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The nutritional effect of tooth loss

Article  in  American Journal of Clinical Nutrition · April 1984

DOI: 10.1093/ajcn/39.3.478 · Source: PubMed

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The nutritional effects of tooth 10551

Catherine A Geissler,2 BDS, PhD and John F Bates,3 DDS, Dr Odont

ABSTRACT In view of the high prevalence of edentulousness in developed countries, the

evidence is reviewed for the effectsoftooth loss on nutrition and health in the following categories
of effects: mortality; food choice and nutrient intake; gastrointestinal irritation; digestion and
nutrient absorption; nutritional status. The evidence indicates reduced consumption of meat,
fresh fruit, and vegetables, and totalenergy resulting in lower Hb and vitamin C levels, increased
gastrointestinal irritationand increased mortality from choking but no striking differences in
digestion or nutritional status. However, most studies are not carefully controlled for other social
and health factors. Am iC/in Nutr l984;39:478-489.

KEY WORDS Tooth loss, mortality, food choice, gastrointestinal irritation, digestion, nu-
tritional status

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Introduction not dramatic: it does not obviously endanger
life as coronary heart disease or protein en-
Forty-four percent of all adults in Scot- ergy malnutrition can; it is not severely crip-
land have no teeth (1). In England and Wales pling as blindness due to vitamin A defi-
the figure for the same year 1968 was 37% ciency is; and it is not such a health and
(2) but the latest 1978 survey shows an im- social stigma as is obesity.
provement to 29% (3). The situation is com- For wild and even domesticated animals
parable in the United States, Sweden, Ice- tooth loss can be fatal. For primitive man
land, and other developed countries for teeth were probably as essential but for mod-
which data are available (4). These astonish- em man commercial food processing and
ing figures raise the question of the effect of refining, home mincers and blenders have
such poor dentition on health and nutrition. removed much of the need for teeth. It is
They refer only to people who have had all technically possible to have complete diets
their teeth extracted and do not include in liquid form, ranging from milk, the nat-
those with poor mastication due to the loss ural food that provides all requirements at
ofsome teeth. The average masticatory per- the time of life when the rate of growth is
formance ofdenture wearers has been shown greatest, to slimmers diets in cans. However,
to be only 12% of normal physiological per- socially a soft diet is impractical. In practice
formance (5). Decay is the principal cause certain kinds of foods are avoided, or they
of tooth loss, followed by periodontal dis- are eaten but scarcely chewed. This could
ease. theoretically be expected to affect the health
Dental research has concentrated on the by altering the intake or absorption of nu-
effects of diet on dental caries and little trients. Diets that are more liquid are gen-
attention has been paid to the effect of tooth erallyless calorie-dense, a fact that is used
loss on health and nutrition. Dental caries is
I From the Department of Nutrition, Queen Eliza-
by far the most prevalent nutritional disease
beth College, University of London, Campden Hill,
in the world (6) and particularily in the London, England and Department of Restorative Den-
developed countries where only a tiny mi- tistry, The Welsh National School of Medicine, Dental
nority escape. More than 99% of these pop- School, Heath Park, Cardiff, Wales.
2 [turer Department of Nutrition, Queen Eliza-
ulations suffer dental decay. Despite this fact
beth College. Author to whom requests for reprints
dental caries is generally overlooked as a should be addressed. 3Professor, Department of Res-
nutritional disease probably because its ap- torative Dentistry, The Welsh National School of Med-
parent effects on health and well-being are icine.

478 The American Journal of clinical Nutrition 39: MARCH 1984, pp 478-489. Printed in U.S.A.
© 1984 American Society for Clinical Nutrition
 NUTRITIONAL EFFECTS OF TOOTH LOSS 479

in the drastic slimming method of wiring presenting at a London hospital in 1 yr with

the teeth together so that only liquids can be a foreign body in the throat, only three had
consumed. In the toothless consumption of normal dentition and 10 had full upper and
a soft diet might have the same effects, lead- lower dentures. This represented more than
ing to weight loss whether this were desirable twice the number of denture patients than
or not. Tooth loss is naturally most prevalent in a control series (9). Ray and Vinson (10)
in the elderly, 80% being edentulous in Eng- studied more than 900 cases ofimpaction of
land and Wales (2). As the population in which about 600 were in the esophagus, and
this age category increases, any problems consisted of mostly bones and meat. made-
associated with tooth loss are likely to be- quate mastication and the loss of sensation
come more prevalent. in the mouth resulting from artificial den-
Herein we review the evidence for the tures was a major factor in these cases. Even
effects of tooth loss on nutrition and health. intestinal obstruction with dried apricots has
It is investigated in the following categories been reported as a cause ofdeath (11).
of effects: mortality; food choice and nu- Canadian data for mortality rates from
trient intake; gastrointestinal irritation; the inhalation and ingestion of food show
digestion and nutrient absorption; and nu- high rates in infants and the elderly (12). In

