Abstract
Background
Diet quality might be impacted among individuals after receiving their dentures. This study assessed nutrient intake and diet quality among adults wearing maxillary and/or mandibular complete dentures using 24-hour dietary recalls and compared with the dietary reference intakes recommended for healthy individuals.
Methods
An observational clinical study was conducted with adult participants aged ≥ 50 years wearing maxillary and/or mandibular complete denture/s. They completed two 24-hour dietary recalls, first at an in-person visit and the second within seven days via phone using the Automated Self-Administered (ASA24®) 24-hour web-based platform. Diet quality for each participant was measured as Healthy Eating Index (HEI) scores ranging from 0 to 100 based on 13 food components. HEI is classified as (1) “poor” (< 51); (2) “needs improvement” (51–80); (3) “good” (> 80) diet quality. Descriptive statistics included participant characteristics, nutrient intake, and diet quality. The Macro and micronutrient intakes of the study participants were compared with the estimated average requirements and adequate intake values. Multivariable regression methods determined the association between the diet quality and participant characteristics. Furthermore, Spearman Correlation was used to estimate the associations between diet quality, macro, and micronutrient intake.
Results
A total of 93 participants participated in the study. 57% were female, 50% were black, 54% wore maxillary and mandibular dentures, 43% received dentures between 50 and 59 years, and 51% wore dentures for more than 10 years. The average HEI score was 54 (sd = 11.9), with a need for diet improvement among 59% of the participants. None of the participants had a good diet quality. More than 90% of the participants consumed dietary fiber, vitamin D, vitamin E, and choline below nutrient recommendations. Study participants with poor diet quality had significantly lower daily intake of fiber, magnesium, potassium, and vitamins A, D, C, B-6, and K (p < 0.05).
Conclusion
The diet of the denture-wearing study participants was inadequate. Routine monitoring of the quality of dietary intake of individuals wearing dentures must be incorporated into a dental clinician’s workflow. Further studies must be conducted to evaluate the diet quality of individuals undergoing prosthodontic treatment plans. Based on evidence-based research findings, interdisciplinary care approaches to promote continuity of care among denture wearers need to be established.
Clinical trial number
Not applicable.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12903-025-06182-0.
Keywords: Complete denture, Older adults, Diet quality, Healthy eating index, ASA24, 24-hour dietary recalls
Introduction
An optimal diet to meet nutrient recommendations is essential for health and well-being [1]. A significant factor affecting food consumption and adequate nutrient intake among adults is impaired chewing ability due to tooth loss. While there has been an overall decrease in the complete loss of teeth, it is still prevalent among 1 in 6 adults aged 65 years or older [2, 3]. Removable complete dentures are predominantly used to treat and replace missing teeth, but they may not provide the same chewing efficiency as natural teeth [4–6]. Loss of natural dentition and compromised oral health in adults may lead to decreased consumption of nutrient-dense foods such as fruits and vegetables [7, 8]. Moreover, when using dentures, individuals may change their food choices, impacting nutrient adequacy and health [8, 9].
Our recent retrospective study of adults receiving maxillary and/or mandibular dentures using linked electronic dental record and electronic health record (EDR-EHR) data revealed a significant decrease in serum protein, albumin, and calcium over two years compared with individuals who did not have dentures [10–12]. These variations in laboratory values for persons before and after wearing dentures could be attributed to an inadequate dietary intake due to oral-myofunctional limitations. Previously, studies have demonstrated that chewing ability based on dentition and/or denture-wearing status is associated with undernutrition [13–16].
A cross-sectional study that examined the relationship between subjective chewing discomfort and nutritional status found lower food and nutrient intake among older adults who had chewing difficulty compared to the normal group who subjectively responded that they had moderate to no difficulty in chewing [17]. However, this study did not report whether the study participants were edentulous or wore dentures. Only limited studies from more than two decades ago have examined the overall dietary quality of adults with dentures [18, 19]. These studies reported inconclusive results, such as self-perceived ill-fitting dentures contributing to poor diet quality and chewing inefficiency leading to poor diet quality. The risk of malnutrition among denture wearers underscores the need for increased nutritional monitoring and personalized nutrition recommendations [17]. Since tooth loss continues to be prevalent, especially among older adults, and the primary treatment is removable dentures [20], it is essential to assess individuals’ diet quality in those who use dentures.
