The Relationship of Dysphagia and Malnutrition to Tooth Loss in the Elderly

Abstract

Objective Malnutrition is a critical health concern for the elderly. It frequently results from impaired oral function due to tooth loss, obstructing eating and swallowing. Dysphagia and malnutrition can diminish the quality of life. Screening instruments, such as the modified water swallow test (MWST) and Eating Assessment Tool (EAT-10-ID), facilitate the early detection of dysphagia. These instruments are precise and assist in identifying dysphagia, facilitating prompt intervention. Timely identification and intervention for dysphagia and malnutrition can reduce morbidity, length of hospital stays, and health care expenditures in geriatric patients. This article examines the relationship between the dysphagia and nutritional status, as well as its association with tooth loss in the elderly in Indonesia.

Materials and Methods This study used a cross-sectional design. The participants in this study were individuals 60 years and above --a total of 130 participants who fulfilled the inclusion criteria engaged in the study. Patients were measured for the number of remaining teeth and the condition of denture use, followed by an evaluation of their nutritional health by filling out the Mini Nutritional Assessment form, and swallowing assessment was performed using two methods, objectively and subjectively. The objective method is by the MWST. Subsequently, the participant's subjective dysphagia was evaluated using the EAT-10-ID questionnaire, which is a 10-item screening instrument for assessing dysphagia risk.

Results Multivariate analysis indicated a strong association between dysphagia, education, and malnutrition. Individuals with objective dysphagia possess a four times greater risk of malnutrition relative to those without dysphagia.

Conclusion Individuals with dysphagia exhibited a fourfold increased risk of malnutrition compared with those without dysphagia. Besides dysphagia, educational attainment was also related with nutritional health. Individuals with an education level of elementary school or higher exhibited a lower risk of malnutrition than those with a primary school education or less. This study indicated that patients with  < 20 teeth who wore dentures exhibited a decreased percentage of dysphagia compared with those with  < 20. Consequently, the diagnosis of dysphagia may be conducted with the EAT-10-ID or by subjective assessment.

Keywords

malnutrition - dysphagia - tooth loss

Introduction

The aging process typically results in heightened vulnerability to disease.[1] Oral frailty, characterized by diminished oral function, presents as reduced articulation, mild choking or spillage during eating, and increased food that cannot be chewed. This is not a sickness but a condition.[2] One cause of diminished oral function is tooth loss, a prevalent dental and oral health issue that can disrupt speech, aesthetics, mastication, and deglutition. Dysphagia is characterized by the conscious perception of an impediment in food movement from the oropharynx to the stomach, perhaps signifying a delay in bolus transit or only its sensation. Dysphagia, a swallowing disorder, and malnutrition can lead to diminished quality of life and increase the risk of comorbidities and mortality.[3] [4] Additionally, age-related alterations in motor or sensory function and oral muscle strength are believed to impact swallowing ability and nutritional health.[5]

A study indicated that a reduced number of teeth correlated with increased carbohydrate consumption, diminished intake of vegetables, vitamin A, and vitamin C, and elevated energy intake.[6] Hildebrandt et al research conducted at the University of Michigan indicates that the elderly consume less food, including meat, vegetables, and fruits, that necessitate chewing ability. Individuals with diminished chewing capacity are inclined to eschew foods that are challenging to chew, such as meat.[7] A study by Furuta et al in Japan has demonstrated a relationship between oral health and various health outcomes, including cardiovascular disease, aspiration pneumonia, and malnutrition. Tooth loss is believed to indirectly elevate death rates through malnutrition, related to inadequate chewing and suboptimal food and dietary selections. In Japan, approximately 6.2 million elderly individuals received long-term care under the Long-Term Care Insurance System in 2015.[8] In Indonesia, the health insurance system has been developed to ensure more equitable access to services for the entire community. However, there are still several challenges faced, such as limited access to health services, which are still not evenly distributed throughout Indonesia, especially in remote and rural areas, in addition, the quality of health services is still not satisfactory, especially in terms of the ability to detect and respond to health emergencies. Limited human resources and limited health facilities and equipment are still major problems. Therefore, it is necessary to monitor and carry out early detection carefully in the elderly who have dysphagia and nutritional status problems so that preventive measures can be taken before the health condition of the elderly worsens so that it can reduce medical costs and allow for more effective and efficient treatment and reduce disease complications that can increase medical costs and improve quality of life by reducing disease symptoms and prolonging life.

