RELATIONSHIP BETWEEN PROSTHODONTIC TREATMENT AND NUTRITIONAL STATUS : A REVIEW Affiliation

Per nent literature search about changes or effects of prosthodon c treatment on nutri onal status was performed. The ar cles were electronically and hand searched in all available journals Including research works, reviews, randomized controlled trials and systema c reviews. The informa on were obtained to answer the ques on whether denture therapy has a role in altering nutri onal intake or not. Most ar cles agreed that the risk of malnutri on is elevated by being edentulous. However, there were contras ng results about improvement of nutri on by providing prosthodon c treatment. Thus, many authors have emphasized the role of nutri onal counseling along with denture therapy for the benefits of geriatric pa ents who undergo the inevitable process of being edentulous.


INTRODUCTION
Prosthodon cs is defined as the specialty replacing missing 1 den on and con guous maxillofacial structures.Prosthodon c treatment not only replaces form, func ons and esthe cs in orofacial region but also enhances the psychological and social levels of dentally handicapped individuals.The oral health is an important en ty of general health.Terming it as the fundamental factor, World Health organiza on (WHO) emphasizes on oral and dental health 2 maintenance throughout life for improving quality of life.Older people are vulnerable to restrict their diet.Significant increase in dietary intake of lipids, carbohydrates and fibers is seen in fully dentate individuals in comparison to 3 complete denture wearers.
Oral rehabilita on is one of the methods to replenish 4,5 malnutri on.There are clear evidences that edentulism is associated with poor diet, compromised nutri on and also 6,7 lower level of subjec ve well-being.
The literature search was performed electronically and also hand searched with the terms, using Medical Subject Headings (MeSH) and free text words.The words used were "nutri onal status", "nutri on", "mini-nutri onal assessment", "denture therapy", "removable prosthodon c treatment", "fixed prosthodon c treatment", "implant therapy".The search was limited to only English ar cles.The reference lists of iden fied ar cles and relevant papers were also be assessed.The Cochrane database, Medline and Google were used for collec ng the ar cles.The search strategy is depicted in flow diagram (figure 1)

Measurement of nutri onal status
Mini nutri onal assessment (MNA) was used by many authors to test and evaluate nutri onal aspect in prosthodon c 1,8-11 pa ents and was found to be a valid and sensi ve tool.Oral health impact profile (OHIP), oral health related quality of life (OHRQoL), closed-ended ques onnaire and chewing efficiency were also used to determine the level of 4,12,13 nutri onal status.

Effects of being edentulous
Dental status greatly influences the perceived ability to take number of foods and having few teeth(less than 21 teeth) or no teeth without replacement increases vulnerability to 14 malnutri on.
Poor oral hygiene can increase the difficulty in ea ng hard 15 foods and thus, decreases ea ng pleasure.When comparing fully dentate to fixed prosthesis wearers, higher level of energy, protein, fat, carbohydrate, calcium, phosphorus and thiamin was consumed by fully dentate group while, other foods rich in fiber and electrolyte did not In contrast, another study revealed that the elevated Body Mass Index (BMI) due to ea ng high-18 calorie selected foods, was found in edentulous pa ents.

