Journal of Gastroenterology and Hepatology (1992) 7 , 61-65
ALIMENTARY TRACT AND PANCREAS Gastrointestinal symptoms and masticatory dysfunction PAUL MERCIER* AND PIERRE POITRASt :’:Maxillary Atrophy Clinic, St Mary’s Hospital, Montreal, Canada and tGastrointestinal Unit, H6pital S t Luc, Montreal, Quebec, Canada Abstract One hundred and forty-two female patients consulting a prosthodontic clinic for masticatory disturbances and suffering from mandibular ridge atrophy were systematically interrogated for the presence of digestive symptoms. Eighty-live subjects (60% of the studied population) reported current digestive complaints; 32 had abdominal pain (burning sensation, bloating or cramps), 12 presented stool transit alteration (constipation or diarrhoea) and 41 reported both abdominal pain and stool transit abnormalities. A prospective evaluation of the digestive symptoms was obtained following surgical reconstruction of the atrophic mandibular ridge and insertion of functional dental prostheses to correct masticatory dysfunction. One year after jaw surgery, 62 of 73 patients (85%) initially complaining of abdominal pain reported symptomatic improvement of their condition, while a marked amelioration in stool habits was noted in 34 of 53 patients (64%) initially suffering intestinal transit alteration. The high incidence of digestive complaints in our patients with dental deficits and the improvement of‘ these symptoms after jaw reconstruction support a case for masticatory failure in the development of digestive symptoms.
Key words: abdominal pain, constipation, dyspepsia, edentulous, mastication, mouth, teeth.
INTRODUCTION Teeth represent the initial step of food processing by the organism. Dental caries, despite a drastic curtailment in recent years, is a prevailing condition in many countries and is the most frequent dental pathology influencing human health. Dental caries leads directly to tooth loss when improperly attended to, and indirectly to alveolar bone loss, a natural consequence of denture wear; the residual ridge resorption thus created affects masticatory function and eating habits. That ‘bad digestion’ is due to poor mastication is considered obvious in popular belief. Medical science, on the other hand, has collected limited information on the functional, physiological or physiopathological implications of the teeth in humans. Whether masticatory disorders can induce gastrointestinal dysfunction is debatable. Despite the possible socio-economic consequences of ‘masticationrelated dyspepsia’, this situation is ignored in most medical and gastroenterological textbooks. Several authors have suggested a causal relationship between inadequate chewing and various gastrointestinal disturbances. Rodriguez-Olleros reported in 1947 that 48% of their 168 edentulous patients were suffering from gastritis, but only 6% of the controls with good masticatory function were afflicted with it.’ The authors proposed that the arrival of a crude bolus of food in the stomach would provoke extra
motility, circulatory disturbances and excessive secretion, and could explain gastritis. Finnish authors also documented a significant correlation between dental deficits and gastrointestinal disorders2 From India, an exhaustive epidemiological study was made by Malhotra, who noted in several articles a striking difference of peptic ulcer disease between the Punjab population in Northern India, whose diet required mastication, and those in the Kashmir and Assam regions who consumed a non-masticatory soggy diet.’-’ St Nikolov conducted endoscopic studies and gastric biopsies in 92 patients suffering from gastrointestinal symptoms and presenting numerous missing teeth.6 He observed marked gastritis in almost all patients. The lesions ranged from atrophic gastritis to ulcerations, and were more frequent in patients missing their teeth for a prolonged period of time. In an exhaustive retrospective study of all factors that could be associated with chronic atrophic gastritis, diagnosed as such by gastric suction biopsy in 100 patients, Bernd showed a significant relationship between the number of years of denture wear and the incidence of gastrointestinal abrasions.’ A causal relationship between inadequate mastication and the development of gastrointestinal disturbances is, however, denied by others. Sircus examined the files of 400 patients undergoing endoscopy and found no chronological relationship between the onset of dyspepsia and the loss of
Correspondence: Dr Pierre Poitras, Andre-Viallet Clinical Research Centre, HBpital Saint Luc, 1058 St Denis St, Montreal, Quebec, H2X 354 Canada. Accepted for publication 24 June 1990.
