Journal of Oral Rehabilitation 2001 28; 668±672
Oral functional characteristics and gastrointestinal
pathology: an epidemiological approach
A . T O S E L L O * , B . F O T I * , C . S EÂ D A R A T ², J . M . B R O D E U R ³, J . M . F E R R I G N O * ,
P . T A V I T I A N * , G . S U S I N I * & J . J . B O N F I L * *Service d'Odontologie, HoÃpital Nord (Unite Fonctionnelle de
Recherche Clinique et d'Evaluation), Marseille, France, ²Faculte de Chirurgie Dentaire, Bordeaux, France and ³Universite de MontreÂal, FaculteÂ
de MeÂdecine, DeÂpartement de MeÂdecine Sociale et PreÂventive, Canada
SUMMARY One of the main problems for aged
people is that of having a balanced diet, improved
by correct conditioning of the alimentary bolus.
Does the masticatory status in¯uence the appear-
ance of gastrointestinal disorders? Such a question
justi®es the present study. The present work con-
cerned all the patients (211) of eight geriatric
institutions, and was completed by a retrospective
approach (case±control study). The main result
brought by the case±control study, showed that
Introduction
Although elderly people may have excellent physical
and mental capacities, they often suffer from a gradual
loss of autonomy. One of the main problems for the
aged is that of having a balanced diet, improved by
correct conditioning of the alimentary bolus through
the masticatory function. Studies concerning the in¯u-
ence of dentures or of oral functional characteristics on
gastrointestinal pathologies, appear to be few. Hunt
et al. (1985) did not ®nd a signi®cant link between the
fact of being edentulous and the risk of developing a
gastric pathology. Similarly, Mumma and Quinton
(1970) stated that masticatory ef®cacity did not in¯u-
ence the appearance of certain digestive symptoms such
as anorexia, nausea and sickness in partially dentate,
hospitalized subjects. A recent study (Gilbert et al.,
2 1998) has con®rmed the link between poor masticatory
ef®cacity and the decrease in the number of functional,
opposable dental (pairs).
The correct conditioning of the alimentary bolus may
avoid gastrointestinal pathologies as shown by certain
ã 2001 Blackwell Science Ltd
poor oral functional characteristics represent a risk
for gastrointestinal pathology (age being neutral-
ized; odds ratio (OR): 2.62). This result indicates
that the loss of teeth must be compensated by
functionally effective dentures. Not only will the
patients' physical and psychic health improve but
also medical and public health problems will be
solved.
KEYWORDS : epidemiology, oral health, gastrointest-
1 inal disorders
studies, notably those conducted by Brodeur et al.
(1993). They mainly highlighted the harmful role of
non-functional prostheses; moreover these studies were
performed on a non-institutionalized sample of the
population of Quebec. The aim of the present work was
to study the in¯uence of oral functional performance in
general on the gastrointestinal pathology, in a sample of
the French population living in geriatric institutions.
Materials and methods
General experimental design
The present investigation was carried out transversally,
and concerned all the patients of eight geriatric insti-
tutions. It was completed by a retrospective approach
(case±control study).
The investigation consisted of an anamnesis followed
by an oral examination of each subject; the medical
record of each individual established by the physicians
of the institution, was consulted and, at the same
time, the auxiliary nursing staff were questioned.
668
 ORAL FUNCTION AND GASTROINTESTINAL PATHOLOGY 669

An assessment relating to the different variables stated Table 1. Oral functional characteristics. The absolute and relative
below was then made. frequencies are indicated. Many subjects are completely edentu-
lous or have full dentures. A signi®cant number has a natural set
of teeth
Variables studied
n %
1. Age;
Complete edentulous subjects (without dentures) 44 20á85
2. Sex;
Subjects with complete (bimaxillary) prostheses 64 30á33
3. Gastrointestinal pathology. More precisely, in the
Natural set of teeth 60 28á44
present work, the following gastrointestinal abnormal- Partially edentulous subjects (teeth + dentures) 43 20á38
ities or pathological events were observed: heart burns;
precocious satiety; gastroesophagal re¯ux; transit dis-
orders; regurgitation; epigastric pain; tumoural forma- Table 2. Diet consistency. The absolute and relative frequencies
tion; pancreatitis and vomiting. (%) of the different types of consistency are indicated. Many
The presence or absence of this pathology was 8 subjects have a soft or semisolid diet
veri®ed. In these institutions such events were detected
n %
or diagnosed by attending physicians, with the aid of
medical staff. As many elderly patients are reluctant Soft 25 21á19
to complain, special attention was required from the Semisolid 27 22á88
medical staff, nurses, during mealtimes. Solid 66 55á93

