Abstract
This study categorizes older adults living in rural areas by denture status, assesses the frequency of wearing dentures during meals, and determines whether denture status or use is associated with dietary quality or the number of foods avoided. A multi-ethnic population-based sample of adults ≥60 years (N=635) in the rural US was interviewed. Survey included denture use, removing dentures before eating, and foods avoided due to oral health problems. Dietary intakes were converted into Healthy Eating Index-2005 scores. Sixty percent wore removable dentures of some type; 55% never, 27% sometimes, and 18% always removed dentures when eating. More frequent removal was associated with lower dietary quality and more foods avoided. Those with severe tooth loss had the lowest dietary quality and avoided the most foods. Many rural older adults wear dentures. Learning how they adapt to denture use will offer insight into their nutritional self-management and help explain differences in dietary quality.
INTRODUCTION
Older adults living in rural areas represent a vulnerable population who are more susceptible to chronic disease and reduced functional status when compared to elders living in urban settings (1). Included in these health disparities is an increased risk of having impaired oral health. Rural elders are more likely to lack dental insurance, make fewer visits to the dentist, and experience severe or complete tooth loss (2). Among older community-dwelling adults living in rural areas of the southeastern US, 10% report having dental insurance, and 27% visited a dentist in the past year, compared to those 65 years and older across the US, for whom the rates are 15% and 55%, respectively (2). Among this same rural population, 28% retain most of their teeth compared to 41% of older adults in the general population. Older adults’ capacity to consume a healthful diet is an important contributor to their overall health status. Tooth loss and edentulism are associated with lower overall dietary quality (3–8).
Because of the extent of impaired oral health and limited dental resources in rural communities (9), it is important to consider the nutritional self-management strategies that elders use in response to changes in their oral health (e.g., changes in their ability to chew or swallow). In response to difficulties with chewing foods, many older adults alter the composition of their diets by avoiding particular foods or modifying some foods to make them easier to eat. These self-management behaviors have been associated with dietary quality (10–12).
Commensurate with tooth loss is the need to have removable dentures. Although the percentage of older adults with removable dentures is not increasing, the total number of older adults with removable dentures is growing as the population of older Americans increases (13). One might assume that having removable dentures provides a nutritional self-management strategy for those who lost some or all of their teeth. However, a positive relationship between actually wearing the dentures that one has and dietary quality has not been established (9,14,15), nor has it been shown that those who wear dentures include foods in their diets that would be difficult to eat without teeth. When denture quality of edentulous older adults in Ireland was improved, quality of life was also improved; but food choices and nutritional status were unchanged (16). There is little information about how various types or combinations of removable dentures are related to food choices. In addition, it is known that many removable denture wearers are dissatisfied with their denture fit and comfort, and, as a result, they frequently do not wear them (17). However, it is not known whether the frequency of wearing dentures during meals can affect the dietary quality of older adults (17).
This report used data from an investigation of the dietary quality and oral health status of a multi-ethnic population of older adults living in the rural South. These data have shown that older adults who avoided the greatest number of foods were more likely to have dentures, that those dentures were more likely to be ill-fitting (11) than those of persons who avoided fewer foods, and that dietary quality was lower among persons who avoided the greatest number of foods (18). This analysis considers types of removable dentures and whether or not individuals wore their dentures while eating. The purpose of this study was to understand the relationships among dietary quality, food avoidance, and removable denture use in older adults.
MATERIALS AND METHODS
Participants and Setting
Data collection for the Rural Nutrition and Oral Health (RUN-OH) Study took place from January 2006 to March 2008. This population-based, cross-sectional survey assessed the oral health and dietary intake of an ethnically diverse (African American, American Indian, and white) population of older adults in rural North Carolina. Eligibility criteria included being 60 years or older, able to speak English and provide informed consent, and physically able to complete the interview. The investigators, in consultation with the University of Illinois Survey Research Laboratory, designed and implemented a random dwelling selection and screening procedure to locate participants (details are presented elsewhere) (8). Of 5,445 dwellings selected, 39 were not screened, 4,647 were screened but did not include an eligible participant, and 859 included an eligible participant, yielding a screening rate of 99.3%. There were 635 eligible residents who completed the interview from the 859 eligible dwelling units; 224 refused to participate, for a response rate of 73.9%.