P.Mercier and P. Poitras
62
teeth.8 Mumma, conducting a retrospective study on 129 patients who had received a dental examination during their hospital admission and whose masticatory function was impaired by the absence of posterior teeth, concluded that no significant relationship could be established between mastication and digestion.' In a critical review of the literature, Geissler and Bates pointed out that the design of most studies was inadequate for drawing valid conclusions.lo However, they estimated that it would be wrong to conclude, from the paucity of wellcontrolled investigations, that tooth loss has no impact on gastrointestinal functions. The object of this paper is to report our experience on the evolution of gastrointestinal complaints in patients treated surgically for reconstruction of atrophic mandibular ridge and correction of masticatory dysfunction. This is the first investigation on this subject done prospectively and based on a therapeutic approach.
optimum level easily reached by anyone with a full complement of teeth and no malocclusion, and 6 the level at which a bleached almond could not be bitten in half.
METHODS
Data were expressed as mean t standard deviation (s.d.). Masticatory performance of patients with or without digestive symptoms before and after surgery was analysed statistically. Contingency tables (with Chi-square analysis) were used to compare non-parametric qualitative data. Wilcoxon or Mann-Whitney tests were performed to compare paired or unpaired quantitative data respectively.
Population studied One hundred and ninety-three patients who had been treated at the Maxillary Atrophy Clinic of St Mary's Hospital between April 1978 and September 1983 and entered in a computerized database were used for selection. This list included 24 men, who were eliminated purely to keep the study as homogeneous as possible. Of the 169 women, 142 were available for a minimal 12-month follow-up and so were included in the study.
Evaluation of digestive symptoms The study was carried out in a prospective manner using a standardized questionnaire (developed by one of the authors (P.M.) and providing multiple data stored on computer for further statistical analysis) completed (by P.M.) at the first visit before surgery and at the follow-up visit 1 year later. The gastrointestinal (GI) questionnaire inquired about the presence of abdominal pain (defined as burning sensation, plenitude or cramps) and stool alteration (including constipation or diarrhoea). The ingestion of medication to relieve these symptoms was recorded. Previous diagnosis or results from GI investigations concerning respondents' digestive problems were also noted.
Description of treatment Denture wearing is usually associated with a loss of supporting bone of the jaw. The reconstructive surgery of the atrophic residual ridge involves a ridge augmentation procedure using artificial or natural bone, followed by skin grafting to provide a ridge from where dentures can be retained in place effectively. These procedures were performed by P.M. Balanced dental prostheses were inserted within 2 months after surgery by the same dental prosthodontic team.
''
Statistical analysis
RESULTS Description of population studied The characteristics of our patients are shown in Table 1. Before surgery, 85 of 142 subjects complained of some GI discomfort; 32 patients had abdominal pain, 12 patients presented stool alterations and 41 patients complained of both symptoms, while 57 subjects were asymptomatic. Complete dentures had been worn for an average of 20 ? 9.5 years, while major denture problems were reported for 9 k 6.7 years. The duration of GI symptoms appeared comparable in the three suffering groups (mean: 13 k 10 years). Various medical investigations (mostly X-rays) had been carried out in 75 of the 85 symptomatic cases in the past. According to the patients, this investigation failed to reveal any precise diagnosis in most cases; peptic ulcer or diverticulosis of the colon were known in 10 patients.