An abnormal behaviour or presenting symptoms

triggered off further investigations through, clinical,
5. Diet
paraclinical and biological examination.
Diet was classi®ed as soft (when reduced to the state
Two groups were established in the present study.
of pureÂe), semisolid (small pieces inferior to 1á5 cm2) or
Subjects who did not present any of the above manifes-
solid (current food).
tations were considered to have no gastrointestinal
pathology. Conversely, subjects presenting at least one
of these manifestations were recorded as with pathology. Statistical study
4. The performance of oral functional characteristics;
Statistical data were studied by using PCSM (Delta Soft,
the subjects were classi®ed in the following categories
Bordeaux) and Epi.Info* software. For the various tests
of the present variable:
used in the analysis of the results, the level of statistical
(a) Subjects with complete dentures.
signi®cance was ®xed at P ˆ 0á005.
(b) Completely edentulous subjects without dentures.
(c) Natural set of teeth. These were subjects present-
ing a complete dental set of teeth or with no more Results and discussion
than four teeth missing other than third molars. Also
included in this category were subjects presenting a Main features of the population studied
limited edentulous area compensated by a ®xed
The population studied was composed of 211 individ-
prosthesis.
uals with an age range between 44 and 100 years. The
(d) Partially edentulous subjects (called `teeth +
mean age was 83á29 years.
dentures'). These subjects generally had partial
Women were in a large majority (84á46%). The oral
prostheses.
functional performance is presented in Table 1, and the
The categories of variable no. 4 have been grouped so
type of diet in Table 2. It is important to notice that the
as to form variable no. 4B, that is to say:
presence of a gastrointestinal pathology was not linked
4B. Normal set of teeth or not
to the sex of the subject, which meant the study could
Yes: subjects classi®ed as having a natural set of teeth
be continued within the envisaged framework (v2 ˆ
(cf. above);
1á2717; P ˆ 0á26).
No: other categories, i.e. subjects with complete
dentures, completely bimaxillary edentulous subjects
without dentures, partially edentulous subjects, etc. *WHO, Geneva.

ã 2001 Blackwell Science Ltd, Journal of Oral Rehabilitation 28; 668±672

670 A . T O S E L L O et al.

Table 3. Natural set of teeth and gastrointestinal pathology. The Table 4. Oral functional performance and gastrointestinal
line and column percentages are indicated in brackets for each pathology. There is a signi®cant link between the variables
subject 9 (v2 ˆ 9á7502; P ˆ 0á002)

Natural set of teeth Edentulous Partially

Gastrointestinal Complete subjects Normal edentulous
pathology No Yes
Gastric bimaxillary without set of subjects (with
No 108 53 problem prostheses dentures teeth dentures)
(67á1) (32á9)
No 49 33 53 26
(72á0) (88á3)
(30á4) (20á5) (32á9) (16á1)
Yes 42 7 (76á6) (75á0) (88á3) (61á9)
(85á7) (14á3)
Yes 15 11 7 16
(28á0) (11á7)
(30á6) (22á4) (14á3) (32á7)
There is a statistically signi®cant link between the `normal set of (23á4) (25á0) (11á7) (38á1)
teeth' (Yes±No) and `gastrointestinal pathology'(Yes±No) variables
The line and column percentages are indicated in brackets, for
(v2 ˆ 6á391; P ˆ 0á011).
each case. There is a statistically signi®cant link between the two
variables (v2 ˆ 9á75; ddl ˆ 3; P ˆ 0á02). The multiple comparison
test of columns shows a signi®cant difference between subjects
Analytical study with a normal set of teeth v. edentulous subjects with partial
dentures.
The statistical analysis shows a correlation between the
age and the presence of a gastrointestinal pathology
(r ˆ 0á1832 with a con®dence interval at 95%
[0á0490±0á3109]; statistical signi®cance of the slope
is established at P ˆ 0á007). Subjects presenting a
gastrointestinal pathology were of a signi®cantly dif-
ferent age from those without this pathology (mean
age: 86á06 years for those with the pathology vs. 82á55
for those without the pathology; with P ˆ 0á007 for the
comparison test of the mean values).
It also appears that subjects with a natural set of teeth
suffer from fewer gastrointestinal pathologies than
others (study with the chi-squared test: P ˆ 0á011; cf.
Table 3). More precisely, a study of the `oral functional
characteristics' variable (no. 4), in accordance with the
gastrointestinal pathology, indicated that it was subjects
with a natural set of teeth vs. partially edentulous
subjects who were at the origin of the statistically
signi®cant difference concerning the gastrointestinal
pathology (comparison test of the columns of Table 4
with corrected P-value equal to 0á00854, also see Fig. 1).
Finally, it appears that the types of diet were related
to oral functional characteristics (cf. Table 5; result of
Fig. 1. Oral functional performance and gastrointestinal pathol-
test v2 ˆ 11á49; P ˆ 0á009). ogy (Yes±No). Distribution in percentage. Note the distinctive
The gastrointestinal pathology was strongly linked to difference in gastrointestinal pathologies between subjects with
the age of the subjects on one hand, and to the oral normal sets of teeth and subjects with dentures.
functional characteristics on the other; the latter also
being linked to age. Age may therefore appear as a The risk which poor oral functional characteristics
confounding variable in a study which aims to establish represent for gastrointestinal pathology was therefore
that poor oral functional characteristics are a risk factor studied after age adjustment in order to neutralize this
for gastrointestinal pathologies. confounding factor. A covariance analysis was then