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tritional status. The aesthetic effects and adults up to the age of 40 the rates are low,
their social consequences of embarassment less than 1/100,000 per annum. The figures
about speaking, eating, and sexual activity then increase progressively with age, so that
are not considered here nor are the effects the rates for 70-yr-old men and women are
on the mandibularjoint and associated pain. 4.7 and 3.3, respectively, and for 80-yr olds
9. 1 and 6. 1, respectively. The age range at
Mortality which the rates are high correspond with the
period when greatest tooth loss occurs and
Tooth loss is not generally thought of as a possibly loss of muscle coordination to con-
fatal condition. However, there is consider- trol dentures and swallowing. No causal re-
able evidence that it is an important factor lationship can be assumed but the circum-
in death caused by blockage of the air and stantial evidence supports the conclusions
food passages. Choking on food is the sixth from the case studies.
most common cause of accidental death in Another potentially fatal condition is can-
the United States, resulting in nearly 2500 cer (13). Poor dentition was shown to be
fatalities annually as estimated by the Na- associated with a higher risk (mortality ratio
tional Safety Council in 1972. On the basis 3.2) ofdeveloping oral cancer. Other factors
ofanswers to a questionnaire from coroners associated were heavy smoking and drink-
and medical examiners representing a pop- ing. It was found that these risks were not
ulation of 40 million, Eller and Haugen (7) merely additive but synergistic. A substan-
estimate that 700 to 1000 deaths by choking tially higher risk than would have been ex-
on food, as proved at autopsy, occur an- pected was found in heavy smokers (mortal-
nually in the United States but that many ity ratio 4.9) and heavy drinkers (mortality
more must pass unrecognized. Such deaths ratio 5.2) with poor dentition. The risk for
are often falsely attributed to heart attacks men with all these traits was 7.7 times that
and the phenomenon has been variously of men with none of the traits.
labeled “cafe coronary” or “backyard bar-
beque syndrome.” As a result of autopsies
performed in all cases in which sudden death Altered food choice and nutrient intake
occurred during eating, Haugen encoun-
tered 55 cases due to food asphyxiation but If mastication is difficult the choice of
only one due to occlusive coronary artery foods is likely to be altered. Several reports
disease. Anderson (8) reviewed the literature have been made of these changes but con-
on death from foreign bodies and found a clusions are often bedeviled by the methods
dental factor implicated in the vast majority used or lack of information on the methods
of such cases. For example, of the 16 patients used for recording dietary intake, evaluating
480 GEISSLER AND BATES

adequacy of nutrient intake, and controlling by Bender and Davies (2 1) in elderly subjects
for social factors that affect food consump- under the care of health visitors.
tion. For example Barone (14) stated that In a further study of dietary selection (22)
the soft diet of geriatric patients high in housebound pensioners were asked whether
carbohydrate and low in protein was usually they ever ate 12 specified foods chosen to
the rule and that a “tea and toast” diet cover a range of easy to chew to very diffi-
resulted in widespread malnutrition. How- cult. Foods such as nuts, hard biscuits, and
ever, Hobson and Pemberton (1 5) studied a raw celery were progressively more excluded
weighed dietary survey of 330 elderly people from the diet of those with poor fitting den-
resident in Sheffield of whom 20% had a tures, no lower dentures, and no dentures so
“poor state ofnutrition” and concluded that that there was a significant difference in the
in old age inadequate dentition did not se- range of diet of the latter two categories as
riously affect dietary intake. Davidson et al compared with the “better” denture group
(16) found chewing efficiency to be related (p < 0.01). Since it was a pilot survey the
only to protein intake in 104 members of a groups were too small to match for relevant
Boston Age Center but details ofmethod are variables such as age, sex, and cultural and
not given other than that intake was assessed social backgrounds. Similar findings were

