. B. Saunders Company ;1989

12. PHYSIOLOGICAL CHANGES Body Composition Dehydration and kidney function Changes in Gastrointestinal tract

13. Changes in body system of elderly Eleanor D. Schlenker , Joyce Gilbert. William’s Essentials of Nutrition and Diet Therapy, 11 th edition. Elsevier Inc. ; 2015.

14. Physiological changes Body Composition: Steady decrease in lean body mass (muscle mass) of about 6.3 per cent for each decade of life. Increase in body fat and decrease in total body water. Abraham E Nizel , Athena. S. Papas. Nutrition in clinical dentistry. 3 rd ed. USA: W. B. Saunders Company ;1989

15. Buch A, Carmeli E, Boker LK, Marcus Y, Shefer G, Kis O, Berner Y, Stern N. Muscle function and fat content in relation to sarcopenia, obesity and frailty of old age—An overview. Experimental gerontology. 2016 Apr 1;76:25-32. Fat distribution in human body:

16. AGING Bone loss (osteopenia/osteoporosis) M uscle loss (Sarcopenia) Fat gain (adiposity) osteopenic obesity sarcopenic obesity O steosarcopenic obesity Risk of fractures Functionality Morbidity Ormsbee MJ, Prado CM, Ilich JZ, Purcell S, Siervo M, Folsom A, Panton L. Osteosarcopenic obesity: the role of bone, muscle, and fat on health. Journal of cachexia , sarcopenia and muscle. 2014 Sep 1;5(3):183-92.

17. Decline in kidney function and total body water metabolism, is a major concern in the older population. Dehydration Sheldon Winkler. Essentials of complete denture prosthodontics. 2 nd ed. USA: Ishiyaku Euro America Inc. Publishers; 2000

18. Britton E, McLaughlin JT. (2013) Ageing and the gut.  The Proceedings of the Nutrition Society; 72: 1, 173-177. Changes in Gastrointestinal tract

19. PSYCHOSOCIAL FACTORS

20. Mental disorders like confusion, forgetfulness, irritability, depression or dementia. Loneliness Loss of companion PSYCHOSOCIAL FACTORS Abraham E Nizel , Athena. S. Papas. Nutrition in clinical dentistry. 3 rd ed. USA: W. B. Saunders Company ;1989

21. ECONOMIC FACTORS

22. A relationship between income and nutritional adequacy. Transportation, housing and facilities for food storage and preparation. Goodwin JS. Social, psychological and physical factors affecting the nutritional status of elderly subjects: separating cause and effect. The American journal of clinical nutrition. 1989 Nov 1;50(5):1201-9.

23. PHARMACOLOGICAL FACTORS

24. Use of multiple medications, known as polypharmacy . Many of these drugs interfere with digestion, absorption, utilization or excretion of essential nutrients. Additionally, some drugs profoundly affect appetite, decrease salivary flow and affect taste and smell acuity. Hilmer SN, Gnjidic D. The effects of polypharmacy in older adults. Clinical Pharmacology & Therapeutics. 2009 Jan;85(1):86-8.

25. CHANGES IN THE ORAL STATUS OF ELDERLY 1. Alteration in gustation. 2. Changes in Salivary function. 3. Oral mucosal changes 4. Changes in muscle function 5. Changes in TMJ 6. Edentualism 7. Alveolar bone loss

26. a) Alteration in gustation : Decreases with age. Boyce JM, Shone GR. Effects of ageing on smell and taste. Postgraduate medical journal. 2006 Apr 1;82(966):239-41.

27. Lose our sense of smell, and ability to discriminate between smells . D ecrease in the sensory aspect of the food D ecrease in food consumption because tasteless, odorless food most likely will not be eaten. 2. Alteration in olfaction More than 75% of people over the age of 80 years have evidence of major olfactory impairment, and that olfaction declines considerably after the seventh decade. Boyce JM, Shone GR. Effects of ageing on smell and taste. Postgraduate medical journal. 2006 Apr 1;82(966):239-41.

28. Factors contributing to taste alteration in elderly – 1. Health disorders 2. Medications 3. Oral hygiene 4. Denture use 5. Smoking Boyce JM, Shone GR. Effects of ageing on smell and taste. Postgraduate medical journal. 2006 Apr 1;82(966):239-41.