ã 2001 Blackwell Science Ltd, Journal of Oral Rehabilitation 28; 668±672

 ORAL FUNCTION AND GASTROINTESTINAL PATHOLOGY 671

Table 5. Oral functional characteristics and type of diet. Line and study, of an odds ratio (OR). The odds ratio determined
column percentages are indicated in brackets for each case. There the risk of a gastrointestinal pathology occurring for
is a statistically signi®cant link between the two variables
subjects presenting poor oral functional characteristics.
(v2 = 11á49; P = 0á0097)
The `case±control' study is con®gured on the contin-
Oral functional characteristics gency table (Table 7). Two strata of age were created in
order to neutralize the confounding factor (®rst stra-
Edentulous Normal
tum ³ 85 years; second stratum < 85 years; 85 years
Type Complete without set of Partially
being the median value of the age distribution). The
of diet prosthesis denture teeth edentulous
subjects were considered at risk if they did not have a
Soft or semisolid 11 17 13 11 natural set of teeth (either subjects with complete
(21á1) (32á7) (25) (21á1)
bimaxillary prostheses or completely edentulous sub-
(28á9) (34á2) (34á2) (55)
jects with no dentures or partially edentulous subjects),
Solid 27 5 25 9
and not at risk if they had a natural set of teeth.
(40á9) (7á6) (37á9) (13á6)
The subjects were considered as `cases' if they presen-
(71á1) (22á7) (65á8) (45)
ted a gastrointestinal pathology, and as `control' if they
did not.
performed, with age as the covariant, the gastrointes- It emerges that Mantel Haenszel's v2 is equal to 4á04
tinal pathology transformed in Boolean variable as (P ˆ 0á044) and that the limits of the con®dence
determined quantitative variable (0á1 depending on interval at 95% for the odds ratio according to Corn®eld
whether it was absent or present). The determining are [1á02 < OR < 6á95] (OR MH: 2á62).
factor was the `oral functional characteristics'. The It is therefore appropriate to say that the fact of being
results of this test with adjustment on age show that edentulous or of having a more or less well compen-
gastrointestinal pathologies continue to be signi®cantly sated set of teeth, constitutes a risk factor of gastroin-
linked to `oral functional characteristics' (P ˆ 0á039; testinal pathology with reference to subjects with
cf. Table 6). normal sets of teeth.
Consequently, the study could continue with the The results attached to this study enable certain
de®nition, within the framework of a `case±control' considerations to be made.

Table 6. Analysis of covariance. The

Variation source Sum of square d.f. Variance F P
lines do not diverge signi®cantly
from parallelism: the analysis of Factor A (natural set of teeth or not) 0á7261 1 0á7261 4á2058 0á0390
covariance is licit with regard to this Deviation from parallelism 0á0160 1 0á0160 0á0928 0á7590
condition of validity (P > 0á0500) Rest 35á5641 206 0á1726

Total 36á3062 208

The adjusted mean values differ signi®cantly (P £ 0á0500). The in¯uence of factor A (natural set
of teeth or not) is statistically signi®cant regarding the presence of a gastrointestinal pathology.

Table 7. Case±control study. Analysis according to a contingency table strati®ed in two age strata (age ³ 85 years and < 85 years). The
subjects without a natural set of teeth are considered as exposed to the supposed risk factor; the subjects presenting gastrointestinal
pathologies are cases; those not presenting such pathologies are controls. There is a statistically signi®cant link between exposure and
pathology, P = 0á044. It is therefore licit to de®ne an odds ratio

Age ³ 85 years Age < 85 years

Natural set of teeth Natural set of teeth

No (Exposed +) Yes (Exposed ±) No (Exposed +) Yes (Exposed ±)

Without gastrointestinal pathology (controls) 57 19 51 34

With gastrointestinal pathology (cases) 29 4 13 3

v2 MH = 4á04; P = 0á044; OR MH: 2á62.

