CLINICAL RESEARCH

Mastication and oral healtherelated quality of life in

removable denture wearers with Alzheimer disease
Camila H. Campos, DDS, MS,a Giselle R. Ribeiro, DDS, MS,b and Renata C. M. Rodrigues Garcia, PhDc

Progressive and degenerative ABSTRACT

Alzheimer disease (AD) affects Statement of problem. Alzheimer disease (AD) can affect masticatory function, affecting oral
the central nervous system healtherelated quality of life (OHRQoL). Whether oral rehabilitation with conventional removable
and causes cognitive impair- prostheses can restore masticatory function and improve OHRQoL in these individuals is unknown.
ment, including memory loss,
Purpose. The purpose of this clinical study was to evaluate the influence of oral rehabilitation with
communication problems, loss removable prostheses on masticatory efficiency and OHRQoL in elders with and without AD.
of time and space orientation,
and inability to acquire new Material and methods. Thirty-two elders with mild AD (n=16, mean age=76.7 ±6.3 years) or
without AD (n=16, mean age=75.2 ±4.4 years) were recruited. All participants first underwent
learning.1,2 Mastication has
masticatory efficiency and OHRQoL evaluations, and 2 months after insertion of new removable
been reported as a way to prostheses, the variables were reassessed. Masticatory efficiency was determined using the sieving
improve cognitive function by method, and OHRQoL was measured by applying the Geriatric Oral Health Assessment Index
enhancing cerebral cortex ac- (GOHAI). The data from the baseline and after insertion of the new removable prostheses were
tivity and increasing cortical compared by paired t test. Group differences at each time point were assessed by t test (a=.05).
blood flow.3,4 Mastication may Results. After insertion of the new removable prostheses, masticatory efficiency and OHRQoL
lead to long-term effects on improved in both the elders with AD and the control. At baseline, elders with AD had lower
the cerebral nervous system masticatory efficiency and higher OHRQoL than controls (P<.05). After removable prosthesis
and be helpful in preventing insertion, elders with AD continued to show lower masticatory efficiency values than controls, but
the degradation of brain func- their OHRQoL was similar.
tions.3,5,6 In addition, epide- Conclusions. Oral rehabilitation with new removable prostheses improved the masticatory effi-
miologic studies have reported ciency and OHRQoL of elders with and without AD, although masticatory efficiency did not reach
that tooth loss is a significant control levels in elders with AD. (J Prosthet Dent 2017;-:---)
risk factor for dementia or
AD5,7,8 and that tooth loss is more prevalent in elders appetite, and motor function and thereby impairing
with dementia.9,10 Animal experiments have identified masticatory function.13-19 Impaired masticatory function
4
tooth loss as impairing spatial learning and memory also can limit eating and social life, negatively affecting
because the number of pyramidal cells in the hippo- oral healtherelated quality of life (OHRQoL).20
campus and the gyrus dentatus decrease with time after In spite of the significant increase in the elderly
tooth loss.11,12 Thus, evidence exists that chronic masti- population and as a consequence the incidence of AD,
catory dysfunction may affect neurobiology of the brain. the effects of the disease on masticatory function and
Brain damage caused by AD can also reduce the OHRQoL are not clear.21-23 Although Rolim et al24 re-
sensations of smell and taste, affecting salivary flow,
13
ported improvements in OHRQoL after general dental

Supported by the National Counsel of Technological and Scientific Development (grant 48.090.3/2013-1); and the São Paulo Research Foundation (grant 2013/10200-7).
a
Postgraduate student, Department of Prosthodontics and Periodontology, Piracicaba Dental School (UNICAMP), University of Campinas, São Paulo, Brazil.
b
Postgraduate student, Department of Prosthodontics and Periodontology, Piracicaba Dental School (UNICAMP), University of Campinas, São Paulo, Brazil.
c
Professor, Department of Prosthodontics and Periodontology, Piracicaba Dental School (UNICAMP), University of Campinas, São Paulo, Brazil.