29. b) Decreased Salivary function Water in the form of saliva is essential for mastication. The elderly patients are tired and restless. The skin , eyes and oral mucosa are dry and easily irritated. Sheldon Winkler. Essentials of complete denture prosthodontics. 2 nd ed. USA: Ishiyaku Euro America Inc. Publishers; 2000

30. Commonly prescribed groups of drugs that produce xerostomia are antihypertensives, anticonvulsants, tranquilizers antidepressants, and anti- Parkinson's drugs. Tan EC, Lexomboon D, Sandborgh ‐Englund G, Haasum Y, Johnell K. Medications that cause dry mouth as an adverse effect in older people: A systematic review and metaanalysis . Journal of the American Geriatrics Society. 2018 Jan;66(1):76-84. MEDICATIONS AND SALIVARY FLOW

31. Without significant salivary flow, food debris will remain in the mouth, where it is fermented by dental plaque bacteria to organic acids that initiate the DENTAL CARIES process. Dawes C, Pedersen AM, Villa A, Ekström J, Proctor GB, Vissink A, McGowan R, Aliko A, Narayana N. The functions of human saliva: A review sponsored by the World Workshop on Oral Medicine VI. Archives of oral biology. 2015 Jun 1;60(6):863-74 Salivary function

32. P revents the formation of a bolus. M akes the mouth sore and chewing painful. M akes swallowing difficult. 4. Cause changes in taste perception that decreases adequate food intake. Salivary function

33. c) Oral mucosal changes: Burning sensation. P ain and dryness of the mouth. Cracks in the lips. D ry , atrophic, and sometimes inflamed, but more often it is pale and translucent. The epithelial membrane is thin, friable and easily injured. Sheldon Winkler. Essentials of complete denture prosthodontics. 2 nd ed. USA: Ishiyaku Euro America Inc. Publishers; 2000

34. TROPONIN cardiac and skeletal muscles d) Muscle function and oral movements: Skeletal muscle contraction Calcium sTnT Several layers of connective tissue, maintain the muscle integrity. If this barrier is injured, internal components of muscle, particularly sTnT , leak into the blood and their measurable presence could indicate sarcopenia . JafariNasabian P, Inglis JE, Reilly W, Kelly OJ, Ilich JZ. Aging human body: changes in bone, muscle and body fat with consequent changes in nutrient intake. Journal of Endocrinology. 2017 Jul 1;234(1):R37-51. contracts

35. Muscle tone decreases by as much as 20% to 25% in old age, which probably explains the shorter chewing strokes and prolonged chewing time. Machida N, Tohara H, Hara K, Kumakura A, Wakasugi Y, Nakane A, Minakuchi S. Effects of aging and sarcopenia on tongue pressure and jaw‐opening force. International Journal of Geriatrics & gerontology. 2016 Feb;(2):295-301.

36. Age may impair the central processing of nerve impulses, impede the activity of striated muscle fibers, and retard the ability to make decisions. Also, there is r eduction in the number of functional motor units along with a decrease in the cross sectional area of the masseter and medial pterygoid muscles. Muscle function and oral movements Machida N, Tohara H, Hara K, Kumakura A, Wakasugi Y, Nakane A, Minakuchi S. Effects of aging and sarcopenia on tongue pressure and jaw‐opening force. Geriatrics & gerontology international. 2017 Feb;17(2):295-301.

37. e) Temporomandibular joint pain: Bruxism and Attrition of incisal and occlusal surfaces takes place. 1. Shortened anatomical crowns 2. Exposed dentin 3. Wide, flattened chewing surfaces 4. Overclosure of the jaws Machida N, Tohara H, Hara K, Kumakura A, Wakasugi Y, Nakane A, Minakuchi S. Effects of aging and sarcopenia on tongue pressure and jaw‐opening force. Geriatrics & gerontology international. 2017 Feb;17(2):295-301.

38. increases with age. over the age of 65 are edentulous consume soft, easily chewed foods that are low in fiber and have a low nutrient density. Released whole or incompletely indigested from the G.I.T.  f) Edentulism: Abraham E Nizel , Athena. S. Papas. Nutrition in clinical dentistry. 3 rd ed. USA: W. B. Saunders Company ;1989

39. body calcium balance Calcium deposited or resorbed Calcium homeostasis g) Alveolar bone loss: Alveolar bone density Abraham E Nizel , Athena. S. Papas. Nutrition in clinical dentistry. 3 rd ed. USA: W. B. Saunders Company ;1989

40. Osteoporosis: Estrogen ----- bone resorption Testosterone ------ bone formation Jonasson G, Rythén M. Alveolar bone loss in osteoporosis: a loaded and cellular affair? . Journal of Clinical, cosmetic and investigational dentistry. 2016;8:95.