Numerous screening instruments exist to identify and assist in diagnosing dysphagia and malnutrition. The modified water swallowing test (MWST) is a noninvasive technique employed to identify dysphagia. The instrument exhibits a sensitivity of 70% and a specificity of 88% for predicting aspiration, a significant consequence of dysphagia.[2] [3] [9] Furthermore, Eating Assessment Tool (EAT-10) is a practical, valid, and reliable tool and can be used by all medical personnel to identify elderly people who are at risk of dysphagia. This measuring tool consists of 10 items that have been validated and assessed for their reliability in detecting oropharyngeal and esophageal dysphagia. This tool has been developed by Belafsky et al in 2008, consisting of 20 items, which were then converted into 10 items.[10] The EAT-10-ID measuring tool has been developed and adapted into Indonesian by Dias et al, rendering it unavailable for medical personnel in Indonesia as a valid and reliable assessment instrument. The dysphagia risk assessment utilized a 10-item screening tool.[11] An EAT-10 score of ≥ 3 indicates potential swallowing issues. However, the inquiry and response procedure about dysphagia and nutritional symptoms necessitates time and the operator's proficiency in patient communication. The availability of a screening instrument for dysphagia and nutritional assessment can assist health care professionals in doing subjective evaluations. These screening instruments can assist in diagnosing and identifying signs and symptoms of dysphagia.[11]

Materials and Methods

This study employs a cross-sectional design. Participants who fulfill the inclusion criteria and are not subject to the exclusion criteria will be utilized as study subjects. The research volunteers will undergo anamnesis, clinical status assessment, and an interview to complete the questionnaire. Subjects were selected successively from the elderly population inside the Kenari neighborhood in DKI Jakarta and the Faculty of Dentistry at the University of Indonesia Dental Hospital from May to July 2024. One hundred thirty people consented to participate in this investigation. All tests and questionnaire completions have been conducted on the study individuals. The subjects' ages ranged from 60 to 80 years, with a mean age of 67.5. There were 34 male participants and 96 females. The study commenced following approval from the Research Ethics Committee of the Faculty of Dentistry at Universitas Indonesia.

Participants received an explanation of the research methodology and objectives, after which those who consented were requested to sign an informed consent form. The subject is to provide information including date, name, gender, date of birth, education, occupation, address, and telephone number. An intraoral examination is performed to assess the quantity of residual tooth structure. Swallowing assessment will be performed using two methods, objectively and subjectively. The MWST was used to assess swallowing function objectively, wherein individuals are told to ingest. It possesses a sensitivity of 70% and a specificity of 88% in predicting aspiration, a significant consequence of dysphagia. Three milliliters of water were administered into the bottom of the mouth using a 5-mL syringe, after which the participant was told to swallow. Their swallowing was assessed as follows: score 1 indicates an inability to swallow accompanied by choking and alterations in breathing, score 2 denotes swallowing with breathing changes, score 3 signifies swallowing without breathing changes but with choking or wet hoarseness, score 4 reflects successful swallowing without choking or wet hoarseness, and score 5, in addition to fulfilling the criteria of score 4, involves more than two instances of deglutition within 30 seconds.[9] If the score was 4 or higher, the test was administered twice, and the lower score was recorded as the final test score. Subsequently, the subject was asked to complete the EAT-10-ID questionnaire, which is a practical, valid, and reliable instrument that all medical professionals can utilize to identify elderly individuals at risk of dysphagia. This measurement instrument comprises 10 items verified and evaluated for their reliability in identifying dysphagia. This tool is straightforward and can furnish information on the function, emotional repercussions, and physical manifestations associated with dysphagia in individuals. Each of the 10 elements is evaluated using a 5-point scale ranging from 0 to 4. Individuals scoring above 3 are presumed to be at risk for dysphagia. The EAT-10 measuring instrument has been developed and adapted into Indonesian by Dias et al, rendering it unavailable as a valid and reliable instrument by medical personnel in Indonesia.[11] Subsequently, subjects are requested to complete the Mini Nutritional Assessment (MNA) form, followed by an interview conducted by the MNA to ascertain the nutritional status of the subjects.