Data collection
Procedures were approved by the Wake Forest University School of Medicine’s Institutional Review Board. Participants were interviewed for approximately 2.5 hours at home by interviewers who had completed 8 hours of training and 6 hours of practice interviews. Ten percent of interviews were verified by telephone. In addition to the study questionnaire, interviews included the Block Food Frequency Questionnaire (FFQ) (Nutrition Quest Block 98.2), which assesses usual intake of 110 foods. One out of every 20 FFQs was audio-recorded and reviewed by research staff, who provided written feedback. Dentate participants were asked to undergo an in-home oral examination. Of 413 dentate participants, 362 (87.6%) completed the oral examination. Two dental hygienists performed examinations in which tooth counts and other measures not used in these analyses were assessed. The research dentist conducted training (1 day) and calibration (1 day) with the dental hygienists and repeated the calibration annually.
Ethnicity based upon self-report was categorized as African American, American Indian or white. Income was dichotomized as either at/above the poverty line or below the poverty line using current-year federal poverty guidelines, taking into account household size (19). Education was categorized as less than high school graduate, high school graduate, or more than high school, based on the participant’s highest level of education completed.
Healthy Eating Index-2005
HEI-2005 contains 12 components (20). These include cup equivalent (eq)/1000 kcals of total fruit, whole fruit, total vegetables, dark green and orange vegetables and legumes, and milk (including soy milk). Meat and beans (which includes eggs, nuts, and soy foods), total grains, and whole grains are calculated in oz eq/1000 kcals. The amounts of oils (as found in mayonnaise, margarine, salad dressing, nuts and seeds, and fish), and sodium, measured in g/1000 kcals, and the percent calories from saturated fat and solid fat, alcohol, and added sugar (SoFAAS) comprise the remaining components.
Completed FFQ forms were scanned by Nutrition Quest, and gram amounts and calories of each item were provided to assist in the calculation of HEI-2005 component scores. The USDA Food Search Tool 3.0 (21) was used to provide necessary information to calculate HEI-2005 components, such as grams per cup or ounce, amounts of fat, or added sugar in certain reference foods.
A maximum score of 5 was assigned to component values that met or exceeded recommended intakes of total Fruit, whole fruit, total vegetable, dark green and orange vegetables and legumes, total grains, and whole grains. A maximum score of 10 was assigned for meeting or exceeding recommended amounts of milk, meat and beans, and oils. Maximum values of 10 were also assigned when saturated fat and sodium were equal to or less than recommended intake. And, finally, the recommended percent of energy contributed by SoFAAS was assigned a score of 20 if it was equal to or less than the recommendations. With the exception of saturated fat, sodium, and SoFAAS, a zero score was assigned to values of 0 for each of the components; and intermediate values were assigned proportionally between 0 and the maximum values. The Total HEI-2005 score, which ranges from 0 to 100, is the sum of the scores for each component.
Food Avoidance
Food avoidance measures were developed based on 10 years of research regarding the nutritional self-management of the study population (22–26) and are described in detail elsewhere (12, 27). Generally the instrument consists of a list of foods commonly consumed by the population and those which represent specific eating challenges (27). These included different types and intensities of biting and chewing, (e.g., baked or stewed chicken vs. grilled or fried pork chops), anterior biting (e.g. apples), and posterior grinding (e.g., grilled or fried meats), as well as foods that can become lodged in teeth or under dentures (e.g., berries and nuts, seeds and small pieces) or adhere to teeth or dental work (e.g., sticky candy). The respondents were read the list and asked if they avoided the food due to the condition of their teeth, mouth, or dentures. Participants received a score for the total number of foods that they avoided.
Denture Status and Removal Frequency
Denture status was assessed by asking participants whether they had removable false teeth (complete or partial dentures) and, if so, which type or types (partial upper plate, full upper plate, partial lower plate, or full lower plate). Participants were then categorized into one of four denture groups: No dentures (ND); removable partial dentures (RPD), removable partial dentures with a complete denture (RPD/CD), and complete dentures (CD). CD had one or two complete removable dentures and no removable partial denture. Three secondary analyses were performed. First, participants were categorized into five denture groups with no dentures being split into those with 11 or more teeth (ND-11+) and 0–10 teeth (ND-0-10). Second, those within the complete denture group who had full removable dentures (i.e., both mandibular and maxillary complete dentures) were considered separately. Third, those in the RPD group were categorized based on the number of occlusal contacts (any opposing pair of natural or fixed prosthetic teeth that make contact when the jaws are closed).
Removal frequency was assessed by asking participants how many times each week they removed their complete or partial dentures during meals or snacks. Participants were categorized into three groups – never, sometimes, or always – based on removal across all meals. The categories were never (does not remove at any meal), sometimes (either seldom, sometimes or often removes at one or more meals or always removed at 1–3 meals), or always (removes at all meals).