41. GERIATRIC NUTRITION

42. Classification of food By origin: Food of animal origin Food of plant origin By chemical composition: Carbohydrates Proteins Fats

43. REGULATORS V itamins M inerals W ater By Fu nction : 1.Body building foods: Milk,meat,eggs,fish 2.Energy giving foods : Cereals,sugars 3.Protective foods: Fruits,vegetables

44. The sum total of ingesting the diet, the digestive functioning, and absorption of nutrition by tissues until its complete usage by the cells. NUTRITIONAL RECOMMENDATION:

45. GERIATRIC NUTRITION ENERGY REQUIREMENT: Decreases in older persons by about 100kcals/decade RDA for energy : 30kcal/kg/day

46. CAR B OHYD R A TES The recommended range of intake is 5 0 % of total calories. Fiber rich complex carbohydrates are recommended. Food sources include grains and cereals, vegetables , fruits and dairy products.

47. PROTEINS Protein depletion seen primarily as a decrease of the skeletal muscle mass. Proteins is a must for denture wearers. The RDA for proteins, for p eople aged 51 and over, is 0.8- 1 g/kg body weight per day .

48. FATS Dietary fats from either animal or plant sources provide an alternate for storage form of energy. Fat is a more concentrated fuel than carbohydrate, with a fuel factor of 9, yielding 9kcal/g . Contains essential fatty acids required for life and health.

49. Promotes bowel function. reduce serum cholesterol. Fiber in the form of bran is added to dry cereals and breads. FIBRE

50. Excessive water loss through damaged kidney. Inadequate fluid intake will lead to rapid dehydration and associated problems such as: Hypotension, elevated body temperature, dryness of mucosa, decreased urine output and mental confusion. Fluid intake should be atleast 30 ml/kg/day . WATER

51. PROTEIN Milk, egg, fish, meat, liver, pulses, nuts and oilseeds. FAT Butter, ghee, vegetable oils, hydrogenated fats, nuts and oilseeds. CARBOHYDRATES Cereals, pulses, sugar and jaggery , roots and tubers. FIBERS Green leafy vegetables, fruits, unrefined cereals, pulses, and legumes CALCIUM Milk and milk products, green leafy vegetables MAJOR FOOD SOURCES OF NUTRIENTS Naik N et al ., Diet guideline for geriatric patient: A litrature review. Int ernational J ournal of Dent al Health Sci enes . 2015 ; 2(4 ):826-833

52. Deficiency is common in older adults. - megaloblastic anemia - causes include – inadequate intake alcoholism medications malabsorption syndrome RDA is 500 microgram.(above 50 years) FOLATE

53. VITAMIN B12 Low gastric acid level Reduced absorption of Vit B12 because gastric acid is required for food bound vitamin B 12 and make it available for absorption. The RDA is 2.5-3.0 microgram (above 50 yrs) 1 microgram (below 50 years) Causes of deficiency include Reduction in consumption of Vit B12 rich diet. Decreased absorption and bioavailability of vitaminB12

54. VITAMIN C The RDA is about 60 microgram. - Protects against stress related and degenerative diseases. - E ssential for synthesis of collagen and thus essential to the healing of wound. -Causes of deficiency include inadequate intake and high doses of salicylates .

55. Required for maintenance of bone health and absorption of calcium Institutionalized and home bound people at particular risk. The RDA is 15-20 microgram (above 50 years) 5 microgram (below 50 years) VITAMIN D

56. Vitamin D (C alcitriol ) Vitamin D intake Skin production of cholecalciferol Activity of both liver and renal hydroxylases

57. CALCIUM SUPPLEMENTS Post menopausal women taking estrogen supplements :1000mg/day Post menopausal estrogen deprived women : 1500mg/day Supplementation needed for the prevention and treatment of osteoporosis.