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by questionnaire and dental efficiency rated obtained in US dental patients and veterans
by a dental team. (23) in Australian men and women (24) in
The most detailed reports are those of whom it was found that older patients had
M#{228}kil#{228}
(17-20) who studied the effects of more eating problems than younger ones,
complete dentures on dietary habits, flu- and in elderly US medical patients and out-
patients (25).
tnent consumption, and blood nutrient 1ev-
A more extensive survey was carried out
els in Finnish subjects aged between I 8 and
in 1967 to 1968 by the UK Department of
82. Information on dietary habits was ob-
Health and Social Security (DHSS) of the
tamed from personal interviews on the fre-
health and nutrition of 700 elderly people
quency of consumption and the quantity of
living at home in various rural and urban
certain foods. (Bread, porridges, potatoes,
parts ofBritain (26). The effects of inefficient
dried peas, fruit, root and green vegetables,
mastication were also reported separately by
milk, curdled milk, cheese, butter, eggs,
Berry (27). Thirteen percent were classified
meat sausages, fish, liver, kidney, blood
by geriatricians on a subjective, unmeasured
dishes, and various beers.) From this infor-
basis as having inefficient mastication. Food
mation the weekly intake of vitamins was
intake was recorded for 1 wk by the subjects
calculated. It is not clear from the reports who were visited at frequent intervals to
how often the subjects were interviewed or quantify their intake diaries which were also
for what period oftime. The method appears cross-checked by food purchases. They con-
inaccurate for the assessment of nutrient sumed on average 20%, and those over 75
intake but adequate to show differences in yr 40%, less meat, but not compounded
dietary patterns. As might be expected, soft meat, and the women and older men con-
foods such as porridge were eaten more fre- sumed 10 to 20% fewer calories. However,
quently by those without teeth (p < 0.05) these relationships are not necessarily cause
and hard and fibrous foods less frequently. and effect, no account having been taken of
These included fruit (p < 0.05), raw vegeta- other factors that could influence the differ-
bles (p < 0.06), cheese (p < 0.05), meat (p ences in intake such as social class, physical
< 0.001), and sausage (p < 0.001). Examples disability, etc, which may affect both food
of differences in the frequency of consump- intake and dental status separately. To ac-
tion of several foods expressed as the per- count for this, 28 men and 25 women with
centage of dentulous compared with eden- efficient mastication and mostly older than
tulous who ate the food daily are as follows: 75 yr of age were matched with controls of
porridge 24 versus 35%; fruit 46 versus 21 %; the same age, sex, and geographical area. To
meat 51 versus 26%. The tendency to avoid determine which foods in particular were
meat due to lack of teeth was also reported consumed less, their consumption of various
 NUTRITIONAL EFFECTS OF TOOTH LOSS 481

foods was compared, taking into account scores, and the extent of variance, the differ-
the overall reduction of energy intake of ences are not great.
20% in subjects with inefficient mastication. Other groups (30) were 40 men and
Consumption oftomatoes, green vegetables, women living in Old People’s Homes in
and raw noncitrus fruits were disproportion- Hertfordshire and 50 men and women par-
ately lower (40%). Unfortunately the overall ticipants in the 1967 to 1968 DHSS survey
nutrient intake ofthese matched groups was (26) of the elderly living at home in Cam-
not reported. bridge. Masticatory efficiency was assessed
Neill (28) has published several papers as before and in addition retention of den-
relating dietary intake to dental function. In tures was assessed. Food intake was meas-
a study to relate the dietary intake of 576 ured in the Cambridge subjects by their
subjects to dental state it was found that keeping a diary offood intake, quantified by
male subjects aged 5 1 to 70 yr wearing den- frequent visits of dietary investigators. The
tures consumed significantly more calories method used in the Old People’s Homes was
than those with their own teeth. The expla- not reported and only half of these subjects
nation proposed was that inefficient masti- took part. In the small numbers examined
cation may lead them to select more readily no clear trend related dietary intake with

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assimilable carbohydrates and fats. To in- masticatory performance in either Cam-
vestigate the subject further he studied the bridge or Hertfordshire. Neill’s original hy-
dietary intake and masticatory performance pothesis that impaired mastication leads to
of other groups of elderly people. One was a the increased selection of easily assimilable
group of 53 Chelsea pensioners (29) aged 65 carbohydrates and fats is therefore not borne
to 93 yr living in a veterans home. Mastica- out by his subsequent studies.
tion was assessed by the percentage recovery The diet of edentulous geriatric patients
of food through a 10-mesh USS sieve after a was analyzed before and after fitting den-
standard amount of mastication. Each sub- tures, from 4-day records, apparently un-
ject was asked to chew a 12-mm cube por- weighed (3 1). Unfortunately the results are
tion of ham using 20 chewing thrusts and not expressed in a way that allows the level
then to spit and rinse into a container. This of intake of nutrients before and after to be
was washed through a sieve. Masticatory satisfactorily compared. Absolute values are
performance was expressed as the percentage not given, only the significance of deviation
of the total mass recovered which passed from recommended dietary allowances.
through the sieve. Mean scores of edentulous However, their statistical analysis shows a
subjects varied according to the quality of significantly increased intake of energy in
the dentures: no dentures 7.5; poor dentures both men and women. This is reflected in
12.7; fair dentures 20. Food intake was es- increased intakes of various nutrients but it
timated by dieticians observing food con- is not possible from the data to see whether
sumed in the dining hall over a 2 day period, individual nutrients were selectively in-
presumably not weighed. In view ofthe error creased. Most of the subjects noted subjec-
involved in estimating intake by observa- tively that they were eating coarser and more
tion, their conclusions that subjects with fibrous foods.
highest masticatory performance consumed Osterberg and Steen (32) used more rig-
the largest quantity of each nutrient are per- orous criteria in their study of 368 elderly
haps unwarranted as they are based on small men and women in Sweden. Mastication
differences. For example the intakes of sub- was measured by Eichner’s index based on
jects with masticatory scores of more than the extent of contact of posterior teeth. The
20, 20 to 10, and less than 10 were as follows: dietary history method used had been vali-
energy 2495, 2366, 2341 kcal; carbohydrate dated for protein intake by 24-h urinary
263, 234, 217 g; animal protein 63, 58, 58 nitrogen outputs. The subjects were classi-
g; total protein 89, 82, 79 g; and fats 96, 90, fled by well-defined criteria into adequate or
89 g. A definite trend is visible but with the insufficient intake of one or more of the
relatively small number of subjects, (10, 21, following nutrients: protein, calcium, iron,
18, the small differences in masticatory vitamin A, thiamin, riboflavin, and ascorbic
482 GEISSLER AND BATES