Results

A total of 130 participants consented to take part in this study. The subjects' age range was 60 to 80 years, with a mean age of 67.5. There were 34 male participants and 96 females. Nutritional status is classified into three categories: standard, at risk of malnutrition, and malnutrition. The frequency distribution of the relationship between nutritional status, as assessed by the MNA questionnaire, revealed that 78 participants in this study exhibited unsatisfactory MNA-ID scores. The chi-square analysis indicated a strong relationship between the nutritional state of respondents, as assessed by the MNA-ID questionnaire, and both dysphagia and the subjects' educational attainment.

The chi-square bivariate analysis results indicated a significant relationship between education, objective dysphagia, subjective dysphagia factors, and nutritional status. [Table 1] indicates that objective dysphagia is associated with a greater malnutrition rate of 82.4%, whereas the malnutrition rate in participants without dysphagia is 52.1%, with a significant difference between the two groups. The odds ratio of 4.38 indicated that individuals with objective dysphagia faced a 4.29-fold increased risk of malnutrition compared with those without dysphagia. The prevalence of malnutrition in those with subjective dysphagia was 78.8%, compared with 52.1% in those without subjective dysphagia, indicating a significant difference. The odds ratio of 3.21 implies that individuals with subjective dysphagia possess a 3.21-fold increased risk of malnutrition relative to those without dysphagia.

Table 1 Dysphagia and other factors with nutritional status

Variable	Category	Normal		Malnutrition		Total	p-Value	OR	95% CI
		N	%	N	%				Lower	Upper
Independent variable
Dysphagia objective	No	46	47.9	50	52.1	96	0.002*	Ref
	Yes	6	17.6	28	82.4	34		4.29	1.63	11.31
Dysphagia subjective	Score < 3 (no risk dysphagia)	45	46.4	52	53.6	97	0.011*	Ref
	Score ≥ 3 (risk dysphagia)	7	21.2	26	78.8	33		3.21	1.27	8.11
Gender	Male	18	52.9	16	47.1	34	0.073**	Ref
	Female	34	35.4	62	64.6	96		2.05	0.93	4.53
Age	< 70 y	33	38.4	53	61.6	86	0.596	Ref
	≥ 70 y	19	43.2	25	56.8	44		0.82	0.39	1.71
Per capita expenditure	Quintile 1 (up to Rp. 666,667)	12	35.3	22	64.7	34	0.909	Ref
	Quintile 2 (Rp. 666,668–750,000)	16	40.0	24	60.0	40		0.82	0.32	2.11
	Quintile 3 (Rp. 750,001–900,000)	3	37.5	5	62.5	8		0.91	0.18	4.48
	Quintile 4 (Rp. 950,001–1,500,000)	13	40.6	19	59.4	32		0.80	0.29	2.16
	Quintile 5 (above Rp. 1,500,000)	8	50.0	8	50.0	16		0.55	0.16	1.82
Education	> Primary school	34	49.3	35	50.7	69	0.022*	Ref
	≤ Primary school	18	29.5	43	70.5	61		2.32	1.12	4.79
Systemic disease	No	24	38.1	39	61.9	63	0.667	Ref
	Yes	28	41.8	39	58.2	67		0.86	0.42	1.73
Missing teeth and denture use	≥ 20 teeth	17	38.6	27	61.4	44	0.692	Ref
	< 20 teeth with denture	14	46.7	16	53.3	30		0.72	0.28	1.84
	< 20 teeth without denture	21	37.5	35	62.5	56		1.05	0.47	2.37

Abbreviations: CI, confidence interval; OR, odds ratio.

*p<0.05; **p<0.25.