58. - Essential for the oxygen carrying capacity of hemoglobin of the blood. Deficiency is associated with: - Inadequate intake - Blood loss associated with hemorrhage or chronic disease - Associated vitamin C deficiency The RDA for iron is 10 mg. IRON

59. VI T A MINS SOUR C ES DEFICIENCY VITAMIN A Liver, kidney, eggyolk , milk, cheese, butter, fish liver oils . VITAMIN D Fatty fish, fish liver oils, egg yolk , milk . Bitot’s spots (eyes) Conjunctival xerosis Xerosis of skin Cereals , pulse, oil seed s ,nuts , yeast . Mi l k and milk products, cereal , fruits, vegetables and fish . Fissuring and redness of eyelid , corners and mouth, Magenta colored tongue . VITAMIN B1 (THIAMINE) VITAMIN B2 (RIBOFLAVIN) Required for maintenance of bone health and absorption of calcium Osteoporosis. Mental confusion, Irritability, Beri Beri , stunted growth. Naik N et al ., Diet guideline for geriatric patient: A litrature review. Int ernational J ournal of Dent al Health Sci enes . 2015 ; 2(4 ):826-833

60. VITAMIN C Citrus food,Amla, guava, tomatoes, green vegetables , potatoes etc. Bleeding in the gums,Delayed wound healing,Hemorrhage and decrease immunity . Meat, milk, fish, egg yolk, corn, wheat Liver , egg,fish,chicken,milk,curd Folic Acid ( Folacin ) Green leafy vegetables, Whole grains, eggs, cereals ,liver , kidney beans Depression , Irratibility , Nervousness, mental confusion, Decrease in hemoglobin levels . VI T A MINS SOUR C ES DEFICIENCY VITAMIN B6 VITAMIN B12 Megaloblastic anemia , Dementia, Neuropsychiatric disorders, Lethargy and Malaise. Glossitis , Skin hyper- pigmentation, Megaloblastic anemia Naik N et al ., Diet guideline for geriatric patient: A litrature review. Int ernational J ournal of Dent al Health Sci enes . 2015 ; 2(4 ):826-833

61. VITAMIN E Vegetables oils (sunflower,soyabean etc) sunflower seeds,green leafy vegetables. Known as anti sterility vitamin . No oral manifestations seen. VITAMIN K Fish, liver, eggs , cereals,green leafy vegetables,brocolli,prues Spontaneous gingival bleeding and Gingival haemorrhages. Naik N et al., Diet guideline for geriatric patient: A litrature review. Int ernational J ournal of Dent al Health Sci enes . 2015; 2(4):826-833 VI T A MINS SOUR C ES DEFICIENCY

62. This is an outline of what to eat each day. It’s not a rigid prescription, but a general guide that let you choose a healthful diet that’s right for you. It emphasizes foods from the five food groups. Food in one group can’t replace those in another. FOOD GUIDE PYRAMID Wardlaw GM, Insel PM, Seyler MF. Contemporary nutrition: issues and insights. Mosby-Year Book, Inc.; 1994.

63. THE FIVE FOOD GROUPS: By Russel et al. Wardlaw GM, Insel PM, Seyler MF. Contemporary nutrition: issues and insights. Mosby-Year Book, Inc.; 1994.

64. Wardlaw GM, Insel PM, Seyler MF. Contemporary nutrition: issues and insights. Mosby-Year Book, Inc.; 1994.

65. Lichtenstein et al .

66. Vegetable and Fruit Group : Four servings subdivided into three categories: Two servings of good sources of vitamin C One serving of good source of Vitamin A One serving of potatoes and other vegetables and fruits. Wardlaw GM, Insel PM, Seyler MF. Contemporary nutrition: issues and insights. Mosby-Year Book, Inc.; 1994.

67. 2. Bread – Cereal Group Four servings of enriched bread, cereals, and flour products . 3. Milk - Cheese group Two Servings of milk and milk based foods, such as cheese (but not butter). 4. Meat, Poultry, Fish and Beans Group Two servings of meats, fish poultry, eggs, dried beans and peas, and nuts. Wardlaw GM, Insel PM, Seyler MF. Contemporary nutrition: issues and insights. Mosby-Year Book, Inc.; 1994.

68. The last item on the pyramid, fats, oils, and sweets, is not considered as a nutritional category and comes with the admonition that these substances are to be used sparingly. Wardlaw GM, Insel PM, Seyler MF. Contemporary nutrition: issues and insights. Mosby-Year Book, Inc.; 1994.

