Teeth and malnutrition

Oral and dental alterations increase the risk of protein-energy malnutrition

Several studies have demonstrated that elderly hospital inpatients and vulnerable communities have generally a low chewing capacity, significant needs for dentures and oral healthcare, and an insufficient access to oral health care



Poor oral health conditions represent an aggravating factor significantly linked to the risk of undernutrition.

In practice, doctors from the institutions for dependants elderly people prescribe enriched food (spontaneous oral feeding), "enriched" food elements (common food) and/or nutritional supplements for undernourished people.

The choice of food takes into account the poor oral health conditions of the target populations: normal, mixed or soft texture (8).

When a malnourished person needs enriched food, dishes can be enriched in proteins and in energy with eggs, some cream, some grated cheese, some powdered milk or some milk proteins (a nutritional supplement) (9). But certain persons do not appreciate the taste of milk given to food, and these home-made enriched dishes generally have a soft texture (soups, quiches, cheese-topped dishes, sweets, etc.). It is true also for the oral nutritional supplements (ONSs), which are often dairy creams or drinks (10,11). But the elderly often complain about an exclusively soft or mixed food, which constitutes an additional source of anorexia and malnutrition (12-15).

According to a clinical trial (16):

  • 50% of the elderly patients who have a normal diet do not eat the recommended dietary allowance.
    100 % of patients who have to have a soft or mixed diet do not eat the recommended dietary allowance.
  • 40% of the elderly patients who have a normal diet do not eat the recommended protein intake
    93% of patients who have to have a soft or mixed diet do not eat the recommended protein intake.


Another study carried out on 51 patients hospitalized in the geriatricward in Nice University Hospital showed that (17):


  • 23 % of the patients refused to consume high protein ONSs in the form of drinks or of creams,
  • 8 % did not take them systematically and
  • 24 % did not finish them. The main causes of refusal were the milky or too much sweetened taste, the liquid texture or the effect of ballast which got away the appetite from the following meal (17).


As the preservation of the nutritional state is directly bound to the masticatory ability (18,19), Protibis cookies constitute a solid nutritional supplement conceived for the persons having a bad oral state (20-23).

Protibis cookies have an innovative a three-level texture (crunched, dipped or soften). They can be even crunched by the persons having a bad oral state: they break easily between the toothless jaws. In case of fatigue of masticatory muscles or oral dryness, Protibis cookies can be dipped into a warm or cold drink without splitting too quickly. For the persons having swallowing disorders, they can be crumbled and softened in a drink.



Several clinical studies have been realized with Protibis cookies at the hospital and in nursing homes. These studies showed that Protibis cookies pleased most of the malnourished elderly, including those who had a poor dental state.


1. Anonyme. Numéro thématique. Surveillance nutritionnelle des populations défavorisées : premiers résultats. Bulletin Epidémiologique Hebdomadaire 2006 ;11-12 :77-84.

2. Dormenval V, Budtz-Jorgensen E, Mojon P et al. Nutrition, general health status and oral health status in hospitalised olders. Gerodontology 1995;12:73-80.

3. Dion N, Cotart JL, Rabilloud M. Correction of nutrition test errors for more accurate quantification of the link between dental health and malnutrition. Nutrition 2007;23:301-307.

4. Zini A, Sgan-Cohen HD. The effect of oral health on quality of life in an underprivileged homebound and non-homebound elderly population in Jerusalem. J Am Geriatr Soc 2008;56:99-104.

5. Shenkin JD, Baum BJ. Oral health and the role of the geriatrician. J Am Geriatr Soc 2001;49:229-230.

6. Ship JA. Improving oral health in older people. J Am Geriatr Soc 2002;50:1454-1455.

7. Ship JA, Pillemer SR, Baum BJ. Xerostomia and the geriatric patient. J Am Geriatr Soc 2002;50:535-543.

8. Haute Autorité de Santé. Recommandations professionnelles. Stratégie de prise en charge en cas de dénutrition protéino-énergétique chez la personne âgée. Avril 2007.

9. Haute Autorité de Santé. Ministère de la santé et des solidarités. Deuxième programme national nutrition santé 2006-2010. Actions et mesures. Septembre 2006.

10. Volkert D, Berner YN, Beery E, Cederholm T, Coti Bertrand P, Milne A et al. ESPEN guidelines on enteral nutrition: geriatrics. Clin Nutr 2006;25:330-60.

11. Bernstein MA, Tucker KL, Ryan ND, O’Neill EF, Clements KM, Nelon ME et al. Higher dietary variety is associated with better nutritional status in frail elderly people. J Am Diet Assoc 2002;102:1096-104.

12. Donini LM, Dominguez LJ, Barbagallo EM, Sarina C, Castellaneta E, Cucinotta D et al. Senile anorexia in different geriatric settings in Italy. J Nutr Health Aging 2011;15:775-81.

13. Morley JE. Anorexia and weight loss in older persons. J Gerontol A Biol Sci Med Med Sci 2003;58,131-7.

14. Bartali B, Salvini S, Turrini A, Lauretani F, Rosso CR, Corsi AM et al. Age and disability affect dietary intake. J Nutr 2003;133:2868-73.

15. Murphy C. Nutrition and sensory perception in the elderly. Crit Rev Food Sci Nutri 1993;33:3-15.

16. Wright L, Cotter D, Hickson M et al. Comparison of energy and protein intakes of older people consuming a texture modified diet with a normal hospital diet. J Hum Nutr Dietet 2005, 18:213-219.

17. Grégoire J. Prise en charge de la dénutrition en milieu hospitalier : de la théorie à la pratique. Mémoire diététique. Département génie biologique, IUT Montpellier. Avril 2008.

18. Suzuki K, Nomura T, Sakurai M, Sugikara N, Yamanaki S, Mastuskubo T. Relationship between number of present teeth and nutritional intake in institutionalized elderly. Bull Tokyo Dent Coll 2019

19. Cousson PY, Bessadet M, Nicolas E, Veyrune JL, Lesourd B, Lassauzay C. Nutritional status, dietary intake and oral quality of life in elderly complete denture wearers. Gerodontology 2012;29:e685-92.

20. Prêcheur I, Brocker P, Schneider S. Development of hyperproteic and hyperenergetic cookies: a solid nutritional supplement for patients with masticatory disabilities. European Society for Clinical Nutrition and Metabolism ESPEN2010-LB-014 2010, Nice France.

21. Prêcheur I, Brocker P, Schneider SM, Barthélémi C, Pesci-Bardon C. Compléments nutritionnels solides pour les personnes ayant des difficultés à mastiquer : enquête de satisfaction sur 30 seniors hospitalisés. Congrès International Francophone de Gériatrie et Gérontologie (CIFGG), P3.3-107, Nice 2010.

22. Solere JP, Brocker P, Schneider SM, Prêcheur I, Reichert E, Breugnon F et al. Distribution de galettes hyperprotidiques hyperénergétiques. Etude multicentrique auprès de seniors dénutris institutionnalisés : résultats intermédiaires sur 63 sujets. Journées Annuelles Francophones de la Société Française de Gériatrie et Gérontologie (JASFGG), P4-12.52, Paris 2011.

23. Philip JL. Lutter contre la dénutrition des malades d’Alzheimer, un exemple. Revue Geriatr 2012 ;37 :141-2.