The receiver operating characteristics (ROC) analysis, Hosmer and Lemeshow goodness of fit, and R ² analysis demonstrate the model's performance. The ROC illustrates the model's capacity to discriminate between malnourished and normal conditions. The final model had a ROC of 0.676 (95% confidence interval [CI] 0.582–0.770). The ROC was 0.676, indicating satisfactory performance. The Hosmer and Lemeshow goodness of fit p-value of 0.605 is insignificant, indicating that the predicted results for malnutrition do not differ significantly from the observed ones, thereby confirming the model's adequacy. Analysis utilizing chi-square indicates that the dysphagia status of the subject assessed by the MWST method does not exhibit a significant link with tooth loss or other variables.

The three independent variables from the bivariate analysis—objective dysphagia, gender, and education—were incorporated into a multiple logistic regression model. [Table 2] presents a comprehensive model illustrating the relationship between objective dysphagia, gender, education, and nutritional status. The significance threshold in multivariate analysis is p < 0.05 or p < 0.1. The table indicates that the relevant factors are objective dysphagia (p < 0.05) and education (p < 0.1). Gender is not statistically significant (p = 0.126). The gender variable was eliminated, and the remaining results are presented in [Table 2].

Table 2 Relationship between dysphagia objective and education with nutritional status

Variable	Category	Coefficient regression (B)	Standard error B (SEB)	p-Value	OR	95% CI OR
						Lower	Upper
Dysphagia objective	No	1,476	0.502	0.003[a]	Ref
	Yes				4.38	1.63	11.71
Education	> Primary school	0.864	0.384	0.025[a]	Ref
	≤ Primary schoollol				2.37	1.12	5.04
Constants		−0.308	0.270

Abbreviations: CI, confidence interval; OR, odds ratio.

^a p < 0.05.

The concluding model in [Table 3] can be read as follows. An odds ratio of 3.44 with a CI of 1.34 to 8.86 signifies that individuals experiencing subjective dysphagia possess a 3.44-fold increased risk of malnutrition relative to those without dysphagia. The 95% CI indicates that if the study were repeated 100 times, the odds ratio would range from 1.34 to 8.86. The education variable shows an odds ratio of 2.48 with a CI of 1.17 to 5.23, indicating that individuals with elementary school education or less have a 2.48 times higher risk of malnutrition than those with education beyond elementary school. The 95% CI indicates that if the study were repeated 100 times, the odds ratio would range from 1.17 to 5.23.

Table 3 Relationship between dysphagia subjective and education with nutritional status

Variable	Category	Coefficient regression (B)	Standard error B (SEB)	p-Value	OR	95% CI OR
						Lower	Upper
Dysphagia subjective	No				Ref
	Yes	1.236	0.483	0.010*	3.44	1.34	8.86
Education	> Primary school				Ref
	≤ Primary schoollol	0.907	0.382	0.018*	2.48	1.17	5.23
Constants		−0.277	0.272

Abbreviations: CI, confidence interval; OR, odds ratio.

*p<0.05; p-Value Hosmer and Lemeshow goodness of fit = 0.605; Adjusted Nagelkerke R Square = 0.126.

According to [Table 4], the frequency distribution of objective dysphagia, as assessed by the MWST, indicates that 96 patients were classified as usual, while 34 subjects exhibited dysphagia. The chi-square analysis indicated that the dysphagia status of the individuals, assessed via the MWST method, did not exhibit a significant relationship with tooth loss or other variables. The chi-square bivariate analysis results indicated that 10 male subjects and 24 female subjects experienced dysphagia, predominantly among individuals with an education level below elementary school, and most had > 20 remaining teeth. Nonetheless, the statistical data did not demonstrate a significant relationship.