69. FOODSTUFF MALES FEMALES CEREALS 320 gms 220 gms PULSES 70 gms 55 gms GREEN LEAFY VEGETABLES 100 gms 125 gms OTHER VEGETABLES 75 gms 75 gms ROOTS AND TUBERS 75 gms 50 gms MILK AND MILK PRODUCTS 600ml 600 ml OILS AND FATS 30 gms 30 gms FRUITS 75 gms 50 gms SUGAR AND JAGGERY 30 gms 30 gms COMPOSITION OF BALANCED DIET FOR GERIATRICS OVER 60 YEARS: Naik N et al ., Diet guideline for geriatric patient: A litrature review. Int ernational J ournal of Dent al Health Sci enes . 2015 ; 2(4 ):826-833

70. Clinical signs of Nutritional Deficiency The physical signs of nutrient deficiency are not early indications that a particular nutrient is lacking. They develop after period of inadequate intake during which tissue stores are depleted and metabolism is disturbed.

71. Assessing nutritional Status: • Anthropometric data • Biochemical tests • Clinical observations Diet evaluation and personal histories (i.e., medical, social, medications) Eleanor D. Schlenker , Joyce Gilbert. William’s Essentials of Nutrition and Diet Therapy, 11 th edition. Elsevier Inc. ; 2015.

72. Triphasic Nutritional Analysis: This is the three phase nutritional evaluation of geriatric population: Phase 1: Qualitative Dietary Assessment Phase 2: Semi-quantitative Dietary Analysis Biochemical Assessment 3. Phase 3: More complex nutritional problems Bandodkar KA, Aras M. Nutrition for geriatric denture patients. The Journal of Indian Prosthodontic Society. 2006 Jan 1;6(1):22.

73. Prosthodontic Considerations Of Nutrition

74. Treatment planning for partially dentate patients with good prognosis: R emovable partial dentures (RPDs): Designed considering hygienic principles, to prevent plaque accumulation. Minimal invasive dentistry (MID): effective and acceptable form of dental management for older adults. Includes the use of resin-bonded or cement-retained bridges. Reduce maintenance burden. Economical as compared to conventional bridges and RPDs. Glass fibre -reinforced composite bridgework Krishnan Y, Jain L, Seth J, Kumar V. Nutritional and prosthodontic care for geriatric patients. International Journal of Oral Health Dentistry; 2017;3(3):127-132

75. Treatment planning for partially edentulous with poor prognosis: Immediate Denture: Maintains satisfactory appearance and function during the post-extraction phase of treatment. Overdentures : Used especially in the mandible where bone resorption can severely compromise denture stability and retention. Also used in hypodontia cases as well as cleft palate or surgical defect cases. Krishnan Y, Jain L, Seth J, Kumar V. Nutritional and prosthodontic care for geriatric patients. International Journal of Oral Health Dentistry; 2017;3(3):127-132

76. Treatment planning in completely edentulous patients: Complete Dentures: Most common and economical Successful treatment modality if its retention and stability are taken care of. 2. Implants: Can overcome many of the functional, psychological and physiological consequences of edentulism . Helps to preserve alveolar bone and bite force is increased when compared with conventional complete dentures. Krishnan Y, Jain L, Seth J, Kumar V. Nutritional and prosthodontic care for geriatric patients. International Journal of Oral Health Dentistry; 2017;3(3):127-132

77. Dietary Counseling of Prosthodontic Patients Patients often are receptive to suggestions aimed at improving the quality of their diets. Nutrition screening begins at the first appointment itself so that counseling and follow up can occur during the course of treatment.

78. Effect of dentures on taste: Maxillary denture covers the taste buds present in the palate. Effect of dentures on chewing ability: Need to use more strokes and chew longer, to prepare food for swallowing. Masticatory efficiency in denture wearers is approx. 80% lower than in people with intact dentition. Sheldon Winkler. Essentials of complete denture prosthodontics . 2 nd ed. USA: Ishiyaku Euro America Inc. Publishers; 2000

79. Use of herbs and condiments can heighten food flavors for denture wearers. Serving foods that are tolerably hot. For maximum taste sensation, the use of sharply contrasting flavors in combinations (such as sweet and sour) Dietary Suggestions For Denture Wearers Modifying food selection and Food Habits: Ejvind , Budtz -Jorgensen. Prosthodontics for the elderly, diagnosis and treatment. 1sts ed. Quintessence Publishing Co Inc: Illinois; 1999.

80. TEACHING THE PATIENT TO MASTICATE WITH THE NEW PROSTHESIS: The process of eating actually involves three steps: Biting or incising Chewing Swallowing. Ejvind , Budtz -Jorgensen. Prosthodontics for the elderly, diagnosis and treatment. 1sts ed. Quintessence Publishing Co Inc: Illinois; 1999.