Oral Health Characteristics
Self-reported oral health was assessed by asking participants to rate the condition of their mouths and teeth, including prosthetic teeth and dentures, which was dichotomized to excellent/very good/good or fair/poor. Self-reported number of teeth was used to categorize those reporting 0 teeth or those dentate participants who refused the oral exam; otherwise, dentate participants were categorized based upon the oral examination. For those who agreed to the oral examination, the Pearson correlation between the examination and self-reported values for number of teeth was 0.92. Number of remaining natural teeth was a four-level categorical variable: 0 teeth, 1–10 teeth, 11–20 teeth and 21 or more teeth. Number of occlusal contacts was characterized by the number of posterior occlusal contacts (0, 1–2, 3–5, and 6–10 pairs) and by the number of anterior occlusal contacts (0, 1–3, and 4–6). Oral health problems included oral pain, ill-fitting dentures, and sore or bleeding gums, all of which were dichotomous variables (yes/no).
Statistical Analyses
All statistical analyses incorporated the multistage cluster sampling design. Weighted sample sizes were used for all analyses. The Rao-Scott Chi-Square test was used to quantify associations between denture status and gender, ethnicity, education, poverty, number of teeth, posterior occlusal contacts, anterior occlusal contacts, self-rated oral health, ill-fitting denture, oral pain, sore or bleeding gums, and denture removal frequency. Linear regression models were used to test for age differences associated with differences in denture status. Linear regression models were also used to test for differences in HEI total score and components and the number of foods avoided by denture status and removal frequency groups, after adjusting for the covariates, such as age, gender, ethnicity, education, and poverty. We also considered the three denture categories and within no dentures, those with 11 or more teeth (ND-11+) and 0–10 teeth (ND-0-10) were considered separately. Those with full dentures (i.e., both maxillary and mandibular complete dentures) were further considered separately to associate denture removal frequency and HEI-2005 total score and number of foods avoided using multivariate linear regression, adjusting for the covariates. To assess the relationship of the number of occlusal contacts and denture usage with dietary quality or the number of foods avoided, removable dentures (the only denture group with occlusal contacts) was categorized by the number of posterior occlusal contacts and by the number of anterior occlusal contacts. Linear regression was used to test for interaction between occlusal contacts and denture removal frequency and the main effects of occlusal contacts on HEI-2005 total score and number of foods avoided (if interaction not detected). The dichotomous oral health variables (ill-fitting dentures, oral pain, and sore or bleeding gums) were analyzed using logistic regression adjusted for covariates mentioned above to test for differences between removal frequency groups. All statistical analyses were conducted using the Statistical Analysis Software (version 9.2, 2009, SAS Institute Inc, Cary, NC). Significance level was set at 0.05.
RESULTS
Characteristics of the study population
The total sample included 635 participants with a mean age of 71.5± 0.4 years, of which 54.1% were female, 21.4% were African American and 30.7% were American Indian. Women were less likely to be married than men (33.5% v. 62.1%, P=0.001) and more likely to have incomes below the poverty line (39.7% v. 23.2%, P=0.001). More than half of the participants (55.7%) had less than a high school education.
Descriptive and oral health characteristics by denture category (N=633, Table 1)
Table 1.
Bivariate comparisons of descriptive and oral health characteristics by removable dentures status (N=633)
| Variable | No Dentures N*=252 | Removable Partial Dentures N=94 | Removable Partial Dentures and a Complete Denture N=41 | Complete Dentures N=246 | p-value |
|---|---|---|---|---|---|