Table 4 Relationship between other factors with objective dysphagia

Variable	Category	Normal (n = 96)		Dysphagia (n = 34)		Total	p-Value	OR	95% CI
		N	%	N	%				Lower	Upper
Gender	Male	24	70.6	10	29.4	34	0.615	Ref
	Female	72	75.0	24	25.0	96		0.80	0.34	1.91
Age	< 70 y	67	77.9	19	22.1	86	0.141	Ref
	≥ 70 y	29	65.9	15	34.1	44		1.82	0.82	4.08
Per capita expenditure	Quintile 1 (up to Rp. 666,667)	30	88.2	4	11.8	34	0.118	Ref
	Quintile 2 (Rp. 666,668–750,000)	25	62.5	15	37.5	40		4.50	1.32	15.30
	Quintile 3 (Rp. 750,001–900,000)	5	62.5	3	37.5	8		4.50	0.77	26.45
	Quintile 4 (Rp. 950,001–1,500,000)	23	71.9	9	28.1	32		2.93	0.80	10.74
	Quintile 5 (above Rp. 1,500,000)	13	81.3	3	18.8	16		1.73	0.34	8.85
Education	> Primary school	52	75.4	17	24.6	69	0.676	Ref
	≤ Primary school	44	72.1	17	27.9	61		1.18	0.54	2.59
Systemic disease	No	47	74.6	16	25.4	63	0.849	Ref
	Yes	49	73.1	18	26.9	67		1.08	0.49	2.36
Missing teeth and denture use	≥ 20 tooth	35	79.5	9	20.5	44	0.091	Ref
	< 20 tooth with denture	25	83.3	5	16.7	30		0.78	0.23	2.60
	< 20 tooth without denture	36	64.3	20	35.7	56		2.16	0.87	5.39

Abbreviations: CI, confidence interval; OR, odds ratio.

[Table 5] examines the relationship between the objective dysphagia test and the subjective dysphagia test, utilizing chi-square statistics. These statistics indicate that the subjective dysphagia variable exhibits strong sensitivity and specificity, recorded at 85.3 and 95.8%, respectively. The ROC score of 0.906 indicates that the subjective dysphagia test effectively differentiates between objective and nonobjective dysphagia. The kappa value is 81.9%, indicating substantial agreement. Consequently, the risk of dysphagia may utilize either EAT-10-ID (subjective assessment) or MWST (objective assessment).

Table 5 Diagnostic test between dysphagia from subjective measurement with dysphagia from objective measurement

Variables	Category	Dysphagia objective		Total	p-Value	Sensitivity	Specificity	ROC	Kappa
		No	Yes
Dysphagia subjective	No	92	5	97	0.000	85.3%	95.8%	0.906	81.9%
	Yes	4	29	33
Total		96	34	130

Abbreviation: ROC, receiver operating characteristics.

Discussion

Swallowing difficulties are strongly associated with malnutrition. Swallowing difficulties hinder the elderly's capacity to ingest adequate food to fulfill their nutritional requirements. This study demonstrates that dysphagia results in a decline in nutritional status among the elderly. The findings of this study align with those of a study by Poisson et al in France, which indicated that older adults with persistent dysphagia suffer from malnutrition. Food consumption is affected by oral health conditions, which pertain to the capacity to chew and swallow. Individuals with dysphagia often select foods that are easier to swallow, a behavior that can lead to nutritional deficiencies and perhaps result in malnutrition.[12] Moreover, their total nutritional consumption was diminished, as seen by their sluggish swallowing and the necessity for assistance when eating. Chewing has multiple purposes, including fragmenting big food particles into smaller bits and moistening and softening food particles into a bolus. Chewing difficulties might result in diminished food absorption and, hence, malnutrition. Nonetheless, this study found no significant relationship between oral health status and malnutrition. This study demonstrated a direct relationship between nutritional status and swallowing difficulties, with no direct relationship to dental health status. The findings of this study align with those presented by Furuta et al, who investigated the relationship between oral health status, swallowing ability, and nutritional status. Their research indicated a strong association between nutritional status and swallowing function, but not with oral health status, among elderly patients in Japan.[3] [13]

Specific literature indicates that poor oral health resulting from tooth loss diminishes masticatory function, which precedes deglutition. In older patients susceptible to malnutrition, the quantity of premolar–molar occlusion pairs is a reliable indicator of mastication proficiency.[14] A study indicated that patients with less than seven pairs of posterior contacts had an elevated risk of dysphagia. The lack of posterior teeth during mastication impedes the creation of a uniform bolus, complicating the swallowing process due to forming a less cohesive mass. In weak senior individuals, this fragmented bolus disrupts swallowing, posing a danger of food aspiration. The relationship between the lack of posterior teeth and diminished tongue strength in the elderly may result in impaired bolus retention in the posterior oral cavity, causing food particles to descend prematurely into the throat. Dion et al indicated that the loss of two molars related with a 1.15-fold increased risk of malnutrition. Inadequate mastication may alter dietary selections and diminish the enjoyment of consumption. This study found no relationship between the absence of posterior teeth and the nutritional status of dependent elderly individuals.[12]