81. Tearing action by the incisor dislodgment of the denture by the pulling action of over-tensed muscle. Biting or incising Ejvind , Budtz -Jorgensen. Prosthodontics for the elderly, diagnosis and treatment. 1sts ed. Quintessence Publishing Co Inc: Illinois; 1999.

82. Chewing Chewing by molars and bicuspids are less difficult than incising. The coordination of many muscles of mastication that produce the hinge and sliding movement of the mandible during eating requires some experience. Therefore it is said that a denture wearer can start adapting to the new denture after 6 weeks of wearing. Ejvind , Budtz -Jorgensen. Prosthodontics for the elderly, diagnosis and treatment. 1sts ed. Quintessence Publishing Co Inc: Illinois; 1999.

83. DIET AFTER DENTURE INSERTION On the first post-insertion day : A new denture wearer can choose food which are essentially liquid and are arranged according to the four basic food groups: Vegetable fruit group - juices Bread cereal group - gruels cooked in either milk or water Milk group - milk may be taken in any form Meat group - for the first day or so, eggs will be the first food choice; meat broths or soups may also be eaten. Bandodkar KA, Aras M. Nutrition for geriatric denture patients. The Journal of Indian Prosthodontic Society. 2006 Jan 1;6(1):22.

84. Third post insertion day: The patient can consume soft foods that require a minimum of chewing. Vegetable fruit group: tender cooked fruits and vegetables Bread-cereal group: cooked cereals ,boiled rice. Milk group: milk. Meat group : ground meat, chicken or fish in a cream sauce;eggs may be scrambled or soft cooked. Bandodkar KA, Aras M. Nutrition for geriatric denture patients. The Journal of Indian Prosthodontic Society. 2006 Jan 1;6(1):22.

85. By the fourth day : In addition to the soft diet, firm foods can be eaten. In most instances, these foods should be cut into small pieces before eating. Raw vegetables and fruits are the least preferred by denture wearers. Bandodkar KA, Aras M. Nutrition for geriatric denture patients. The Journal of Indian Prosthodontic Society. 2006 Jan 1;6(1):22.

86. Nutrition is one of the factors which determine the success or failure of prosthetic appliances in the mouth of aging people. Therefore, as a prosthodontist we should be aware that, a well-balanced diet of essential nutrients is vital to the general health of the patient and also to the success of the prosthesis. Geriatric patients are particularly exposed to compromised nutritional health so care must be taken to maintain healthy nutritional status. Conclusion 87

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88. 9. Buch A, Carmeli E, Boker LK, Marcus Y, Shefer G, Kis O, Berner Y, Stern N. Muscle function and fat content in relation to sarcopenia, obesity and frailty of old age—An overview. Experimental gerontology. 2016 Apr 1;76:25-32. 10. Goodwin JS. Social, psychological and physical factors affecting the nutritional status of elderly subjects: separating cause and effect. The American journal of clinical nutrition. 1989 Nov 1;50(5):1201-9. 11. Boyce JM, Shone GR. Effects of ageing on smell and taste. Postgraduate medical journal. 2006 Apr 1;82(966):239-41 12. Tan EC, Lexomboon D, Sandborgh ‐Englund G, Haasum Y, Johnell K. Medications that cause dry mouth as an adverse effect in older people: A systematic review and metaanalysis . Journal of the American Geriatrics Society. 2018 Jan;66(1):76-84.

89. 13. Dawes C, Pedersen AM, Villa A, Ekström J, Proctor GB, Vissink A, McGowan R, Aliko A, Narayana N. The functions of human saliva: A review sponsored by the World Workshop on Oral Medicine VI. Archives of oral biology. 2015 Jun 1;60(6):863-74 14. Bandodkar KA, Aras M. Nutrition for geriatric denture patients. The Journal of Indian Prosthodontic Society. 2006 Jan 1;6(1):22. 15. Rathee M, Singla S, Bhoria M, Kundu R. Role of Nutrition Assessment and Dietary Counselling in Geriatric Denture Population-An Overview. J Oral Health Res. 2015 Apr 1;6(2): 16. Eleanor D. Schlenker , Joyce Gilbert. William’s Essentials of Nutrition and Diet Therapy, 11 th edition. Elsevier Inc. ; 2015.