This study aimed to determine the nutrient intake and diet quality of adults wearing maxillary and/or mandibular dentures using 24-hour dietary recalls. We assessed diet quality using the Healthy Eating Index (HEI) and compared macro- and micronutrient intakes to recommendations based on Dietary Reference Intakes (DRIs) [21, 22]. The association between HEI, demographics, the age at which these individuals received their first dentures, the duration of wearing dentures, and the denture type were also assessed.
Methods
An observational cross-sectional clinical study was conducted to obtain participant characteristics, including demographics, height and weight, age at which they received their denture, the type of denture used, and two 24-hour dietary recalls, the first one in-person, and the second one within seven days via a follow-up telephone call. This study is part of a larger study that evaluated participants’ malnutrition risk. The Indiana University Institutional Review Board approved the clinical study (# 15766) as an expedited protocol. The study complied with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [23].
Study participants
Inclusion criteria: individuals aged 50 years and older who received removable maxillary and/or mandibular complete dentures, immediate and overdentures when they were 18 years or older, were considered eligible. Exclusion criteria: Individuals with the following conditions were not recruited for the study: (1) current history of terminal cancer, chronic obstructive pulmonary disease (COPD), dementia, inflammatory bowel disease, Crohn’s disease, ulcerative colitis, gastroesophageal disease (GERD), end-stage renal disease (ESRD) with dialysis, cystic fibrosis; (2) history of hospitalizations for more than two days within a month of the in-person clinical study visit; and (3) major gastrointestinal surgery (e.g., gastric bypass). Any individuals currently involved in nutritional intervention studies or receiving dietary counselling and those who were edentulous and never wore dentures were also excluded from the study.
Study participant recruitment
Eligible study participants were recruited through three approaches. First, the EDR database at Indiana University School of Dentistry (IUSD) was queried for patients who received dentures (Code on Dental Procedures and Nomenclature (CDT code): D5110; D5120, D5130, D5140, D5860, D5863, D5865, D6110, D6111) between 2014 and 2023, met the inclusion criteria described above, and who had consented to be contacted for research. The resulting participants were invited to participate in the study by postal mail. The mailing included a brief study description to solicit interest and a flier with the research team’s telephone contact information. Interested participants left a voice message through the Oral Health Research Institute (OHRI) recruitment phone line for the research team.
Consequently, a research team member contacted the interested participants to confirm eligibility by reviewing the inclusion and exclusion criteria. Once eligibility was confirmed, the recruited participant was scheduled for a 60–100-minute in-person clinical study visit. Second, prior participants in the IUSD Oral Health Research Institute’s (OHRI) denture-related studies who consented to be contacted were recruited through phone calls. Finally, fliers with a brief study description were posted to recruit participants in IUSD clinic patient waiting areas and public places such as libraries, hospitals, clinics, and non-profit organizations in and around Indianapolis.
In-person clinical study visit
On the day of the visit, after obtaining the signed informed consent, the following information was collected and recorded: (1) participant demographics, including age, sex, and race; (2) denture-wearing characteristics, including type of dentures worn, duration of wearing dentures, age of receiving first dentures, and when and where dentures received; and (3) anthropometric measures including height (meters), and weight (kilograms) for body mass index (BMI) calculation weight (kg)/[height (m)]2 [24].
Dietary recall assessment
A research team member interviewed the participants to collect dietary recalls using the Automated Self-Administered 24-hour (ASA24®) dietary assessment tool [25]. Two non-consecutive 24-hour dietary weekday recalls were collected, one at the in-person clinical study visit and a second within seven days via phone The standardized multiple pass method through ASA24® allowed collection of the complete list of foods and drinks, prompting participants and probing for foods to collect detailed information, adding more details to the diet list to obtain accurate information, amount of consumption, information on the time, and location of the meal or snack [25]. Study participants were compensated with an honorarium, refreshments, and a denture cleaning kit at the end of the in-person clinical study visit, as well as a gift card delivered after the completion of the second dietary recall over the phone.