THE JOURNAL OF PROSTHETIC DENTISTRY 1

2 Volume
Clinical Implications
Oral rehabilitation with removable prostheses
improves oral healtherelated quality of life and
mastication in elders with Alzheimer disease (AD).
However, masticatory difficulties remain. Clinicians
should be aware of the masticatory impairment of
elders with AD when proposing rehabilitative
therapies and adjustments in diet.
treatment, the authors are unaware of reports that show
whether removable prostheses would improve mastica-
tion or OHRQoL in elderly people with AD.
Therefore, the purpose of this clinical study was to
compare the masticatory function and OHRQoL of
elderly people with mild AD with a control group of el-
ders without cognitive impairment before and after oral
rehabilitation with removable partial dentures (RPDs)
and/or complete dentures (CDs). The null hypotheses
were that those with AD and the controls would not
differ in masticatory function and OHRQoL, and that
oral rehabilitation with removable prostheses would not
improve masticatory function and OHRQoL.
MATERIAL AND METHODS
This was a nonrandomized, single-center, controlled
clinical trial that compared mastication and OHRQoL
between individuals with and without AD. Additionally,
a paired design was used to compare the same variables
before and after the use of new RPDs and/or CDs.
Masticatory function was evaluated by measuring
masticatory efficiency, and OHRQoL was measured by
applying the Geriatric Oral Health Assessment Index
(GOHAI). The assessments were performed before and 2
months after the prosthetic treatment.
Thirty-two partially or completely edentulous elderly
individuals who had participated in a previous study25
and who used removable prostheses were assigned to 2
groups: with AD (n=16, aged 76.7 ±6.3 years) and
without AD (n=16, aged 75.2 ±4.4 years). Details about
the participants of this study have been previously
described.25 The ethics committee of Piracicaba Dental
School, University of Campinas, approved this study
(protocol 043/2013). The study was also registered in the
Brazilian Registry of Clinical Trials database
(RBR_5v5bvw), which is linked to the International
Clinical Trials Registration Platform (ICTRP/World
Health Organization). Participation in this study was
voluntary, and participants and their families or legal
representatives provided signed written informed con-
sent before enrollment.
According to the earlier report,25 to be included in the
experimental group, elders had to be in the mild stage of
THE JOURNAL OF PROSTHETIC DENTISTRY
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AD as diagnosed by a neurologist using the International
Classification of Diseases (ICD-10), Diagnostic and Sta-
tistical Manual of Mental Disorders (DSM-IV), Mini-
Mental State Examination (MMSE), and Clinical
Dementia Rating scale (CDR).26 To be part of the control
group, elders had to be free of AD or any other type of
dementia. Also excluded were individuals with severe
periodontal disease, temporomandibular disorders,
cognitive impairment, and major depression or other
mood disorders.25
In addition to matching by age, groups were also
matched by sex (8 men and 8 women in each group) and
dental status, with each group presenting 11 completely
edentulous and 5 partially edentulous participants.25 The
MMSE26 was applied by a single calibrated researcher
(C.H.C.) for participants in both groups, and cutoffs were
applied for the control group selection.27
During clinical examination, stimulated salivary flow rate
was estimated using a 0.02-mm thick piece of plastic paraffin
film (Parafilm M; Bemis Co Inc). The participant was
instructed to masticate the piece for 5 minutes, expectorating
the produced saliva into a preweighed container. Salivary
flow rate (g/min) was then calculated by subtracting the
initial weight from the final weight of the container.28
After receiving general dental treatment,25 all partic-
ipants underwent baseline assessment of OHRQoL and
masticatory efficiency. New CDs and/or RPDs were then
processed and delivered. After a 2-month adaptation
period, OHRQoL and masticatory efficiency were
reassessed.
Patient-based assessment of OHRQoL was evaluated
using the validated Portuguese-language version of
GOHAI.29 A single examiner (C.H.C.) asked the partici-
pants about 12 GOHAI items in reference to the previous
3 months. They were asked to respond using a 3-point
scoring scale (always, sometimes, or never). The final
GOHAI score was calculated as previously described by
Atchison and Dolan.30 The GOHAI score could range
between 12 and 36 and was classified as high if the scores
ranged between 34 and 36, moderate if between 31 and
33, and low if less than 30. Participants presenting high
GOHAI scores indicated that they had a positive
perception of their oral health, and those with lower
GOHAI scores had more self-reported oral health
problems and were expected to have poorer oral health
conditions.30 To improve the reliability of self-reporting,
active listening and slow speech were used while
applying the questionnaire to the elders with AD.31,32
Masticatory efficiency was evaluated using an artificial
test material composed of 5.6×5.6×5.6 mm Optocal33
cubes. Portions containing 17 cubes of Optocal (3.7 g in
weight) were given to each participant, who masticated
them for 40 cycles; they were monitored by a single
calibrated operator (C.H.C.). The comminuted particles
were collected in a paper filter, dried for 1 week at room
Campos et al
- 2017 3