Evaluation of masticatory performance
Evolution of the gastrointestinal symptoms
A qualitative evaluation was made by asking patients, before and after surgery, whether: (i) they swallowed unchewed food; (ii) they were eating rapidly; or (iii) they were compelled to eat a soft diet. An objective test, initially proposed by Helkimo, was also used to evaluate quantitatively the masticatory performance." The period necessary to grind and swallow a specific food portion was determined. The results were transposed to a graduated scale (1-6) where 1 was the
Table 2 shows the characteristics of abdominal pain before and after surgery. As shown in this table, a major improvement in abdominal pain was noted in 85% of patients after surgery; only 11 of 73 patients did not report any changes. The effect of surgery on the improvement of the initial abdominal pain was highly significant (73 of 142 patients before vs 11 of 142 patients after surgery; P
ALIMENTARY TRACT AND PANCREAS Gastrointestinal symptoms and masticatory dysfunction PAUL MERCIER* AND PIERRE POITRASt :’:Maxillary Atrophy Clinic, St Mary’s Hospital, Montreal, Canada and tGastrointestinal Unit, H6pital S t Luc, Montreal, Quebec, Canada Abstract One hundred and forty-two female patients consulting a prosthodontic clinic for masticatory disturbances and suffering from mandibular ridge atrophy were systematically interrogated for the presence of digestive symptoms. Eighty-live subjects (60% of the studied population) reported current digestive complaints; 32 had abdominal pain (burning sensation, bloating or cramps), 12 presented stool transit alteration (constipation or diarrhoea) and 41 reported both abdominal pain and stool transit abnormalities. A prospective evaluation of the digestive symptoms was obtained following surgical reconstruction of the atrophic mandibular ridge and insertion of functional dental prostheses to correct masticatory dysfunction. One year after jaw surgery, 62 of 73 patients (85%) initially complaining of abdominal pain reported symptomatic improvement of their condition, while a marked amelioration in stool habits was noted in 34 of 53 patients (64%) initially suffering intestinal transit alteration. The high incidence of digestive complaints in our patients with dental deficits and the improvement of‘ these symptoms after jaw reconstruction support a case for masticatory failure in the development of digestive symptoms.
Key words: abdominal pain, constipation, dyspepsia, edentulous, mastication, mouth, teeth.
INTRODUCTION Teeth represent the initial step of food processing by the organism. Dental caries, despite a drastic curtailment in recent years, is a prevailing condition in many countries and is the most frequent dental pathology influencing human health. Dental caries leads directly to tooth loss when improperly attended to, and indirectly to alveolar bone loss, a natural consequence of denture wear; the residual ridge resorption thus created affects masticatory function and eating habits. That ‘bad digestion’ is due to poor mastication is considered obvious in popular belief. Medical science, on the other hand, has collected limited information on the functional, physiological or physiopathological implications of the teeth in humans. Whether masticatory disorders can induce gastrointestinal dysfunction is debatable. Despite the possible socio-economic consequences of ‘masticationrelated dyspepsia’, this situation is ignored in most medical and gastroenterological textbooks. Several authors have suggested a causal relationship between inadequate chewing and various gastrointestinal disturbances. Rodriguez-Olleros reported in 1947 that 48% of their 168 edentulous patients were suffering from gastritis, but only 6% of the controls with good masticatory function were afflicted with it.’ The authors proposed that the arrival of a crude bolus of food in the stomach would provoke extra
motility, circulatory disturbances and excessive secretion, and could explain gastritis. Finnish authors also documented a significant correlation between dental deficits and gastrointestinal disorders2 From India, an exhaustive epidemiological study was made by Malhotra, who noted in several articles a striking difference of peptic ulcer disease between the Punjab population in Northern India, whose diet required mastication, and those in the Kashmir and Assam regions who consumed a non-masticatory soggy diet.’-’ St Nikolov conducted endoscopic studies and gastric biopsies in 92 patients suffering from gastrointestinal symptoms and presenting numerous missing teeth.6 He observed marked gastritis in almost all patients. The lesions ranged from atrophic gastritis to ulcerations, and were more frequent in patients missing their teeth for a prolonged period of time. In an exhaustive retrospective study of all factors that could be associated with chronic atrophic gastritis, diagnosed as such by gastric suction biopsy in 100 patients, Bernd showed a significant relationship between the number of years of denture wear and the incidence of gastrointestinal abrasions.’ A causal relationship between inadequate mastication and the development of gastrointestinal disturbances is, however, denied by others. Sircus examined the files of 400 patients undergoing endoscopy and found no chronological relationship between the onset of dyspepsia and the loss of
Correspondence: Dr Pierre Poitras, Andre-Viallet Clinical Research Centre, HBpital Saint Luc, 1058 St Denis St, Montreal, Quebec, H2X 354 Canada. Accepted for publication 24 June 1990.