Study variables
Dietary quality was measured using the HEI-2015 based on the two 24-hour dietary recalls. The HEI score is an overall measure of how dietary intakes align with the Dietary Guidelines [22] and is based on 13 food group components. Nine components including total fruits including 100% fruit juice, whole fruits excluding fruit juice, total vegetables, greens and beans, whole grains, dairy, total protein foods, seafood and plant proteins, and fatty acids (monounsaturated and polyunsaturated fatty acids should be consumed for adequate nutrition and good health. The other four components including refined grains, sodium, added sugars, and saturated fats should be consumed sparingly/in moderation. HEI scores increase when the intake of components to encourage is higher. The HEI was developed in 2005 and is updated every 5 years with the DGA, and therefore, the scoring algorithm changes for each version [26]. The total HEI score can range from 0 to 100, with total HEI scores above 80 indicating good diet quality, scores between 51 and 80 indicating that diet quality needs improvement, and scores less than 50 indicating poor diet quality [27, 28]. In addition to diet quality, we analyzed 24 nutrients including macronutrients (protein, carbohydrate, and fiber), and micronutrients (calcium, copper, iron, magnesium, phosphorous, potassium, selenium, sodium, zinc, vitamins A, E, D, C, B-6, B-12, K, thiamin, riboflavin, niacin, choline, and folate) from the 24-hour diet recalls (Table 1S; Additional file 1: Supplementary Table 1). Study participants’ dietary intake of macro- and micronutrients was compared to dietary reference intake (DRI) for those 50 years and older [22, 29].
Covariates
Demographic variables such as age, sex, race, type of dentures, years of using current dentures, and age at the time of receiving dentures were used to investigate the relationships between the confounding variables and diet quality.
Statistical analysis
The sample size was estimated to achieve an 80% power to detect a 10% difference, to produce a two-sided 95% confidence interval at a significance level of 0.05. The descriptive characteristics of the study participants were summarized using counts and proportions for categorical variables. Continuous variables were summarized using means and standard deviations if the distribution was symmetric and medians and interquartile ranges if the distribution was skewed. Analysis of daily dietary intake used the average of two 24-hour dietary recalls. The HEI per study participant was generated by pooling all the food items from the two 24-hour dietary recalls. Associations between dietary quality and demographics were evaluated using ANOVA for continuous variables and Pearson’s chi-square test or Fisher’s exact test for categorical variables. Differences in daily dietary intake of energy, macro-, and micronutrients between subjects with various levels of dietary quality were evaluated using the non-parametric Wilcoxon rank sum test and multiple regression methods. The Spearman correlation coefficient [30] was used to determine the associations between overall HEI based on food groups and daily dietary intake of macro- and micronutrients.
Results
Demographics of the study participants
Of the 4,202 qualified individuals retrieved from the EDR database and contacted through postal mail, 217 (5.2%) responded through the recruitment timeline. After eliminating individuals based on the exclusion criteria, 54 participated. From prior denture-related studies at OHRI, out of 56 eligible participants, 27 participated in this study. Finally, twelve study participants were recruited based on advertisements through fliers at various community sites. A total of 93 individuals participated and completed the study. Two of them did not complete the second 24-hour dietary recall. The study participants were predominantly older adults, and the average age was 71 ± (8.8) years (range 51–95). Most study participants were women, comprising 57%. Further, race was almost equally distributed, with about 50% being black and 47% being white (see Table 1).
Table 1.