Table 1. Two-way ANOVA for GOHAI and masticatory efficiency among Table 2. Masticatory efficiency (mean ±SD) of AD and control groups
groups and before and after prosthetic treatment before and after prosthetic treatment
Sum of Mean AD (n=16) Control (n=16)
Source Squares df Squares F P
Characteristic Before PT After PT Before PT After PT
ME
ME (%) 3.13 ±6.62Aa 9.54 ±13.41Ab 15.12 ±9.90Ba 25.85 ±16.28Bb
Groups 10.11 1 10.11 7.69 .007
GOHAI 34.56 ±2.00Aa 35.58 ±0.61Ab 30.56 ±4.49Ba 34.69 ±1.49Bb
Prosthetic treatment 1.67 1 1.67 46.63 <.001
AD, Alzheimer disease; GOHAI, Geriatric Oral Health Assessment Index; ME, masticatory
Group×Prosthetic <.001 efficiency; PT, prosthetic treatment. Different superscript uppercase letters represent
treatment interaction differences between groups (P<.05). Different superscript lowercase letters represent
GOHAI intragroup differences (P<.05).
Groups 97.52 1 97.52 13.60 <.001
Prosthetic treatment 112.89 1 112.89 15.75 <.001
Group×Prosthetic <.001 Table 3. AD and control groups in each GOHAI category before and after
treatment interaction prosthetic treatment
ME, masticatory efficiency; GOHAI, Geriatric Oral Health Assessment Index. AD (n=16), Controls (n=16),
n (%) n (%)
GOHAI Category Before PT After PT Before PT After PT
temperature, and vibrated in a sieving machine (elec-
High 13 (81.25) 16 (100) 5 (31.25) 12 (75.00)
tromagnetic vibrator; Bertel Indústria Metalúrgica Ltd) Moderate 1 (6.25) 0 5 (31.25) 4 (25.00)
through a stack of 10 sieves with mesh varying between Low 2 (12.50) 0 6 (37.50) 0
0.5 and 5.6 mm.34 Materials retained on the sieves were
AD, Alzheimer disease; GOHAI, Geriatric Oral Health Assessment Index; PT, prosthetic
weighed on a 0.001-g analytic balance (Mark, BEL En- treatment.
gineering), and the masticatory efficiency was calculated
as the percentage weight of the comminuted material
that passed through the 2.8-mm sieve.34 is presented in Table 1. GOHAI and masticatory effi-
After baseline evaluations, all participants received ciency were significantly influenced (P<.05) by the 2
new CDs or RPDs for both maxillary and mandibular times (before and after prosthetic insertion) and by group
arches. These were fabricated by a single experienced (AD and controls) factors.
dental technician with heat-polymerized acrylic resin Masticatory efficiency was impaired in patients with
(Vipi Cril Flash; Dental Vipi) and by following conven- AD compared with the control group both before and
tional techniques.35 As in the prior study,36 RPD frame- after prosthetic treatment (P<.05). Both groups benefited
works were composed of cobalt-chromium alloy from treatment, which increased the masticatory effi-
(Dentorium) and were designed to accommodate the ciency values (P<.05) (Table 2).
anatomy of the supporting tissues and remaining teeth. After rehabilitation with new removable prostheses,
They consisted of a major bar, rests, and clasp retainers. both the AD and control groups presented higher
Both maxillary and mandibular prostheses were delivered GOHAI values, demonstrating improvement in OHR-
and adjusted for a bilateral balanced occlusal scheme. QoL (P<.05) (Table 2). However, comparisons between
After 2 months of using the new prostheses, OHRQoL groups showed that GOHAI values were significantly
and masticatory efficiency were reevaluated. higher for the AD group than for the control group in
The data were evaluated by statistical software (SAS both analyzed times (P<.05), showing less impact of oral
v9.3; SAS Institute Inc) (a=.05). Shapiro-Wilk tests for health on quality of life of patients with AD (Table 2).
each group at baseline and after insertion of the remov- Table 3 shows the distribution of patients in GOHAI
able prostheses revealed normal distributions for salivary categories (high, moderate, and low) before and after
flow rate and GOHAI. A nonparametric distribution was prosthetic treatment. After prosthetic treatment, neither
detected for masticatory efficiency, which underwent a group presented patients in the low GOHAI category,
logarithmic transformation. Data on masticatory efficiency and the number of patients in the high GOHAI category
and GOHAI were submitted to a 2-way ANOVA and the increased, showing improvement in OHRQoL. The
Tukey Studentized range post hoc test, considering time Fisher test revealed P=.02 before prosthetic treatment
(before and after prosthetic insertion) and group (AD and and P=.05 after prosthetic treatment.
controls) as factors. The Fisher test was applied to analyze
the GOHAI category difference between groups. DISCUSSION
This clinical study showed that individuals with AD had
RESULTS
reduced masticatory efficiency and less improvement in
The salivary flow rate was lower (P<.05) in the AD group OHRQoL compared with controls, rejecting the null
(0.73 ±0.52) than in the control group (1.19 ±0.65). The hypothesis. Oral rehabilitation with removable prosthe-
2-way ANOVA for GOHAI and masticatory efficiency ses improved mastication and OHRQoL in both groups.
among groups and before and after prosthetic treatment However, mastication remained impaired for participants