Effects of prosthodon c treatment
According to a study conducted in a sample size of 35 pa ents, food consump on behavior was not affected by prosthodon c therapy as provision of complete denture had reduced the chewing difficul es but didn't have a role 14 in reduc on of malnutri on.Another follow-up study suggested that prosthe c treatment alone is not sufficient to provide an improvement in MNA, serum parameters, 13 OHIP and mas catory efficiency test.Consistent with these studies, the other also did not find correla on with 19,20 any prostheses to the prosthodon c treatment.
Though mas catory func on was seen to be improved in new denture users but there was no significant difference where both the new denture and old denture users had 21 almost 100% of total intake of energy and nutri on.Choice of food (food rich in fat, micronutrients, hard to chew food) was also affected by denture replacement.However, total energy intake, anthropometry and 22 biochemical indices experienced no significant impact.
It was also found that prosthe c treatment improves nutri onal status as higher MNA was reported in edentulous pa ents a er treatment with complete 23,24 dentures.
Kikutani et al examined a group of 716 elderly pa entswith 25 the use of MNA-SF and Barthel index to evaluate nutri on.It was concluded that occlusal status was significantly related to malnutri on risk.The limited daily ac vity was sorted as a confounding factor.
Another compara ve study showed that presence of few teeth in the oral cavity was associated with lower intake of fish and fruits, lower BMI, low mid arm circumference (MAC), low serum albumin in non-denture wearers.A er denture replacement, only MAC was significantly associated with denture therapy.However, in par cipants who had both fewer teeth and no dentures, marked decrease of 26 nutri onal intake was observed.Sadamori et al. divided their study sample into five groups and studied for two years taking the anthropometric and biochemical parameters.They concluded that it is necessary to have prosthodon c treatment for long-term maintenance of calorie intake.However, their study was focused in the 27 people with demen a.
Compared to denture wearers, non-denture wearers were found to have lower phosphorus, iron, potassium, niacin 28 and Vitamin C intake.Contras ng reports were also found making the role of prosthodon c therapy ques onable in 3,29,30 improvement of nutri on.
In comparing various types of dental prostheses, implant therapy was shown to be beneficial for improving 12, 16, ,31-34 nutri onal status.
Removable prostheses, however, were reported to have less contribu on than fixed prostheses 35 for subjec ve improvement in nutri onal status.In contrast, a study was done in a group of 135 pa ents divided into four groups; Complete denture (CD), distalextension removable par al denture (RPD); toothsupported RPD and fixed par al denture (FPD) showed significant improvement of BMI and energy intake in CD groups.In this study,removable prostheses had be er results in terms of protein, carbohydrate, calorie, iron and 36 vitamin B. However, serum albumin increased in all groups.RPD wearers were less capable for deriving nutri on in terms of mixing and shaping the bolus, and number of strokes while, level of fat, calcium and BMI were almost similar in removable par al dentures and fixed dentures 37 wearers.Some other cross-sec onal studies showed contrast results to the findings of the previous studies and concluded that dental implant does not necessarily improve the nutri onal 12,31,38 status, however can improve mas catory efficiency.Randomized controlled trials for comparing conven onal CD and implant overdenture (IOD) showed insignificant improvement in nutri onal status by implant over denture, however IOD wearers had improvement if we considered 39-41 fiber intake.Another systema c review and meta-analysis also concluded insignificant benefits of implant overdenture over the conven onal complete denture in terms of BMI, 12,42 albumin or vitamin B.

Other factors
Several authors have emphasized on nutri onal counseling as a part to improve nutri on along with prosthodon c therapy because denture alone was not the only factor for 19,39,[43][44][45][46] be er nutri on in their studies.In denture wearing pa ents, changing to new dentures along with periodic counseling played an important role in 43 increasing levels of energy, iron and vitamin C intake.With the use of denture adhesive improvement in taking 44 vegetables, fruits was seen.But the reinforcement with nutri onal counseling was also done during adhesive provision.Influence of number of ar ficial teeth in complete denture was also tested in a randomized controlled trial, which showed no significance of removing or adding the second 47 molar ar ficial teeth.Shortened dental arch was studied to assess the impact on nutri on, which showed objec ve 48 improvement despite insignificant subjec ve percep on.
One month a er prosthodon c treatment, MNA and hematological parameters were measured in a randomized controlled trial.This study comprised conven onal and func onally orientated dentures in par ally dentate groups.The results showed increase in vitamin B12, 49 albumin, and MNA.
Despite the denture therapy, some studies concluded that lack of appe te or limited daily ac vity play as confounding factors 25,50 along with poor oral status and/or prosthe c status.

CONCLUSIONS
A review of various literature regarding nutri onal status in prosthodon c pa ents was done in this study.Emphasis was drawn to the studies which had objec vely assessed the role of denture (fixed, removable or implant-supported) in improving nutri onal status.Also, randomized controlled trials and systema c reviews were further analyzed to draw the inference.It was common finding that the nutri on is affected by edentulism and, hence, early prosthodon c rehabilita on has some role in decreasing the vulnerability to malnutri on.However, the mere provision of denture therapy alone cannot replenish the nutri on.Periodic counseling plays a vital role for the reduc on of malnutri on risk in elderly pa ents.

RECOMMENDATIONS
The studies on nutri onal assessment a er various REFERENCES prosthodon c treatment is being done globally, however, very few studies are found in our parts of world.While the modern treatment like implant therapy has been found to be great boon for improvement of nutri onal status according to these studies, conven onal therapies like removable par al denture, fixed par al denture and conven onal complete denture cannot be overlooked.Thus, it is recommended that more studies regarding the effects of conven onal denture therapies need to be done and especially in the less developed regions of world.

Figure 1 :
Figure 1: Search strategy used in this review