Anthropometric measures, demographics, and denture-wearing characteristics of 93 study participants. Caption: Study variables on anthropometrics, clinical characteristics on denture-specific variables, and demographics of study participants with dentures
| Study variables | Mean | (SD) |
|---|---|---|
| Anthropometric measures | ||
| Height (meters) | 1.65 | (0.09) |
| Weight (kg) | 85.15 | (19.4) |
| BMI ([kg/m2] | 31.06 | (6.5) |
| Demographics | Frequency (N) | (%) |
| Age in years | 71.1 | (8.8) |
| Sex | ||
| Female | 53 | (57) |
| Male | 40 | (43) |
| Race | ||
| African American/African heritage | 46 | (49.5) |
| White - White/Caucasian/European heritage | 44 | (47.3) |
| White - Arabic/North African heritage | 2 | (2.2) |
| Other | 1 | (1.1) |
| Denture-specific variables | ||
| Type of denture | ||
| Upper | 43 | (46.2) |
| Both | 50 | (53.8) |
| Years wearing current denture | ||
| <=1 year | 25 | (26.9) |
| 2–5 years | 26 | (28) |
| 6–10 years | 19 | (20.4) |
| 11 + years | 23 | (24.7) |
| Years of wearing dentures | ||
| Less than ten years | 46 | (49.5) |
| 10 to 20 years | 29 | (31.2) |
| More than 20 years | 18 | (19.4) |
| Age (years) at the time of receiving a denture | ||
| <50 | 7 | (7.5) |
| 50–59 | 40 | (43) |
| 60–69 | 33 | (35.5) |
| 70+ | 13 | (14) |
SD- Standard deviation; study variables are represented as mean ± sd
Clinical characteristics of the study participants according to denture-specific variables
As Table 1 shows, most (92%) study participants received their dentures from 50 years of age. The earliest age to receive a denture among the study participants was 28 years, and the oldest was 80 years. Over half of the study participants wore upper and lower dentures (see Table 1). About 75% of the study participants had worn their current dentures for ≤ 10 years (range ≤ 1 year − 40 years). However, approximately 51% of the participants had worn dentures for more than 10 years (range 0–49 years).
Anthropometric measures
For the 93 participants, the mean height (m) was 1.65 (range 1.47 to 1.72), mean weight (kg) was 85.15 (range 34.47 to 152.86), and the BMI was 31 (range 13.8–55.5) (Table 1).
Descriptive summary of study participants’ daily dietary nutrient intake and lower nutrient intake
Table 2 provides the study participants’ median daily intake for macro- and micronutrients based on two ASA24® dietary recalls for 91 participants. Also, the dietary intake for two participants with one dietary recall was included. Table 1S (Supplementary material) provides the reference range for macro- and micronutrients from the estimated average requirement (EAR) and Adequate Intake (AI) in DGA [21]. In addition, Table 1S lists the frequency distribution of the number of study participants with low nutrient intake for at least one recall. The median energy intake (kcal) based on the study participant’s age and sex was 1746.2 kcal (range 1426.8–2302.0 kcal). Of the 24 listed macro and micronutrients, 14 nutrients were below recommendations for the majority of the study participants. About 90% of our study participants had intakes below the recommendations for vitamin D (D2 + D3) (mcg); vitamin E, alpha-tocopherol (mg); total fiber (g); and choline (mg). We observed that more than 70% of our participants met the recommended EAR intake for carbohydrates, phosphorous, niacin, riboflavin, selenium, and sodium.
Table 2.