| Age (mean ± SE) | 70.8 ± 0.59 | 70.1 ± 0.8 | 71.1 ± 1.6 | 73.0 ± 0.6 | 0.01 |
| Gender (N[% female]) | 114 (45.1) | 32 (34.1) | 18 (43.3) | 128 (52.0) | 0.15 |
| Ethnicity (N[%]) | |||||
| White | 124 (49.2) | 31 (32.9) | 17 (41.8) | 132 (53.7) | 0.12 |
| African American | 52 (20.6) | 25 (26.7) | 11 (28.1) | 45 (18.2) | |
| American Indian | 76 (30.2) | 38 (40.4) | 12 (30.0) | 69 (28.1) | |
| Education (N [%]) | |||||
| Less than HS | 118 (46.8) | 42 (44.6) | 24 (58.4) | 168 (68.5) | 0.001 |
| HS | 65 (25.8) | 33 (35.2) | 8 (19.0) | 50 (20.2) | |
| More than HS | 68 (27.4) | 19 (20.2) | 9 (22.6) | 28 (11.3) | |
| Below poverty level (N[%]) | 62 (24.6) | 25 (27.0) | 15 (37.0) | 99 (40.5) | 0.01 |
| Number of teeth (N[%]) | |||||
| 0 | 14 (5.7) | 0 | 0 | 207 (84.4) | NA |
| 1–10 | 24 (9.3) | 12 (12.6) | 41 (100) | 30 (12.0) | |
| 11–20 | 56 (22.3) | 64 (68.0) | 0 (0) | 9 (3.5) | |
| 21+ | 158 (62.6) | 18 (19.4) | 0 | 0 | |
| Posterior occlusal contacts (N[%]) | 0.002 | ||||
| 0 | 31 (15.3) | 18 (22.6) | NA | NA | |
| 1–2 | 23 (11.3) | 24 (30.4) | NA | NA | |
| 3–5 pairs | 54 (26.9) | 25 (31.2) | NA | NA | |
| 6–10 | 94 (46.5) | 13 (15.8) | NA | NA | |
| Anterior occlusal contacts (N[%]) | .002 | ||||
| 0 | 21 (10.4) | 17 (21.0) | NA | NA | |
| 1–3 | 29 (14.5) | 26 (32.5) | NA | NA | |
| 4–6 | 152 (75.1) | 7 (46.5) | NA | NA | |
| Self-rated oral health (N[%])† | |||||
| Excellent/Very good/Good | 130 (51.6) | 42 (45.7) | 19 (45.8) | 156 (63.9) | 0.03 |
| Fair/Poor | 122 (48.4) | 50 (54.3) | 22 (54.2) | 88 (36.1) | |
| Ill-fitting denture (N[%]) | NA | 26 (27.8) | 15 (36.2) | 90 (36.2) | 0.39 |
| Oral pain (N[%]) | 41 (16.3) | 16 (16.8) | 1 (3.4) | 11 (4.6) | <.0001 |
| Sore or bleeding gums (N[%]) | 41 (16.3) | 21 (21.4) | 11 (29.1) | 61 (25.2) | 0.19 |
| Eats or drinks without dentures (N[%]) | |||||
| Never (0 meals/day) | NA | 45 (47.8) | 23 (57.2) | 143 (58.3) | 0.15 |
| Sometimes (1–2 meals/day) | NA | 27 (28.9) | 14 (36.3) | 63 (25.7) | |
| Always (3 meals/day) | NA | 22 (23.3) | 3 (6.5) | 39 (16.0) | |
N= weighted sample size
Self-rated oral health is missing four weighted participant (two in no denture group and two in complete denture group).
Two participants did not provide information on denture status so the categorization and analysis of denture usage includes 633 individuals. ND (N=252, 39.8%) comprised the largest group, of which 84.9% had 11 or more teeth. This was followed by CD (N=246, 38.7%). Most in this category had no teeth (N=207, 84.4%); 78.4% had both dentures, 21.2% had just a maxillary denture, and 0.41% (1 person) had just a mandibular denture. There were 94 (14.8%) in RPD, of whom 87.4% had 11 or more teeth and none were edentulous; there were equal numbers (41.5%) with both maxillary and mandibular removable partial dentures and maxillary only; 17% had a mandibular removable partial denture only. As expected, the ND had a more posterior and anterior occlusal contacts. Finally, RPD/CD included 41 (6.45%), and 97.6% of these had maxillary complete dentures and a mandibular removable partial denture. Forty-four (7%) participants reported having implants. This included 16 (6.4%) ND, 12 (12.8%) RPD, 1 (2.4%) RPD/CD, and 15 (6.1%) CD.
CD were older (73.0± 0.6 years) than ND (70.8 ± 0.6 years, P=0.008) and RPD (70.1 ± 0.6 years, P=0.002) and were less likely to have at least a high school degree (31.5%) compared to 53% of ND or 55.4% of RPD (odds ratios 0.39 [0.23, 0.65] and 0.41 [0.24, 0.73], respectively). ND were half as likely to live below the poverty level as CD (odds ratio 0.39 [0.23, 0.65]). Approximately half of ND, RPD and RPD/CD reported having excellent/very good, or good oral health compare to two-thirds of CD (odds ratios 0.59 [0.37, 0.95], 0.47 [0.26, 0.84], 0.48 [0.23, 0.99], respectively. ND and RPD were 4–6 times more likely to experience oral pain compared to RPD/CD (odds ratios 5.4 [1.4, 20.6], 5.7 [1.1, 31.1]) and CD (4.0 [1.9, 8.4], 4.2 [1.5, 11.5]); 16–17% of ND and RPD compared to fewer than 5% of RPD/CD and CD. Removal frequency did not differ across the denture status groups (p=0.15). Together, 55% never, 27% sometimes, and 18% always removed dentures when eating.