acid. A significantly greater proportion of that are likely to be reduced are vitamin C,
subjects with poor dentition had intakes of vitamin A precursors, folic acid, and readily
one or several nutrients below their criteria assimilable iron and fiber. Some of these
for sufficiency. This difference remained reductions may be compensated for by other
even when confounding factors of school items in the diet. Only accurate dietary rec-
education, professional education, marital ords, preferably weighed, could estimate the
status, and family income, are taken into overall effect of these dietary changes on
account. The authors recognize that the re- nutrient intake. For this purpose only the
lationship i not necessarily causal, that bad 1967 to 1968 DHSS nutrition survey re-
dietary practices maintained from earlier in ported by Berry is satisfactory. Reductions
life could have been a factor both in tooth in intake do not necessarily mean deficien-
loss and in poor nutrient intake. cies. Some studies have measured serum
In most of these studies the methods of vitamin levels and clinical parameters of
dietary estimation by questionnaire are ad- nutritional status in edentulous subjects.
equate for qualitative evaluation or even However, no studies have looked specifically
roughly quantitative ifdaily food records are at the fiber content oftheir diets, despite the
kept over several days. However, many pa- frequent statement that coarse, fibrous foods

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pers do not report methodological details are avoided. In view of the accumulating
and some calculate with deceiving exacti- evidence ofthe beneficial role ofdietary fiber
tude nutrient intake based on an inaccurate in the control of obesity, diabetes, divertic-
method and see trends in very small differ- ulitis, cancer, and other diseases of affluence
ences. In some, nutritional adequacy of the this is an important omission. No doubt this
diet is classified by means that are dubious is partly due to the lack of data on the fiber
by current knowledge such as supposedly content offoods but not entirely as no report
beneficial combinations of food groups. has mentioned the health aspects of fiber.
Dietary habits are greatly affected by so-
cial class and geographical area, which also Gastrointestinal disturbances
affect dental care. Only the 1967 to 1968
DHSS study reported by Berry (27) and to Although the edentulous tend to eat soft
some extent Osterberg and Steen (32) take foods, they do often eat food requiring mas-
these factors into account. Berry used con- tication which are then less well chewed.
trol subjects matched for age, sex, and area, Several authors have reported gastrointes-
while Osterberg and Steen analyzed their tinal disturbances caused by inadequate
data considering educational and economic chewing. Acute intestinal blockage has al-
factors. Several reports (22, 23, 29, 30) were ready been discussed: chronic gastrointes-
of housebound or institutionalized pension- tinal irritation has also been studied in hu-
ers and therefore a selected group less rep- man case reports and in animal experiments.
resentative of the elderly than the DHSS Rodriguez-Olleros (33) reviewed 3684
nationwide survey. Although tooth loss medical histories from which were chosen
starts early in life all of these studies have those with severe dental deficiency number-
concentrated almost entirely on the elderly. ing 168. The total number of cases of pri-
The nutritional significance of these re- mary gastritis was 299 of which 83 were
ported changes in dietary habits related to toothless. Therefore almost 50% of the
tooth loss are the reduction in energy intake toothless had primary gastritis compared
and reduction in specific nutrients of which with only 6% of those with relatively effi-
the avoided foods may be particularily good cient mastication. No account was taken of
sources. Reduced energy intake may even age which is an important factor in such
be beneficial rather than detrimental to studies because tooth loss is closely related
health as almost half of the adult British to age. However, antecedents likely to pro-
population is obese and the incidence of duce gastritis such as excessive alcohol or
obesity increases with age. The obesity situ- caffeine consumption were taken into ac-
ation is similar in other developed countries. count and the proportion was the same in
The specific nutrients and dietary factors the two groups.
 NUTRITIONAL EFFECTS OF TOOTH LOSS 483