Participant dietary intake in comparison to DRIs. Caption: Descriptive data of study participants’ median daily intake for macro- and micronutrients based on two ASA24® dietary recalls for 91 participants. Also, the dietary intake for two participants with one dietary recall was included
| Dietary intake per day (N = 93) | Median* | Interquartile range (IQR) | |
|---|---|---|---|
| Lower limit | Upper limit | ||
| Macronutrients | |||
| Protein (g)1 | 62.7 | 52.6 | 83.8 |
| Carbohydrate (g) | 217.0 | 165.8 | 290.2 |
| Total fiber (g) | 13.8 | 10.5 | 19.1 |
| Micronutrients | |||
| Minerals | |||
| Calcium (mg)2 | 835.1 | 645.6 | 1142.5 |
| Copper (mg) | 1.0 | 0.8 | 1.3 |
| Iron (mg) | 11.7 | 8.7 | 16.8 |
| Magnesium (mg) | 255.5 | 201.6 3 | 328.0 |
| Phosphorus (mg) | 1121.9 | 890.3 | 1485.8 |
| Potassium (mg) | 2376.2 | 1890.4 | 2970.1 |
| Selenium (mcg) | 88.7 | 64.1 | 118.7 |
| Sodium (mg) | 2744.3 | 2062.9 | 3511.9 |
| Zinc (mg) | 9.1 | 6.4 | 11.3 |
| Vitamins | |||
| Vitamin A, (mcg_RAE)3 | 573.2 | 334.8 | 785.2 |
| Vitamin E, (mg) | 6.7 | 5.1 | 10.1 |
| Vitamin D (D2 + D3) (mcg)4 | 3.8 | 1.9 | 6.1 |
| Vitamin C (mg) | 62.0 | 30.7 | 101.2 |
| Thiamin (mg) | 1.4 | 1.1 | 1.7 |
| Riboflavin (mg) | 1.8 | 1.3 | 2.4 |
| Niacin (mg) | 19.5 | 14.1 | 25.8 |
| Vitamin B-6 (mg) | 1.6 | 1.2 | 2.1 |
| Vitamin B-12 (mcg) | 3.6 | 2.4 | 5.5 |
| Choline, total (mg) | 272.5 | 216.9 | 394.3 |
| Vitamin K, phylloquinone (mcg) | 76.7 | 52.9 | 142.6 |
| Folate (mcg_DFE)5 | 396.3 | 258.8 | 560.4 |
*Report of dietary intake is based on average of two 24-hour dietary recalls for 91 participants; Dietary intake for two participants with one dietary recall; 1g is gram; 2mg is milligram; 3RAE is retinol activity equivalents; 4mcg is microgram; 5DFE is dietary folate equivalents
Dietary quality
Table 2S (Additional file 2: Supplementary Table 2) summarizes the mean and median total HEI scores and the HEI scores for the individual 13 components. The study participants’ HEI scores as median (IQR) were lower than the maximum HEI scores for the following components: greens and beans 1.4 (0.0–5.0), total fruits 2.3 (0.6–4.1), whole grains 2.0 (0.3–4.2), total dairy 5.3 (2.4–7.8), and fatty acids 4.1 (1.9–6.7) indicating that improvements in diet quality are needed. The study participants had a HEI score for the component of total protein foods at the maximum score (5.0 (4.4–5.0), indicating good quality for this component.
Greens and beans were consumed less than the recommended 0.2 cups per 1000 kcal. The total fruit and total vegetable consumption were lower than the recommended 0.8 and 1.1 cups, respectively, per 1000 kcal. Whole grain consumption was lower than 1.5 oz per 1000 kcal. The components of refined grains and added sugars, recommended to be consumed in moderation scored higher, indicating a consumption of no more than 4.3 oz for 1000 kcal for refined grains and 26% of energy for added sugars. While, the components of sodium and saturated fats, also recommended to be consumed in moderation scored lower indicating increased consumption of more than or equal to 2.0 g per 1000 kcal and more than or equal to 16% of energy. Figure 1 illustrates mean HEI scores for each of the 13 components for the study participants wearing dentures based on the dietary recalls compared with the maximum HEI scores and the national average of HEI scores for older adults. The average daily total HEI score for the study participants was 54 compared to the average total HEI score for US adults over the age of 60 years was 61 [31].
Fig. 1.
Radar plot of Healthy Eating Index (HEI 2015) of study participants wearing dentures. Caption: Radar plot of the Healthy Eating Index (HEI 2015) of study participants wearing dentures compared to published data for US older adults. Mean scores for each food component are provided radially for maximum points for the HEI score, the average HEI for older adults, and the HEI for individuals with dentures
Associations of participant demographics with dietary quality
There was no significant association between demographic characteristics and dietary quality, with the HEI total score. There was also no significant difference (p > 0.05) in the associations between categorized levels of dietary quality and demographics (age, sex, race), participants’ denture-specific variables (years of wearing dentures, years of using current dentures, age at the time of receiving dentures), and anthropometrics (BMI) (Table 3S; Additional file 3: Supplementary Table 3). Since there were no participants with good diet quality, only two levels of diet quality were included in the analysis (poor quality and quality needs improvement).