Descriptive and oral health characteristics by denture removal frequency (N=379, Tables 2 & 3) There were no differences across the frequency of removing dentures categories for age (p=0.32), gender (p=0.25), education (p=0.21), or poverty status (p=0.07). Similar to the total sample, approximately 20% of each of the removal frequency categories was African American. Differences for whites and American Indians were found among those who sometimes removed their dentures while eating. While whites represented 48% of the total sample, only 35% reported sometimes removing their dentures and American Indians comprised 31% of the total sample but 45% reported sometimes removing their dentures (p=0.01).
Table 2.
Descriptive characteristics, Healthy Eating Index (HEI-2005) Total Score, and Number of Foods Avoided by frequency of removing dentures before eating (N=379)
| Variable | Never removes N=211 (55.7%) | Sometimes removes N=104 (27.4%) | Always removes N=64 (16.9%) | p-value |
|---|---|---|---|---|
| Age (mean ± SE) | 72.9 ± 0.8 | 71.1 ± 1.0 | 71.0 ± 1.6 | 0.32 |
| Gender (N[% female]) | 92 (43.9) | 45 (43.3) | 39 (60.8) | 0.25 |
| Ethnicity (N[%]) | ||||
| White | 111 (52.7) | 36 (35.0) | 33 (51.4) | 0.01 |
| African American | 47 (22.2) | 21 (19.8) | 14 (21.5) | |
| American Indian | 53 (25.1) | 47 (45.2) | 17 (27.1) | |
| Education (N [%]) | ||||
| Less than HS | 120 (57.1) | 68 (65.3) | 45 (71.4) | 0.21 |
| HS | 60 (28.5) | 16 (15.8) | 14 (22.0) | |
| More than HS | 30 (14.3) | 20 (18.9) | 4 (6.6) | |
| Below Poverty Level (N[%]) | 69 (32.7) | 37 (36.0) | 34 (53.0) | 0.07 |
| HEI-2005 Total Score* | 61.9 ± 1.2 | 62.8 ± 1.6 | 60.3 ± 1.9 | 0.57 |
| Foods avoided* | 2.1 ± 0.3 | 2.6 ± 0.4 | 2.8 ± 0.5 | 0.27 |
Least square means adjusted for age, gender, ethnicity, education, and poverty status
Table 3.
Associations between oral health characteristics and the frequency of removing dentures while eating (odds ratio and 95% confidence intervals from logistic regression analysis)*
| Sometimes vs. Never removes | Always vs. Never | Always vs. Sometimes | |
|---|---|---|---|
| Ill-fitting Denture (Yes vs. No) | 2.3 (1.2, 4.5) | 4.1 (1.7, 9.7) | 1.8 (0.6, 5.0) |
| Oral Pain (Yes vs. No) | 1.4 (0.5, 4.0) | 1.2 (0.3, 4.2) | 0.8 (0.2, 3.1) |
| Sore or bleeding gums (Yes vs. No) | 1.1 (0.6, 2.1) | 1.2 (0.6, 2.4) | 1.1 (0.5, 2.1) |
Adjusted for age, gender, ethnicity, education, and poverty status.
In adjusted models, removal frequency (Table 2) was not associated with HEI-2005 total score (p=0.57) and the number of foods avoided (p=0.27). In addition, removal frequency was not associated with oral pain or sore and bleeding gums, but was associated with having ill-fitting dentures (Table 3). Those with ill-fitting dentures were two times (2.3 [1.2, 4.5]) more likely to sometimes remove their dentures and four times (4.1 [1.7, 9.7]) more likely to always remove their dentures compared to those who reported having dentures that fit (Table 3).
HEI-2005 Scores and the Number of Foods Avoided by Denture Status (N=379, Table 4) Because there was not a statistically significant interaction between removal frequency and denture status, results are reported without removal frequency in the model. Significant differences are those reported for p-values which are <0.05; individual pair-wise comparisons are found in Table 4. After adjusting for age, gender, ethnicity, education, and poverty status, CD and ND (0–10) had HEI-2005 total scores that were four to six points lower than ND (11+), RPD, and RPD/CD. ND (11+), RPD, and RPD/CD had comparable HEI-2005 total scores. After adjustments, there were no differences across denture status for five of twelve HEI-2005 categories, total fruit, total grains, whole grains, milk, and sodium. Numerous pair-wise differences were found among the denture status groups for the remaining HEI components (total fruit, whole fruit, total vegetable, dark green and orange vegetables and legumes, total grains, whole grains, and energy from SoFAAS). In general, ND (1–10) and CD consumed the least amounts of whole fruits, total vegetables, dark green and yellow vegetables and legumes, meat and beans, and oils and the most energy from SoFAAS. Although ND (11+), RPD, and RPD/CD were similar for most of these categories, RPD ranked highest for whole fruit, total vegetables, dark green and orange vegetables and legumes, and oils and had the lowest percentage of energy from saturated fat and SoFAAS.