His conclusion that tooth loss was an im- south where peptic ulceration is much more
portant cause ofgastritis did not correspond common. The diets are, however, different
with experimental work in the rat (34, 35) in other respects that are not considered in
and the contradiction led Mumma and the early papers (39, 40) but are in the later
Quinton (36) to conduct a similar but much papers (41, 42) including fat, fiber, and spice
smaller study, controlling for age and length content. Both fiber and spice have been pro-
of stay in hospital. Efficiency of mastication posed to correlate with peptic ulceration
was compared against records ofgastric dis- (43).
tress (including anorexia, epigastric distress, Malhotra suggests that the amount of
nausea, and vomiting). Their results are less chewing required and the constituents of the
convincing. The authors conclude that mas- diet both have an effect on bile excretion
ticatory efficiency had some influence on and he attempted to separate these two fac-
gastric distress as a combination of two or tors. Fecal and urinary urobilinogen were
more symptoms occurred more frequently used in his studies as indirect indices of the
in the inefficient (14%) than in the efficient amount ofbile entering the duodenal lumen,
(5%) masticators. However, comparing sub- as urobilinogen excretion depends primarily
jects with one or more symptoms the con- on the amount of bilirubin entering the in-

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clusion can be reversed as the equivalent testine. When the diet of subjects was
figures are 20 and 25%. changed from chappati to rice type, fecal
A report from a South African work col- urobilinogen excretion doubled and urinary
ony (37) is frequently quoted but is not excretion quintupled. When the rice diet was
scientifically sound. The author bases his deliberately chewed fecal urobilinogen ex-
conclusion, that gastrointestinal disorders cretion was reduced by 30%. The paper does
were due to lack of teeth, on the fact that not report changes in urinary urobilinogen.
after fitting dentures to 33 edentulous men The explanation proposed is that chewing
who complained of abdominal pains after produces more saliva with greater buffering
meals “they did not complain subse- capacity that would reduce the effects of HCI
quently.” Of the 33, 26 had been admitted as the most potent stimulus for gallbladder
for drunkenness and “it could not be estab- evacuation. Alternatively the mucus content
lished whether the fitting of dentures or the of the saliva might prevent stimuli for the
total abstention from alcohol cured the al- release ofcholecystokinin from reaching the
leged complaint.” receptors. The hypothesis is that when the
No evidence was found in 53 army pen- flow rate ofbile is decreased, it is held longer
sioners in a residential home of a relation- in the gallbladder where it loses alkilinity
ship between masticatory performance and and therefore the ability to damage the mu-
gastrointestinal symptoms of chronic gastri- cosa.
tis (29). However, 30% of patients with he- Boccardo and Betancor (44), working on
reditary malformation of the jaws were re- the hypothesis that it is gastric acidity that
ported to suffer from gastric and intestinal causes peptic ulceration, compared gastric
disorders (38). secretion in dentate and edentulous subjects
Some studies have attempted to explain after subcutaneous injections of histamine.
the mechanisms connecting mastication Volume and acidity of secretion before and
with gastrointestinal irritation. It has been after histamine stimulation was greater by at
postulated that gastric ulceration may be least 35% in subjects whose teeth had been
related to bile reflux. On this basis Malhotra recently extracted (1 5 to 30 days previously).
(39-42) investigated the higher incidence of However, such differences were less marked
peptic ulcer in Southern compared to North- in subjects with chronic loss of occlusion.
ern Indians. His hypothesis that ulceration Only total acid in the nonstimulated gastric
is related to lack of mastication is based on secretions was greater by 25% in the eden-
the fact that the diet of North Indians, with tulous.
a low incidence of peptic ulceration, consists Although Sognnaes (34, 35) did not show
largely of wheat chappatis which require that tooth loss was an important factor in
more chewing than the rice-based diet of the gastritis in the rat, several experimental an-
484 GEISSLER AND BATES

imal studies have demonstrated disturb- mastication. The experiment was extended
ances of the digestive system. In rats, scle- to subjects with poor masticatory efficiency
rosis and dystrophy of the pancreas were due to loss of teeth and it was found that
reported (45) after dental extraction, increas- even the slightest degree of mastication was
ing with time after extraction. In pigs, cereal enough to ensure maximal digestion. This
particle size has a marked effect on the in- study is often quoted to show that mastica-
cidence of gastric ulceration, the finer the tion is not important for digestion. However,
grinding the greater the frequency of ulcers the quantity of foods used in the experiment
in the esophageal region of the stomach and was only 1 g and so one would not expect
the more fluid the stomach contents (46). great differences due to mastication, either
One hypothesis suggests that ulceration is from the physical aspect ofgrinding or from
due to acid and pepsin which could be trans- more complete mixing with saliva.
ported more easily to the esophageal region, Sognnaes (49) quotes the work of Becker
another that it may be due to duodenal (1927) on one 32-yr-old woman in normal
regurgitation. This evidence runs contrary health except for very defective teeth. Anal-
to the idea that poor mastication causes yses ofexcreta showed no marked difference
gastric ulceration. in the degree of food utilization before teeth