Associations between dietary quality, macro, and micronutrients
None of the participants had good diet quality based on HEI assessment (HEI above 80). Table 3 shows that about 59% (N = 55) of participants had diets that needed improvement (HEI 51–80), and 41% (N = 38) of the study participants had poor diet quality (HEI < 51). Study participants with poor diet quality had significantly lower intakes of fiber, potassium, magnesium, and vitamins A, B-6, C, D, and K (p < 0.05). There was a positive correlation between lower dietary intake of fiber, calcium, magnesium, potassium, vitamins A, D, C, B-6, and K (p < 0.05) and the HEI total score. The study participants with the lowest HEI scores, indicating poor diet quality, had the lowest intake of nutrients that are encouraged for consumption.
Table 3.
Association between daily dietary intake and two categories of dietary quality. Caption: The daily dietary intake of macro- and micronutrients and their associations are based on dietary quality (improvement needed and poor)
| Dietary quality (categorized as two levels) | P Value | ||
|---|---|---|---|
| Poor (HEI < 51) (N = 38) |
Improvement needed (HEI 51–80) (N = 55) | ||
| Macronutrients | |||
| Protein (g)1 | 62.7 (51.1–83.8) | 64.3 (53.8–86.1) | 0.76 |
| Carbohydrate (g) | 207.8 (163.6–310.9) | 221.0 (171.1–270.9) | 0.89 |
| Total fiber (g) | 11.8 (9.4–17.5) | 15.1 (11.7–20.9) | 0.006* |
| Minerals | |||
| Calcium (mg)2 | 753.9 (646.1–968.1) | 928.4 (620.0–1295.1) | 0.075 |
| Copper (mg) | 1.0 (0.7–1.2) | 1.0 (0.8–1.4) | 0.18 |
| Iron (mg) | 11.6 (8.1–15.3) | 12.1 (8.7–20.6) | 0.28 |
| Magnesium (mg) | 218.0 (192.7–273.0) | 284.7 (225.6–341.7) | 0.003* |
| Phosphorus (mg) | 1090.7 (886.9–1430.8) | 1201.6 (890.3–1586.5) | 0.36 |
| Potassium (mg) | 2196.7 (1726.0–2861.3) | 2488.0 (2108.1–3306.8) | 0.043* |
| Copper (mg) | 1.0 (0.7–1.2) | 1.0 (0.8–1.4) | 0.18 |
| Sodium (mg) | 2965.3 (1884.7–4077.8) | 2721.3 (2062.9–3303.0) | 0.38 |
| Zinc (mg) | 8.7 (6.6–11.2) | 9.4 (6.4–13.0) | 0.51 |
| Vitamins | |||
| Vitamin A, (mcg_RAE)3 | 465.8 (263.5–712.4) | 596.9 (363.4–1065.3) | 0.033* |
| Vitamin E, (mg) | 6.8 (4.5–10.0) | 6.7 (5.5–10.9) | 0.39 |
| Vitamin D (D2 + D3) (mcg) | 3.3 (1.3–4.4) | 5.2 (2.1–8.3) | 0.015* |
| Vitamin C (mg) | 34.8 (16.9–89.0) | 74.7 (52.0–103.9) | 0.004* |
| Thiamin (mg) | 1.4 (1.0–1.7) | 1.3 (1.1–1.9) | 0.29 |
| Riboflavin (mg) | 1.7 (1.3–2.2) | 1.9 (1.2–2.6) | 0.33 |
| Niacin (mg) | 19.3 (13.7–25.9) | 20.0 (14.4–25.8) | 0.51 |
| Vitamin B-6 (mg) | 1.4 (1.0–1.9) | 1.8 (1.2–2.6) | 0.023* |
| Vitamin B-12 (mcg)4 | 3.5 (2.4–4.2) | 3.9 (2.4–7.4) | 0.29 |
| Choline, total (mg) | 265.7 (209.1–401.3) | 274.3 (221.3–370.0) | 0.94 |
| Vitamin K, (mcg) | 70.6 (41.2–139.6) | 87.8 (60.9–168.5) | 0.045* |
| Folate (mcg_DFE)5 | 376.4 (238.5–517.7) | 425.2 (280.3–568.1) | 0.27 |
Asterisk (*) indicates statistical significance with p value < 0.05; kcal is kilocalories; 1g is gram; 2mg is milligram, 3RAE is retinol activity equivalents; 4mcg is microgram; 5DFE is dietary folate equivalents
Discussion