Table 4.
Association between Healthy Eating Index-2005 (HEI-2005) components and the number of foods avoided with denture status* (Least Square Mean [SE])
| Variable (mean ± SE) | No denture with 0–10 teeth N=38 | No denture with 11+ teeth N=214 | Removable Partial Dentures N=94 | Removable Partial Denture and a Complete Denture N=41 | Complete Denture N=246 | p-value |
|---|---|---|---|---|---|---|
| Total Score (0–100 points) | 58.0 ± 1.7x | 63.5 ± 0.8y | 66.3 ± 1.5y | 63.4± 1.9y | 59.0 ± 1.1x | <0.0001 |
| Total Fruit (cup eq/1000 kcal) | 0.48 ±0.08 | 0.58 ± 0.03 | 0.62 ±0.06 | 0.62 ± 0.06 | 0.56± 0.05 | 0.11 |
| Whole Fruit (cup eq/1000 kcal) | 0.25 ±0.03x | 0.35 ± 0.02y | 0.39± 0.03y | 0.37 ± 0.04y | 0.33 ± 0.03y | 0.0025 |
| Total Vegetable (cup eq/1000 kcal) | 0.65± 0.09x | 0.85 ± 0.05y,z | 0.98 ± 0.07z | 0.89 ± 0.10y,z | 0.80 ± 0.05y | 0.0021 |
| Dark Green and Orange Vegetables and Legumes (cup eq/1000 kcal) | 0.37 ± 0.06x | 0.46 ± 0.04x,y | 0.56 ± 0.05y | 0.47 ± 0.08x,y | 0.42 ± 0.04x | 0.05 |
| Total Grains (oz/1000 kcal) | 2.73 ± 0.17 | 2.54 ± 0.08 | 2.73 ± 0.20 | 2.44 ± 0.15 | 2.31 ± 0.10 | 0.20 |
| Whole Grains (oz/1000 kcal) | 1.05 ± 0.16 | 0.96 ± 0.06 | 1.24 ± 0.12 | 0.87 ± 0.08 | 0.91 ±0.06 | 0.06 |
| Milk (cup eq/1000 kcal) | 0.42 ± 0.57 | 0.45 ± 0.04 | 0.50± 0.06 | 0.42± 0.04 | 0.47 ± 0.04 | 0.81 |
| Meat and Beans (oz eq/1000 kcal) | 2.26 ± 0.15x,y | 2.44 ± 0.07y | 2.30 ± 0.15x,y | 2.63 ± 0.17y | 2.16 ± 0.07x | 0.04 |
| Oils (g eq/1000 kcal) | 4.31 ± 0.67x | 6.46 ± 0.52y,z | 7.56 ± 1.04y,z | 6.94 ± 1.35x,y,z | 5.25 ± 0.44x,y | 0.03 |
| Saturated Fat (% of kcal) | 11.00 ± 0.35 x,y | 11.10 ± 0.16x | 10.36 ± 0.24y | 10.50 ± 0.17y | 11.4 ±0.31x | 0.0016 |
| Sodium (mg/1000 kcal) | 1329 ± 36.60 | 1340.3 ±27.78 | 1314 ± 27.67 | 1286 ± 37.87 | 1328 ± 27.41 | 0.79 |
| Calories from Solid Fat, Alcohol, and Added Sugar (% of kcal) | 29.69 ± 1.52x,y | 27.48 ± 0.71y | 26.23 ± 0.79y | 28.84 ± 1.37x,y | 30.30± 0.86 | 0.0029 |
| Foods Avoided | 3.5± 0.4w | 0.9 ± 0.1x | 1.8 ± 0.2y | 2.2 ± 0.5y,z | 2.7 ± 0.3w,z | <0.0001 |
| Whole apples with skin (N [%]) | 28 (73.7) | 50 (23.4) | 39 (41.5) | 23 (56.1) | 161 (65.5) | |
| Sticky Candy (N [%]) | 12 (31.6) | 29 (13.6) | 51 (54.2) | 17 (41.5) | 90 (36.6) | |
| Carrot sticks or whole (N [%]) | 25 (65.7) | 30 (14.0) | 18 (19.1) | 11 (26.8) | 101 (41.1) | |
| Whole nuts (N [%]) | 26 (68.4) | 26 (12.1) | 20 (21.3) | 12 (29.3) | 114 (46.3) | |
| Corn (N [%]) | 9 (23.7) | 4 (1.9) | 16 (17.0) | 5 (12.2) | 51 (20.7) | |
| Steak (N [%]) | 7 (18.4) | 6 (2.8) | 5 (5.3) | 4 (9.8) | 40 (16.3) | |
| Popcorn (N [%]) | 10 (26.3) | 10 (4.7) | 7 (7.4) | 6 (14.6) | 35 (14.3) | |
| Grilled or fried pork chops (N [%]) | 10 (26.3) | 10 (4.7) | 5 (5.3) | 3 (7.3) | 36 (13.6) | |
| Lettuce or tossed salad (N [%]) | 10 (26.3) | 5 (2.3) | 1 (1.1) | 3 (7.3) | 30 (12.2) |
Adjusted for age, gender, ethnicity, education, and poverty status.