Campos et al THE JOURNAL OF PROSTHETIC DENTISTRY

4 Volume
with AD even after prosthetic treatment, suggesting that
AD was responsible for the masticatory impairment
rather than the prosthesis insertion.
Salivary flow rate was lower in the AD group than in
the control group. These data confirm previous find-
ings16,17,19 and indicate an increased risk of caries,
mucosal inflammation, and reduced food bolus lubrica-
tion in those with the disease.13 Submandibular gland
function is impaired in those with AD.13,15 In addition,
many of the medications taken by elders with AD have
anticholinergic effects that result in reduced salivary
flow.15 Although no consensus has been reached in the
literature regarding the influence of salivary flow rate in
mastication,14 it may be an additional factor in the
impaired mastication of those with AD.
Although the dental condition between the AD and
control groups was matched, masticatory efficiency was
significantly lower in patients with mild AD before and
after insertion of the new prostheses. Data from the
controls were consistent with those from a previous study
involving elderly individuals.34 On the basis of the lower
number of teeth present in cognitively impaired elders,
previous reports9,10 have estimated that this group have
worse masticatory function compared with controls.
Although a study19 has verified reduced masticatory
efficiency in elderly individuals with other types of
dementia by comparing controls with balanced oral
characteristics, the authors are unaware of a prior study
on elderly individuals with AD using matched groups.
The masticatory efficiency results suggest that masti-
catory function is not only related to the presence of
natural teeth but also depends on sensory feedback and
motor coordination among the masticatory muscles, lips,
cheeks, and tongue.18,19 As dementia, even in an early
stage, is associated with impaired motor skill,1 this un-
derlying pathology might directly contribute to the lower
masticatory efficiency observed in the present study.
In addition, some studies3,4 have found reduced ce-
rebral blood flow in individuals with impaired mastica-
tion, making mastication a risk factor for developing
dementia.5 However, AD affects brain regions related to
mastication,3 which could negatively affect this function.
Thus, dementia impairs mastication and motor skills, and
lack of mastication accelerates dementia by reducing
cerebral blood flow and brain activity.8
Regarding the subjective assessments, differences
were observed between the AD and control elders in the
GOHAI values before oral rehabilitation. The GOHAI
values were considered high for the AD group and
moderate for the control group. Although there are few
reports on subjective assessments of individuals with AD,
the results of the present study agree with those found by
Warren et al,23 which demonstrated that participants
with AD reported better self-perceived oral health than
THE JOURNAL OF PROSTHETIC DENTISTRY
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controls. However, Ribeiro et al2 found no difference
between AD and control groups. These contrasting re-
sults may be elucidated by the severity level of AD in our
participants. Unlike our study, which evaluated only
elderly individuals with mild AD, the latter study2
assessed elderly individuals at different levels of AD.
Nevertheless, Lee et al21 found lower GOHAI values for
the AD group than for the control group; however, their
patients with AD had fewer teeth and more oral health
problems than their controls. Because our study groups
had similar oral characteristics, this may explain the
difference.
In general, our findings showed that new and better-
fitted removable prostheses had positive effects on
OHRQoL for both AD and controls. Although we are
unaware of previous research on oral rehabilitation in
elderly patients with AD, Rolim et al24 found improve-
ment in OHRQoL after providing general dental treat-
ment for elders with AD.
The gains in masticatory efficiency and OHRQoL
emphasize the importance of dental treatment and
prosthetic rehabilitation in elders with AD. Because AD is
still a disease with no cure, efforts should be made to
maintain or improve the quality of life of the affected
individuals. In addition, although patients with AD are
thought to require special attention by dental pro-
fessionals, we found no difficulties in treating patients
with mild AD. Furthermore, adaptation to the new
dentures was similar for both AD and control partici-
pants. Thus, dentists and researchers should be encour-
aged to attend to this group of special-needs patients.
CONCLUSIONS
On the basis of the findings from this clinical study, the
following conclusions were drawn:
1. Oral rehabilitation with new removable dental
prostheses improves the OHRQoL and masticatory
efficiency of elders with and without AD.
2. However, masticatory efficiency in elders with AD
remained below control levels.
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Corresponding author:
Dr Renata Cunha Matheus Rodrigues Garcia
Department of Prosthodontics and Periodontology
Piracicaba Dental School (UNICAMP)
University of Campinas
Avenida Limeira, 901
Piracicaba, São Paulo, 13414-903
BRAZIL
Email: regarcia@fop.unicamp.br
Copyright © 2017 by the Editorial Council for The Journal of Prosthetic Dentistry.
THE JOURNAL OF PROSTHETIC DENTISTRY