This observational clinical study determined the overall dietary quality and nutrient intake of adults wearing dentures by capturing their dietary intake using two non-consecutive 24-hour weekday dietary recalls. The median total HEI score was 54 for the study participants, which was less than the total HEI score of 61 for Americans 60 years and older [31]. None of the study participants had good- diet quality based on the HEI score. Most of our study participants, 59%, had diet quality categorized as “needs improvement” (HEI scores between 51 and 80) and 41% had “poor-quality” diets (HEI scores < 51). The data indicate that diet quality in denture wearers is poor or needs improvement based on HEI scores.
The present study classified denture wearers based on their dietary quality and evaluated their associations with demographics, denture-wearing characteristics, and BMI. Recent studies including older adults from the general population with no information on their use of dentures had diet quality scores of 61 and 67 [26, 32]. A previous study [18] showed a total HEI score of 69.5 among subjects wearing poor, medium, and good quality dentures, which is higher than the HEI score of Americans 60 years and older and the HEI score of our study participants. However, subjects with good-quality dentures had a lower HEI score (60.5) than those with poor-quality dentures (72.0). The authors concluded that an individual’s good denture quality does not necessarily indicate that an individual has a high diet quality. Unlike this study [18], which used ten food groups in the diet quality assessment, our study used the HEI 2015, which included 13 food components and we assessed macro-, and micronutrient intake. Further, our study included maxillary and/or mandibular complete dentures, while Shinkai et al. used both maxillary and mandibular complete dentures. We did not assess denture quality during the study.
Total protein foods include lean meats, poultry, eggs, seafood, beans, peas and lentils, nuts, seeds, dairy, and soy products [26]. The DGA encourages to have protein from all these sources [33]. Although the intake of greens, beans, and total vegetables was lower than the recommended amount among the current study participants, it is encouraging that denture wearers had adequate protein intake. The protein diet for our study participants was likely meat and poultry-based and not plant-based protein [34–36]. Our study participants had a HEI score for greens and beans which was low suggesting that they did not consume much plant protein. Despite their high diet quality, lentils/legumes/dried peas are consumed less among U.S. adults and children [34, 35]. With HEI-2015, legumes in a daily intake are considered within the category of plant proteins and greens and beans. It is also considered a component of total protein and total vegetables. Since greens and beans scored low, our denture-wearing study participants likely met total protein standards from meat, poultry, eggs, seafood, and not much from plant proteins [33].
Our study participants consumed low amounts of whole grains. Whole grains are highly nutrient-dense as sources of vitamins, protein, and fiber [1]. Some whole grains and fibrous foods may be difficult to chew and avoided by individuals with complete dentures. Poor diet quality among denture wearers signifies underconsumption of certain nutrients. Encouraging denture wearers to incorporate nutrient dense foods such as whole grains, fruits, and vegetables into their diets is important to improve their diet quality. Educating on food preparation and cooking methods that could make foods easier to chew and consume could assist denture wearers to improve eating habits and diet quality.