Different superscipts (w, x, y, z) in rows indicate differences between means (P<0.05) using orthogonal contrasts to test pair-wise differences.
The ND-11+ avoided the fewest foods compared to all other groups. In contrast, ND-0-10 avoided more foods than all other groups except for CD. Among the three denture groups, RPD avoided fewer foods than CD; the number of foods avoided by RPD/CD was not statistically different from CD or RPD. Few individuals in all groups avoided berries, fried chicken, raw tomatoes, fried fish or shrimp, ground beef or hamburger, and baked or stewed chicken. Table 4 includes the number of participants in each denture group avoiding the remaining 9 foods. Of these nine, whole apples with skin, sticky candy, carrots (whole or sticks), and whole nuts were avoided by the most people. With the exception of sticky candy, the pattern of avoidance for these foods was consistent across the remaining five foods (corn, popcorn, grilled or fried pork chops, steak, and lettuce or tossed salad). That is ND-0-10 was the most likely to avoid the food, followed by CD, RPD/CD, RPD, and ND-11+. The exception was that RPD included the greatest percentage (54.2%) of those avoiding sticky candy and approximately 30–40% of other denture wearing groups and 14% of ND-11+.
Full Denture Usage and HEI-2005 and Foods Avoided (N=191)
There were 191 of CD that had full dentures (two complete dentures). Among those with full dentures, after adjustments, removing dentures before eating was associated with lower HEI-2005 total scores (p=.02). Those who always remove their dentures before eating had a lower HEI-2005 score (54.5±1.9) compared to those who never (60.1±1.5, p=.009) or sometimes (59.7±2.2, p=.02) removed their dentures before eating. For those with full dentures, there was no statistically significant association between those who removed their dentures before eating and the number of foods avoided (p=.12). The number of foods avoided was 2.6±0.4 for those with full dentures who never, 3.5±0.4 for those who sometimes, and 4.3±0.8 for those who always removed dentures before eating.
Number of Occlusal Contacts, Removal Frequency, and HEI-2005 and Foods Avoided (N=94) RPD was the only denture group that had occlusal contacts. Two-thirds of this group had 1–5 posterior occlusal contacts and 46.5% had 4–6 anterior occlusal contacts. Without adjusting for socio-demographic variables, there was a statistically significant positive relationship between the HEI-2005 total score and the number of posterior contacts, (p=.02) and after adjustments the effect became a trend (p=.10). There was no interaction between posterior occlusal contacts and frequency of removing dentures and the HEI-2005 total score. For the number of foods avoided, there was not a relationship with posterior occlusal contacts (either adjusted or unadjusted), nor was there an interaction between number of posterior occlusal contacts and frequency of wearing dentures. The number of anterior occlusal contacts or the interaction between anterior occlusal contacts and removal frequency were not related to HEI-2005 total score. However, after adjustments, the number of anterior occlusal contacts was negatively associated with the number of foods avoided (p=.002), and there was significant interaction between anterior occlusal contacts and removal frequency (p=.0047). Individuals with 4–6 anterior contacts who sometimes or always removed their dentures when eating avoided fewer foods (1.1±0.2) compared to those with 0 or 1–3 anterior contacts who sometimes or always removed their dentures, 3.1±0.4 and 3.2±0.9, respectively. For those who never removed their dentures when eating, the number of foods avoided was similar regardless of whether they had 0, 1–3 or 4–6 anterior occlusal contacts, 2.1±0.6, 2.3±0.4, 2.0±0.5, respectively.