P.Mercier and P. Poitras
62
teeth.8 Mumma, conducting a retrospective study on 129 patients who had received a dental examination during their hospital admission and whose masticatory function was impaired by the absence of posterior teeth, concluded that no significant relationship could be established between mastication and digestion.' In a critical review of the literature, Geissler and Bates pointed out that the design of most studies was inadequate for drawing valid conclusions.lo However, they estimated that it would be wrong to conclude, from the paucity of wellcontrolled investigations, that tooth loss has no impact on gastrointestinal functions. The object of this paper is to report our experience on the evolution of gastrointestinal complaints in patients treated surgically for reconstruction of atrophic mandibular ridge and correction of masticatory dysfunction. This is the first investigation on this subject done prospectively and based on a therapeutic approach.
optimum level easily reached by anyone with a full complement of teeth and no malocclusion, and 6 the level at which a bleached almond could not be bitten in half.
METHODS
Data were expressed as mean t standard deviation (s.d.). Masticatory performance of patients with or without digestive symptoms before and after surgery was analysed statistically. Contingency tables (with Chi-square analysis) were used to compare non-parametric qualitative data. Wilcoxon or Mann-Whitney tests were performed to compare paired or unpaired quantitative data respectively.
Population studied One hundred and ninety-three patients who had been treated at the Maxillary Atrophy Clinic of St Mary's Hospital between April 1978 and September 1983 and entered in a computerized database were used for selection. This list included 24 men, who were eliminated purely to keep the study as homogeneous as possible. Of the 169 women, 142 were available for a minimal 12-month follow-up and so were included in the study.
Evaluation of digestive symptoms The study was carried out in a prospective manner using a standardized questionnaire (developed by one of the authors (P.M.) and providing multiple data stored on computer for further statistical analysis) completed (by P.M.) at the first visit before surgery and at the follow-up visit 1 year later. The gastrointestinal (GI) questionnaire inquired about the presence of abdominal pain (defined as burning sensation, plenitude or cramps) and stool alteration (including constipation or diarrhoea). The ingestion of medication to relieve these symptoms was recorded. Previous diagnosis or results from GI investigations concerning respondents' digestive problems were also noted.
Description of treatment Denture wearing is usually associated with a loss of supporting bone of the jaw. The reconstructive surgery of the atrophic residual ridge involves a ridge augmentation procedure using artificial or natural bone, followed by skin grafting to provide a ridge from where dentures can be retained in place effectively. These procedures were performed by P.M. Balanced dental prostheses were inserted within 2 months after surgery by the same dental prosthodontic team.
''
Statistical analysis
RESULTS Description of population studied The characteristics of our patients are shown in Table 1. Before surgery, 85 of 142 subjects complained of some GI discomfort; 32 patients had abdominal pain, 12 patients presented stool alterations and 41 patients complained of both symptoms, while 57 subjects were asymptomatic. Complete dentures had been worn for an average of 20 ? 9.5 years, while major denture problems were reported for 9 k 6.7 years. The duration of GI symptoms appeared comparable in the three suffering groups (mean: 13 k 10 years). Various medical investigations (mostly X-rays) had been carried out in 75 of the 85 symptomatic cases in the past. According to the patients, this investigation failed to reveal any precise diagnosis in most cases; peptic ulcer or diverticulosis of the colon were known in 10 patients.
Evaluation of masticatory performance
Evolution of the gastrointestinal symptoms
A qualitative evaluation was made by asking patients, before and after surgery, whether: (i) they swallowed unchewed food; (ii) they were eating rapidly; or (iii) they were compelled to eat a soft diet. An objective test, initially proposed by Helkimo, was also used to evaluate quantitatively the masticatory performance." The period necessary to grind and swallow a specific food portion was determined. The results were transposed to a graduated scale (1-6) where 1 was the
Table 2 shows the characteristics of abdominal pain before and after surgery. As shown in this table, a major improvement in abdominal pain was noted in 85% of patients after surgery; only 11 of 73 patients did not report any changes. The effect of surgery on the improvement of the initial abdominal pain was highly significant (73 of 142 patients before vs 11 of 142 patients after surgery; P