Fukai et al investigated the relationship among the number of functional teeth (teeth possessing sufficient chewing capability), denture utilization, and self-reported swallowing difficulties in 5,643 individuals aged 40 to 89.[15] Subjective swallowing difficulties were defined as any perceived impairment in eating function, including challenges in biting, swallowing issues attributable to missing teeth, lack of dentures, or other oral conditions. They determined that a reduced number of teeth or the absence of denture use may lead to perceived swallowing difficulties and proposed that denture use would help mitigate such issues. This study revealed that among subjects with > 20 remaining teeth, 20.5% (9 individuals) experienced dysphagia. In contrast, among those with < 20 teeth who used dentures, 16.7% (5 individuals) reported dysphagia, while the group with < 20 teeth without dentures exhibited a dysphagia rate of 35.7% (20 individuals). Although these differences were not statistically significant, the findings suggest that elderly patients utilizing dentures have a reduced risk of swallowing disorders compared with those who have lost teeth and do not use dentures.[15]

The relationship between tooth loss and nutritional status remains contentious despite certain studies indicating a relationship between tooth loss and nutritional deficiency. A study indicated that a reduced number of teeth related with increased carbohydrate consumption, diminished vegetable intake, and lower levels of vitamins A and C, alongside elevated energy intake. Likewise, another study indicated that the intake of sodium, zinc, vitamin B1, α-carotene, and β-carotene was associated with the count of remaining teeth. Moreover, the number of teeth led to a diminished consumption of certain nutrients (protein, salt, potassium, calcium, vitamin A, vitamin E, and dietary fiber) and food categories (vegetables and meat). Izumi et al concluded in their study that molar occlusion, evaluated by the count of natural teeth, did not exhibit a significant relationship with nutritional status. Izumi et al elucidated that tongue strength surpasses molar occlusion and tooth quantity in significance. Tongue thrust is a crucial element in the deglutition process. The movement of the bolus is mainly facilitated by the tongue's pressure on the palate. The strength and speed of tongue muscles are intimately associated with chewing performance and bolus production. Furthermore, the palate and tongue interaction is crucial in bolus transmission stage II. This elucidates the findings of the study, in which a chi-square test was performed to examine the relationship between tooth loss, denture utilization, and nutritional status.[16]

This study did not comprehensively analyze the length of denture use among the subjects. The length of denture use may influence nutritional status. Nutritional status may also be associated with oral and nonoral factors, including socioeconomic status, systemic disorders experienced by individuals, and prior appetite levels. This study identifies these factors as confounders.[17] In conclusion, our findings suggest that dietary status correlates with denture use among elderly. This indicates that older adults who do not use dentures may elevate their risk of malnutrition, conversely, the use of dentures can assist in preserving or enhancing nutritional status.[3] [18]

Conclusion

The research indicates a relationship between dysphagia and nutritional status. Individuals with dysphagia exhibit a fourfold increased risk of malnutrition relative to those without dysphagia. Besides dysphagia, educational attainment is also related with nutritional status. Individuals with education above elementary school are at a reduced risk of malnutrition compared with those with elementary school education or less. This study indicated that patients with > 20 teeth who wore dentures exhibited less dysphagia than those with < 20 who did not. However, tooth loss and denture use had no statistically significant influence. This study employed the MWST as an objective assessment tool and the EAT-10-ID questionnaire as a subjective evaluation tool, yielding a subjective dysphagia test with sensitivity and specificity of 85.3 and 95.8%, respectively. The kappa score was 81.9%, indicating substantial agreement. Consequently, the EAT-10-ID may serve as a subjective assessment for the diagnosis of dysphagia.

Conflict of Interest

None declared.

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Publication History

Article published online:
01 May 2025