DISCUSSION
This study demonstrated the range of differences in denture status among rural adults. Sixty percent of these rural elders had either removable partial or complete dentures, and half of those with dentures had full dentures, i.e., both maxillary and mandibular complete dentures. Compared to past estimates of removable partial and complete dentures among US older adults, our sample had fewer individuals without dentures (39.7% vs. 61.9%) (12), This is consistent with the findings that show that rural older adults are more likely to experience severe tooth loss compared to urban dwellers (27). However, within each denture group the proportion of individuals with either maxillary or mandibular or both types of dentures were comparable to a national sample (12). Because dentures wearers represent more than half of rural elders, learning more about their denture experiences is important to increasing our understanding of how dietary quality is affected by impaired oral health.
Those with severe tooth loss without dentures and the edentulous who wore full dentures had the poorest dietary quality and avoided the greatest number of foods. This is consistent with the report of Nowjack-Raymer and Sheiham. They found that the intakes of nutrient-rich foods and associated nutrients were lower among the edentulous who wore dentures compared to those with natural teeth (28). Those who had eleven or more teeth without dentures and those with removable partial dentures had comparable dietary quality and avoided a similar number of foods. Surprisingly, this result was true for the small group that had one complete denture (all but one had a maxillary denture) and a partial denture and no occlusal contacts. The results suggest that the effects on diet quality of severe or complete tooth loss may not be overcome with removable dentures and that those with less severe tooth loss with removable dentures are able to maintain a certain level of dietary quality and range of foods in their diets. However, without knowing how these older adults ate in the past, it is not possible to know how any of these denture groups may have altered their food choices after they began wearing dentures.
We considered the impact that wearing removable dentures when eating has on dietary quality and the number of foods avoided. Regardless of denture type, almost half reported removing dentures while eating at least some of the time, and approximately one in five always removed their dentures when eating. Approximately one-third of our sample reported having dentures that fit poorly, and these individuals were more likely to remove their dentures when eating. While our assessment of denture fit was self-reported, objective assessments support our result. Dental examinations performed in a population-based sample of Americans found that only one third of removable partial dentures were considered free of defects and lack of stability was the most prevalent single defect (12). Although in the present study, generally the frequency of removal was not related to dietary quality or the number of foods they avoided eating, those who had full dentures (complete mandibular and maxillary removable dentures) and removed their dentures when eating had compromised dietary quality. Shinkai and colleagues found that among those with full dentures, denture quality, chewing capacity, and perceived chewing ability were not related to diet quality (13). Others have shown that poor denture fit has been associated with lower dietary quality (14, 29). It may be that dentures that do not fit well lead individuals to remove their dentures when eating and that behavior (if assessed) can help explain differences in dietary quality found among those with dentures. However, improvement in denture fit alone has not changed food choices or improved dietary quality (8, 15, 30–32). Dietary counseling, along with changes in denture fit, may be needed to alter diet quality (33, 34).
Consistent with other reports, we found that the number of posterior occlusal contacts alone was related to dietary quality among those who had removable partial dentures (5, 35) but was not related to the number of foods avoided; these relationships were not altered by removal frequency. Dietary quality was not associated with number of anterior occlusal contacts. However, we saw that those with fewer anterior occlusal contacts who removed their dentures when eating avoided more foods than those who always wore their dentures when eating. It should be noted that this group was limited in sample size, preventing us from being able to compare sub-groups of those with only mandibular, maxillary, or both types of dentures or various configurations of posterior and anterior occlusal contacts. Individuals with removable dentures only represented 15% of the sample and little has been reported about their denture use. These results suggest a better understanding of the characteristics of denture wearers is needed.
There are limitations to this investigation. These assessments were cross-sectional; therefore, we do not know how participants may have eaten in the past and whether current patterns are a departure from prior eating practices. While we have accounted for socio-demographic variables, there may be other characteristics that were not measured that may be associated with denture status. For example, a measure of denture quality was not available and these differences may have been associated with particular denture groups and explained some of the variations found in dietary quality, the number of foods avoided, or the removal frequency. As noted, the sample size for comparisons of occlusal contacts and removal frequency was limited and future research should consider these differences among a larger group.
The present study does have several strengths. First, this was a population-based sample that represented the characteristics found in rural areas. Second, we were able to provide details on the types and numbers of dentures used by this population, which, to our knowledge, has not been previously reported. Finally, this investigation demonstrated that assessing denture usage when eating may be a useful variable when considering dietary quality among any population of older adults.
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