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The human studies point toward a link were removed, after removal and wound
between gastrointestinal irritation and tooth healing, and when dentures were inserted.
loss; however, no study exists in which other He concludes that modern food requires
known related factors have been carefully little mastication and the gastrointestinal
controlled. The most stringent from this tract can compensate for no chewing. An
point of view is that of Rodriguez-Olleros alternative interpretation ofthis report could
(33). In addition the large number of sub- be that defective teeth, edentulous jaws, and
jects makes the conclusion relating gastritis newly inserted artificial teeth are equally
to tooth loss the most convincing. Animal inefficient.
experiments provide conflicting evidence. However, further evidence that chewing
is unnecessary for digestion was quoted from
Altered digestion and absorption of Seppa (1929). He examined the absorption
nutrients of ordinary foods after poor, normal, and
prolonged mastication. The absorption was
If inadequate chewing is associated with reported to be about the same except for
gastrointestinal irritation, as some evidence bacon which was considerably better di-
suggests, then the digestion of food and ab- gested after prolonged chewing.
sorption of nutrients could be altered. This In the early years of this century the im-
has been studied in several species of animals portance of proper mastication was widely
and in man. The human work is mainly advocated. fletcher was such a proponent
from the first halfofthis century. Van Oefele that very thorough mastication was de-
(47) and other workers in Germany found scnbed as Fletcherizing. To clarify the con-
that when mastication was impaired higher flict between the observation that all high
residues of starch, protein, and fat were protein feeding animals bolt their food and
found in the feces. the then current advocacy of Fletcherizing.
In humans, the classic study was Farrell’s Foster and Hawk (50) studied the utilization
(48). Volunteers swallowed two small cotton of protein in a uniform diet under different
bags tied together, one of which contained degrees of chewing in two young men over
about 1 g of masticated food and the other periods of 4 to 7 days. The nitrogen content
the same food before mastication. The bags ofthe food, feces, and urine were measured.
were subsequently removed from the feces Less than 2% difference was shown in the
and weighed. The 29 foods tested were class- apparent or real (corrected for metabolic
ified into three groups according to the ef- nitrogen losses in feces from digestive juices
fects of mastication on their residue. Some and epithelium) digestibility of food nitro-
foods were better digested with mastication, gen.
others were just as well digested without Most of the limited evidence in humans
 NUTRITIONAL EFFECTS OF TOOTH LOSS 485

therefore suggests that the degree of masti- Further experiments (52) on the influence
cation is not important for digestion at least of particle size showed no significant differ-
in young, healthy subjects. ence between male or female experimental
In animals the evidence is less harmoni- (molarless) and control rats in the intake of
ous. Sognnaes (34) demonstrated a large fall whole cracked corn but the body weights of
in masticatory efficiency in rats with maxil- the molarless male rats were substantially
lary molars removed and fed a diet of 60% lower than controls. Females showed no dif-
coarsely ground corn. The size of particles ference in body weight. Weight recovery oc-
in the stomach and feces was increased. curred in the experimental male group when
However, there was no significant change in pulverized corn was substituted. This was
growth rate or general health and it was accompanied by a temporary sharp increase
concluded that the rats must have compen- in food intake in both groups, but was
sated for the lower digestibility either by greater in the experimental than control
eating more or selecting a larger proportion group. The catch-up in growth could have
of finer parts of the diet. been related to either the increased intake
Other animal experiments have shown or to increased digestibility ofthe pulverized
that impaired mastication leads to reduced diet in the molarless rats. The author takes