ã 2001 Blackwell Science Ltd, Journal of Oral Rehabilitation 28; 668±672

672 A . T O S E L L O et al.
It would appear that mainly subjects having only
a few teeth and more or less suitable dentures are
preferentially exposed to gastrointestinal pathologies.
Therefore, within the framework of this study, one can
af®rm that it is advisable to maintain as many pairs as
possible of antagonistic teeth in good condition; but
one can suppose it is not recommended to keep non-
functional teeth, in poor condition, connected to poorly
effective dentures. In these last cases, it would probably
be advisable to envisage a complete prosthesis (cf. data
in Table 4 and Fig. 1).
Moreover, this study suggests that the poor func-
tional characteristics leads to a semisolid or soft consis-
tency of the alimentary bolus. There has been a
suggestion that the origin of some gastric disorders
may be connected with such a form of bolus which is a
result of a low ®bre diet. Some Canadian studies have
stressed the need of a high ®bre intake in order to
prevent certain gastro-intestinal disorders requiring
medical treatment (Health and Welfare, 1982). In a
4 Scandinavian study Sandstrom and Lindquist (1987)
reported on the dif®culty of completely edentulous
subjects aged 61 and over, and wearing a prosthesis,
when trying to eat raw carrots or whole apples.
These are examples of foods with high ®bre content
5,6 (Schneeman, 1987). Brodeur and Simard (1990) also
supported the relationship between a low ®bre diet and
digestive disorders.
Conclusion
The considerations which link functionally de®cient
oral characteristics to gastrointestinal disorders indicate
that the loss of teeth during the course of life must be as
far as possible avoided; in any case, tooth loss must be
compensated by functionally effective dentures. Not
only will the patients' physical and psychic comfort be
improved, but medical and public health problems will
also be reduced.
One can consider that upon retirement, when the
subjects have a lower purchasing power, teeth will not
be replaced and gastrointestinal and nutrition problems
ã 2001 Blackwell Science Ltd, Journal of Oral Rehabilitation 28; 668±672
may result. It therefore appears completely justi®ed to
reduce the costs and improve the payment of dental
expenses for such elderly people. The agreed cost would
be compensated by the effectiveness (avoided gastroin-
testinal disorders and health expenses, etc.). If it is of
particular relevance for residents of geriatric institutions
to maintain subjects with functional teeth, then their
oral health and hygiene must be regularly monitored.
Moreover, geriatricians concerned by the problem of
malnutrition should be better informed about the
signi®cance of oral health and an adequate dentition.
References
BRODEUR , J.M. & SIMARD , P.L. (1990) ProbleÁmes gastro-intestin-
aux et nutrition inadeÂquate chez les personnes aÃgeÂes compleÁt-
ement eÂdenteÂes sans protheÁse fonctionnelle Rapport de
Recherche. (Document Interne) Groupe de Recherche en SanteÂ
7 Dentaire Communautaire, Universite de Laval.
BRODEUR , J.M., LAURIN , D., VALLE Â E , R. & LACHAPELLE , D. (1993)
ALLEE
Nutrient intake and gastro-intestinal disorders related to mas-
ticatory performance in the edentulous elderly. Journal of
Prosthetic Dentistry, 70, 468.
GILBERT , G.H., FOESTER , U. & DUNGAN , R.P. (1998) Satisfaction
with chewing ability in a diverse sample of dentate adults.
Journal of Oral Rehabilitation, 15, 15.
HEALTH AND WELFARE (1982) Canada's Food Guide Handbook
(Revised). Supply and Services Canada, Ottawa, Canada.
HUNT , R.J., BECK , J.D., LEMKE , J.H., KOHOUT , F.J. & WALLACE ,
R.B. (1985) Edentulism and oral health problems among elderly
rural iowans: the Iowa 65 rural health study. American Journal
of Public Health, 75, 1177.
MUMMA , R.D. & QUINTON , K. (1970) Effect of masticatory
ef®ciency on the occurrence of geriatric distress. Journal of
Dental Research, 49, 69.
SANDSTROM , B. & LINDQUIST , L.W. (1987) The effect of different
prosthetic restorations on the dietary selection in edentulous
patients. A longitudinal study of patients initially treated with
optimal complete dentures and ®nally with tissue integrated
prostheses. Acta Odontologica Scandinavica, 45, 423.
SCHNEEMAN , B.O. (1987) Dietary ®ber and gastro-intestinal
function. Nutrition Review, 45, 129.
Correspondence: Prof. Jean-Jacques Bon®l, Service d'Odontologie,
HoÃpital Nord, Chemin des Bourrellys, 13915 Marseille Cedex 20,
France.
E-mail: jbon®l@ap-hm.fr