The Link between Malnutrition and Poor Oral Health in Older Adults
June 4, 2019
West Health Contributors: Andrea M. Morris, Jessa K. Engelberg, Mario Orozco, Brenda Schmitthenner
Malnutrition among Older Adults in the U.S.
Malnutrition is a growing and urgent problem among older Americans. It contributes to poor health outcomes and greater healthcare costs, and threatens the independence and well-being of older adults.1-5 In 2010 the economic burden of disease-associated malnutrition in the United States (U.S.) was over $155 billion/year, with over $51 billion of that attributable to older adults.4,5 Given the high cost and negative health effects, and the fact that up to 1 out of 2 older adults are at-risk for malnutrition,2,3 it is imperative that greater attention is dedicated to addressing and preventing malnutrition among this at-risk population.
What is Malnutrition?
Malnutrition is a complex condition defined as a lack of proper nutrients that leads to a change in body composition and functional decline.6 Contributors can be non-medical (i.e., social) or medical in nature and are often synergistic or bidirectional. Some of these contributors include transportation barriers, food insecurity, poverty, social isolation, chronic conditions, medications, frailty, depression, impaired swallowing, and poor oral health.1,7,8
Poor Oral Health among Older Adults in the U.S.
Poor oral health, including tooth decay, periodontal disease (i.e., infections of structures around the teeth and gums), and lesions in other oral tissues among older adults can profoundly diminish quality of life and have an adverse impact on general health.9,10 Currently, 19% of older adults have untreated tooth decay,11 and an estimated 60% of seniors have periodontal (gum) disease.12 Nearly 1 in 5 older adults have lost all their teeth13 and 1 in 3 has lost six or more teeth due to tooth decay or gum disease.11 Lack of dental coverage, high out-of-pocket expenditures,14-16 and other barriers, such as lack of awareness of dental needs, fear of dentists,15 difficulties with transportation and assistance navigating healthcare systems16 keep older adults from seeking needed care.
The Link between Malnutrition and Oral Health
There is a strong link between malnutrition and poor oral health. Impaired oral health, such as an inability to chew or swallow food, having missing teeth or gum disease, can negatively impact nutritional intake (e.g., consuming fewer meals or meals with lower nutritional value) leading to poor nutritional status and increased risk of malnutrition.17-19 Being malnourished, or having a lack of proper nutrients, can negatively affect the mouth (e.g., teeth and gums) leading to increased risk of gum disease and other oral health-related problems.20
Older adults are at an increased risk of malnutrition and poor oral health.21 In a study of three emergency departments (ED), older patients were screened for malnutrition and contributing risk factors, including oral health. The authors found that oral health was the most common risk factor identified, with patients with poor or moderate oral health 54% more likely to be malnourished than those with good oral health. Of those malnourished patients, 41% had not seen a dentist in the past 2 years.7 A separate study found that over 25% of older patients screened for malnutrition in a dental clinic were malnourished or at risk.21
Taken together, these studies provide further support for the relationship among malnutrition and oral health and shine a light on the importance of considering both health-related problems when caring for older adults in healthcare, dental, and social service settings.
There are numerous organizations, coalitions and initiatives advancing comprehensive malnutrition care for older adults by improving and promoting malnutrition screening, diagnosis and treatment in clinical and community settings.22-24 However, these efforts do not typically address oral health as a major contributor or risk factor. Efforts to raise awareness about poor oral health as a serious health issue for older adults have primarily focused on advocating for a covered dental benefit, but have not called attention to the connection with malnutrition and its pertinent consequences.25,26 As such, there is an opportunity for medical, dental, and social service practitioners to leverage and unite efforts in both areas to maximize the positive impact on the health and well-being of our nation’s most vulnerable older adults.
What can you do?
There are several actions you can take to jointly address malnutrition and poor oral health and positively impact older adults today!
- Increase awareness about the link between malnutrition and oral health.
For example, educate your staff, patients/clients and their caregivers about the relationship between malnutrition and oral health the significant impact they have on older adults health and well-being. Provide informational posters or pamphlets around your clinic, waiting room or office, or train your staff about malnutrition and oral health so they are prepared to discuss both issues. The National Council on Aging and Defeat Malnutrition Today have many resources to help with education, including infographics. Similarly, organizations such as the Gerontological Society of America, Dental Lifeline Network, and the National Association of Free & Charitable Clinics provide information about the importance of oral health and access to affordable dental services in your area.
- Incorporate screening for malnutrition and oral health into your practice to provide better care and support to your older adult patients and clients.
There are many validated malnutrition screeners that could be incorporated into medical, dental and social service practices, depending on staffing and workflows, such as the two-item Malnutrition Screening Tool (MST). Screening for malnutrition can alert you if someone is at risk for malnutrition. Similarly, there are validated oral health assessments that can be conducted, such as the Rapid Oral Health Screening and Risk Assessment or the Geriatric/General Oral Health Assessment Index (GOHAI). Alternatively, you could look in an older adult’s mouth for missing teeth or dentures or simply ask them if they have trouble or pain when chewing or swallowing.
- Provide information or connect at-risk older patients to local resources to address their needs.
This may include increasing awareness of federal and state assistance programs and local community resources. Or consider creating and/or distributing informational packets or resource lists, such as food assistance benefits or information on low-income dental clinics to at-risk older adults that could help address the underlying contributors. If possible, take the initiative to connect older adults to programs and local resources that help address their oral health and nutritional needs.
- Agarwal E, Miller M, Yaxley A, Isenring E, “Malnutrition in the Elderly: a Narrative Review,” Maturitas, 2013, vol.76, pgs.296-302.