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weight gain. Kapur and Okubo (5 1) pro- these results to suggest the clinical impor-
posed that lack of oral gratification from tance of impaired mastication in affecting
mastication could alter both food intake and digestibilty, particularly in underdeveloped
the secretion of digestive enzymes. They countries and undernourished groups. How-
tested the hypothesis on 4- and 12-month- ever, we question the comparability of this
old rats from which all posterior teeth were cracked corn diet to human eating habits
removed or which were sham operated. where the staple is invariably well cooked.
They were fed whole cracked corn ad libi- Furthermore even in these extreme expen-
tum. Differences in food intake and weight mental conditions most rats were unaffected
gain were significant only in the older males. by impaired mastication; only the old and
Despite greater food intake of the experi- males losing weight, and this weight loss
mental group weight was lost, not gained. A could be due partly to raised metabolism
greater percentage of coarse food particles from trauma as well as to impaired diges-
was also found in the gastrointestinal tract tion.
of the experimental animals. From these Gyimesi and Zelles (53) fed young rats on
observations the authors conclude that various combinations of solid or pulpy food
digestion is impaired. Another factor, how- ad libitum or pair fed. The body weight of
ever, may be increased metabolism due to the control group compared with the molar-
the trauma of total molar extraction which less group was 16% greater on the pulpy diet
was presumably greater than the trauma of despite a 15% lower food consumption (per
the sham operation. The difference in weight unit body weight) and 23% greater on the
gain from presurgery to 1 3 or 17 wk post- solid diet of which consumption was twice
surgery between the experimental and con- that of the molarless rats. Even when the
trol groups ofolder rats was about 30 g. This dietary intake was equal, whether solid or
might reasonably be lost postsurgery in rats pulpy, the control rats grew faster than the
which at 12 months must weigh in the order molarless rats, indicating either impaired
of 300 g. Catch-up growth would occur in digestion or higher posttrauma metabolism
most animals after recovery; however, pos- in the molarless rats. The reported measure-
sibly the older male rats were unable to ments were made at the end of the 8th wk
recover to the same extent. We can conclude after extraction which was probably enough
therefore that the effect oftooth loss in most time for recovery from trauma in young rats.
of these animals was negligible except in the In pigs, which are poor masticators, cereal
older males. The effect was not to reduce particles of small size are better digested and
food intake but possibly to impair digestion give better growth and food conversion effi-
although increased metabolism cannot be ciency than large particles, according to sev-
ruled out. eral reports reviewed by Lawrence (46).
486 GEISSLER AND BATES

The apparently contradictory observation (24% females and 37% males) of edentulous
that in dogs, meat is more completely di- subjects with Hb values less than 12.5
gested when fed in large lumps than when g/lOO ml than controls (13% females and
finely ground is surprising (54). Precise fig- 19% males).
ures are not given but interpretation of a In the 1967 to 1968 DHSS study of elderly
chart indicates a residue of about 5% from people throughout Britain, reported by
meat in lumps compared with about 10% Berry (27), no relationship was found be-
when ground. As part of research for a low tween masticatory efficiency and Hb levels
residue diet these studies were performed in in a small sample (53) matched with controls
six dogs deprived ofa colon and the amount of the same age, sex, and geographical area.
of residue measured after digestion of var- However, in the whole sample (700) Hb
ious foods. Ground meat leaves the stomach levels were related to the amount of meat
almost unaltered and the intestine may be consumed. The levels of Hb measured were
less able to digest it completely, whereas unlikely to be associated with ill effects. The
lumps are held in the stomach and the prod- group from the whole sample with ineffi-
ucts ofgastric digestion are expelled in small cient mastication did, however, show a
lots into the intestine. higher prevalence of underweight (Quetelet

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From the human and animal evidence it index wt/ht2) and leanness (low skinfold
appears that mastication does not have an thickness). These results are concordant with
important role in the digestion ofmost foods the 20% lower energy intake of the subjects
by most people and most animals. The ex- with inefficient mastication.
ceptions may be for uncooked fibrous foods However, these differences in adiposity
such as cereals. In the human diet cereals were not confirmed by Elwood and Bates
are almost always cooked but the digestibil- (55) nor were there significant differences in
ity of other fibrous foods eaten raw may be serum folic acid and thiamin between effi-
impaired. In animals it was the older one cient and inefficient masticators. Only in the
that adapted least well to impaired mastica- female toothless subjects were Hb and hem-
tion or increased particle size. The probabil- atocnt significantly lower but the differences
ity is that poor mastication is of importance were small (Hb 12.7 versus 13.3, hematocrit
to humans only where normal digestive ca- 39.6 versus 4 1 .8). These surveys were con-
pacity is impaired. This may be the case ducted to obtain an unbiased sample of el-
particularly in older people. derly people from mining valleys (300 and
150 subjects) and a town (250 subjects) in
Effects on nutritional status and general South Wales.
health Other studies were based on less rigorous
sampling methods. Setyaadmadja (56) con-
The reductions in body weight on expen- cluded that elderly edentulous subjects had
mental diets in molarless animals are of significantly more health complaints than
doubtful significance for humans because of those with teeth. This was based on the
our wide range of food choice and tech- results of a self-administered health ques-
niques of food preparation. Several human tionnaire from “presumably” healthy female
studies have reported serum vitamin levels subjects. The edentulous and dentate in the
in experimental conditions, and indices of age group 55 to 66 yr were compared for the
nutritional status in surveys of edentulous number of symptoms and signs of ill health
people. reported. However, the numbers of subjects
Makila’s studies (1 8-20) on edentulous were small (23 edentulous versus nine den-
subjects in Finland compared with controls tate) and their backgrounds unreported. The
found no significant trends in weight change. results were further analyzed by age group
As might be expected from changes in food comparing the dental state ofthose with high
choice described earlier, the significant dif- scores against those with low scores. In all
ferences in blood values were lower serum but one age group the subjects with many
ascorbic acid values in edentulous compared health problems had fewer teeth than those
to control subjects and a greater proportion with few health problems but the differences
 NUTRITIONAL EFFECTS OF TOOTH LOSS 487