The study has some limitations that need consideration for future studies. A study sample size of only 93 individuals wearing dentures who live in/around Indianapolis, Indiana, may not be generalizable to the national population of adults wearing dentures. We used two non-consecutive weekday 24-hour dietary recalls to assess diet quality and nutrient intake, which would not be able to capture weekday-to-weekend variations [37]. We attempted to minimize response bias by interviewing the study participants regarding their prior day of consumption; however, with any diet, recall memory can impact the data collection. Additionally, social desirability bias may impact the type of food and beverage intake reported by study participants [38]. Although, we included CDT codes for immediate dentures and overdentures to retrieve patient records from axiUm databases, we did not ask the study participants on whether they have immediate or overdentures. We determined their diet quality based on the years of wearing dentures and on whether they have one or both dentures but did not evaluate the differences based on overdentures or immediate dentures. Despite these limitations, this study provides critical insights regarding the dietary quality and nutrient intake of individuals wearing complete dentures. Based on our study, the dietary quality and nutrient intake of individuals aged ≥ 50 years who are wearing dentures are suboptimal, and improvement is needed. This might be due to their choice of selecting and consuming fewer types of food that are not healthy causing poor nutrient intake. Providing dietary counseling during denture treatment with a focus on foods to encourage, such as fruits, vegetables, and whole grains, and moderate consumption of sodium and saturated fat could improve diet quality and health.
Conclusion
Nutritional screening should be implemented as part of comprehensive oral care when an individual receives complete dentures. Additionally, longitudinal nutritional screening before and after receiving dentures need to be evaluated for further consideration. A quick, inexpensive, and user-friendly screening tool could assess a denture-wearing patient’s risk for malnutrition, whether administered at a dental visit or as a self-screening tool through electronic applications used by patients at home. Cross-disciplinary communication among prosthodontists, medical providers, and registered dietitians is needed. Further studies are needed to understand the dietary quality of individuals using dentures and those in the process of treatment planning for prosthodontic rehabilitation. Therefore, a longitudinal study should be conducted to determine denture wearers’ nutritional intake and risk for malnutrition.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Acknowledgements
We thank all the study participants for their time contribution in this study. We thank ASA24 helpdesk team from Westat Inc., for the constant support in using ASA24 web-based platform. We thank Dr. Domenick Zero (Emeritus professor), Dr. Anderson Hara (Director of Oral Health Research Institute), Ms. Sharon Gwinn, Ms. Mei Wang, Ms. Sue Kelly, Ms. Judith Wilkinson, Ms. Kari Blackley, Mr. Kiran Burlakunta Kumar, Ms. Leslie Sawyer, Dr. Sanjana Madarapu for providing facilities and resources, management of finances, preparation of IRB documents, retrieval of patient records, and data verification in supporting the conduct of the study.
Author contributions
Conceptualization of the research, along with study design, was substantially contributed by the corresponding author, GFG, and further by TPT, HX, NGM, LS, and DC. The original draft was prepared by GFG and was critically revised by NGM, LS, TPT, DC, and HX. Recruitment of patients, data collection, inputs before conducting the study, approval was provided by PP, VB, and BC. Data management was completed by GFG, BC, and VB. The figure was prepared by GFG. Tables were prepared by GFG and HX. All authors reviewed the manuscript.
Funding
The corresponding author of this study received support from the Delta Dental Foundation Inc grant (GG-0000000807). The funders had no role in the study design, data collection, and analysis, decision to publish, or preparation of the manuscript.
Data availability
Interest in obtaining data used for this research will be available based on request. Protected health information such as date of birth will not be shared. Any request will require submission of the specific purpose of the data access for review and after approval through IU School of Dentistry privacy and compliance office before authorization for data access is granted.
Declarations
Ethics approval and consent to participate
This study received expedited approval from the Indiana University Institutional Review Board (IRB approval # 15766). The study participants provided an informed consent with their signature indicating their interest to participate in the research study. The procedures performed in this clinical study involving human participants adhered to the ethical principles of the Declaration of Helsinki developed by the World Medical Association.
Consent for publication
Not applicable (N/A).
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Interest in obtaining data used for this research will be available based on request. Protected health information such as date of birth will not be shared. Any request will require submission of the specific purpose of the data access for review and after approval through IU School of Dentistry privacy and compliance office before authorization for data access is granted.