- Kaiser MJ, Bauer JM, et al. Frequency of malnutrition in older adults: a multinational perspective using the mini nutritional assessment. Journal of the American Geriatrics Society. 2010;58(9):1734-1738.
- Agarwal, E. (2017). Disease‐related malnutrition in the twenty‐first century: From best evidence to best practice. Nutrition & Dietetics, 74(3), 213-216.
- Correia, M. I. T., & Waitzberg, D. L. (2003). The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clinical Nutrition, 22(3), 235-239.
- Snider, J. T., Linthicum, M. T., Wu, Y., LaVallee, C., Lakdawalla, D. N., Hegazi, R., & Matarese, L. (2014). Economic burden of community-based disease-associated malnutrition in the United States. Journal of Parenteral and Enteral Nutrition, 38(2_suppl), 77S-85S.
- (6)Soeters PB, Schols AM. Advances in understanding and assessing malnutrition. Curr Opin Clin Nutr Metab Care 2009; 12(5):487–494).
- Burks, C. E., Jones, C. W., Braz, V. A., Swor, R. A., Richmond, N. L., Hwang, K. S., … & Platts‐Mills, T. F. (2017). Risk Factors for Malnutrition among Older Adults in the Emergency Department: A Multicenter Study. Journal of the American Geriatrics Society.
- National Academies of Sciences, Engineering, and Medicine (NASEM). 2016. Meeting the dietary needs of older adults: Exploring the impact of the physical, social, and cultural environment: Workshop summary. Washington, DC: The National Academies Press. doi: 10.17226/23496.
- Griffin, S.O., Jones, J.A., Brunson, D., Griffin, P.M., Bailey, W.D. (2012). Burden of oral disease among older adults and implications for public health priorities. American Journal of Public Health, 102(3):411-418
- Association of State and Territorial Dental Directors (ASTDD) Best Practices Committee. Best practice approach: oral health in the older adult population (age 65 and older) [monograph on the Internet]. Reno, NV: Association of State and Territorial Dental Directors; Mar 2017. 29p. Available from: http://www.astdd.org.
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Oral Health. Oral Health Data [online]. 2015. [accessed Apr 29, 2019]. URL: https://nccd.cdc.gov/oralhealthdata/
- Eke, P.I.,Thornton-Evans, G.O., Wei, L., Borgnake, W.S., Dye, B.A., Genco, R.J. (2018). Periodontitis in U.S. adults. JADA, 149(7):576-588.
- Dye, B.A., Weatherspoon, D.J., Lopez Mitnik, G. (2019). Tooth loss among older adults according to poverty status in the United States from 1999 through 2004 and 2009 through 2014. JADA, 150(1):9-23.
- Manski RJ and Rohde F. Dental Services: Use, Expenses, Source of Payment, Coverage and Procedure Type, 1996–2015: Research Findings No. 38. November 2017. Agency for Healthcare Research and Quality, Rockville, MD. https://meps.ahrq.gov/mepsweb/data_files/publications/rf38/rf38.pdf.
- Vujicic, M., Buchmueller, T., Klein, R. (2016). Dental care presents the highest level of financial barriers, compared to other types of health care services. Health Affairs. 35(12):2176-2182
- Montini, T., Tseng, T.Y., Patel,H., Shelley, D. (2014). Barriers to dental services for older adults. American Journal of Health Behavior, 38(5):781-8 doi: 10.5993/AJHB.38.5.15
- El Hélou, M., Boulos, C., Adib, S. M., & Tabbal, N. (2014). Relationship between oral health and nutritional status in the elderly: a pilot study in Lebanon. Journal of Clinical Gerontology and Geriatrics, 5(3), 91-95.
- Sahyoun NR, Lin CL, Krall E. Nutritional status of the older adult is associated with dentition status. J Am Diet Assoc 2003;103(1):61-6 doi: 10.1053/jada.2003.50003
- Sheiham A, Steele J. Does the condition of the mouth and teeth affect the ability to eat certain foods, nutrient, and dietary intake and nutritional status amongst older people? Public Health Nutr 2001;4(3):797-803
- Sheetal, A., Hiremath, V. K., Patil, A. G., Sajjansetty, S., & Kumar, S. R. (2013). Malnutrition and its oral outcome–A review. Journal of clinical and diagnostic research: JCDR, 7(1), 178.
- Zelig, R., Byham-Gray, L., Singer, S. R., Hoskin, E. R., Fleisch Marcus, A., Verdino, G., … & Touger-Decker, R. (2018). Dentition and malnutrition risk in community dwelling older adults. J Aging Res Clin Pract, 7, 107-114.
- White, J. V., Guenter, P., Jensen, G., Malone, A., Schofield, M., Group, A. M. W., … & of Directors, A. B. (2012). Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). Journal of the Academy of Nutrition and Dietetics, 112(5), 730-738.
- McCauley, S. M. (2016). Malnutrition care: Preparing for the next level of quality. Journal of the Academy of Nutrition and Dietetics, 116(5), 852-855.
- Avalere Health and the Academy of Nutrition and Dietetics. Launching the Malnutrition Quality Improvement Initiative. Proceedings from the Launching the Malnutrition Quality Improvement Initiative Dialogue; 2014 September 16; Washington, DC. Washington DC: Avalere Health; 2014
- U.S. Department of Health and Human Services. (July 2000). Oral Health in America: A Report of the Surgeon General. Retrieved from https://www.nidcr.nih.gov/research/data-statistics/surgeon-general
- Iwasaki M, Taylor GW, Manz MC, et al. Oral health status: relationship to nutrient and food intake among 80-year-old Japanese adults. Community Dent Oral Epidemiol 2014;42(5):441-50