were significant only in the 55 to 66 yr age effects on nutritional status, health, gastroin-
group. testinal disturbances, and digestion. How-
Another report (57) compared the mci- ever, in dissecting closely the reports the
dence ofpoor occlusion in 460 consecutively evidence is much weaker than it would ap-
selected patients of a nutrition clinic in Bir- pear. The main weaknesses are that 1 ) most
mingham, AL, with patients of private den- human studies have not been carefully con-
tal practitioners, patients in a dental school trolled for social and health factors that af-
clinic, and in a cross-sectional survey of the feet food choice and nutrition, 2) the
general population. The fact that the per- method of dietary assessment is often poor
centage edentulous was higher, by as much or unreported, and 3) extrapolation from
as 40% in age groups over 35 yr, in the animal studies is not necessarily relevant in
nutrition clinic population was taken by the view of our greater flexibility in choosing
authors as evidence supporting the hypoth- and preparing different foods. On the other
esis ofa relationship between impaired mas- hand, human experiments in digestion re-
tication and general nutritive failure. Such a lated to mastication have been mainly on
conclusion is unfounded in view of the se-
young and healthy subjects, whereas the sig-
lection bias.
nificance of improper mastication is more
Further evidence for the association of

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likely to be where there is some impairment
edentulousness with undernutrition comes
in the function of the gastrointestinal tract
from the 1972 to 1973 British DHSS survey
which would then be less able to cope with
of nutrition and health in old age (58) on a
the extra burden of inadequately chewed
sample of 365 people over 65 yr living at
home in rural and urban areas throughout food. However, even in the studies of nutri-
Britain. Assessment ofnutritional status was tional status which have been mainly in old
based on 7-day weighed dietary intake rec- people in whom there is a greater chance of
ords and clinical signs supported by labora- deficient digestive function, well-sampled
tory determinations. Twenty-six people were studies reveal some but no very striking
diagnosed as malnourished. Undernutrition differences between those with efficient and
was associated with various medical and so- inefficient mastication. Although it is con-
cial conditions. Of these endentulousness sistently reported that fibrous foods are
showed a significant correlation with under- avoided, no study has been made of dietary
nutriton. In the malnourished group a fiber intake related to tooth loss. This is an
higher proportion of the edentulous never important omission in view of recent evi-
wore dentures when eating (23%) than in dence relating dietary fiber to health.
the well-nourished group (5%). Again no It would, however, be wrong to conclude
cause and effect can be claimed for these from the paucity of well-controlled studies
findings. that tooth loss is of no importance: it does
Nutritional status should give the overall alter food choice reducing the consumption
picture of the effects of mastication on the of meat and fresh fruit and vegetables, re-
several components offood assimilation that sulting in lower Hb and serum vitamin C
we have reviewed: food choice, gastrointes- levels; total energy consumption may be re-
tinal disturbances, digestion, and absorp- duced; it appears to be related to gastritis
tion. Studies of nutritional status and gen- and therefore discomfort it not impaired
eral health are few and far between and most
digestion and absorption; it may affect diges-
do not adequately separate mastication from
tion if uncooked fibrous foods are eaten or
other social and health factors that influence
if gastrointestinal function is impaired. The
food consumption. The evidence for body
additional burden of poor chewing is there-
weight loss is conflicting. The most positive
fore likely to be ofsignificance to health and
evidence is for reduced Hb and ascorbate
nutrition only in conjunction with other risk
levels.
factors. The most serious effect is the in-
Conclusions creased risk ofdeath by choking on improp-
erly chewed food. The technical measures of
Most studies have concluded that tooth physiological function that we have dis-
loss in humans and animals has significant cussed also completely ignore the depriva-
488 GEISSLER AND BATES

tion experienced by those with severe tooth 21. Bender AE, Davies L. Milk consumption in the
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22. Heath MR. Dietary selection by elderly persons
of food, which is one of the great pleasures related to dental state. Br Dent J l972;l 32:145-8.
oflife. El 23. Anderson E. Eating patterns before and after den-
tures. J Am Diet Assoc 197 l;58:42l-6.
24. Ettinger RL. Diet, nutrition and masticatory ability
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