**4. Interventions**

The managemen<sup>t</sup> of older people should be multimodal and multidisciplinary, especially for those with or at risk of malnutrition [147], in order to improve di fferent conditions (i.e., oral problems and sarcopenia). From a practical point of view, comprehensive geriatric assessment (CGA) is the multidimensional, interdisciplinary diagnostic and therapeutic process aimed at determining the medical, psychological, and functional problems of older people. The CGA's objective is the development of a coordinated and integrated plan for treatment and follow-up in order to maximize overall health with aging [148]. To date, increasing evidence suggests that prosthodontic treatment in combination with personalized dietary counselling may improve the nutritional status of patients [51]. Here, we provide an overview on the managemen<sup>t</sup> of oral problems, malnutrition, and sarcopenia.

## *4.1. Oral Management*

The stomatognathic system is very vulnerable over time, but with special care, it can be preserved throughout the lifetime [30]. Nevertheless, one of the major challenges in providing both restorative and preventive care for older adults is to check dental status on a regular basis [34]. Prevention is pivotal to detecting oral disease as soon as possible and requires regular patient contact. However, since it has been reported that older people frequently fail to achieve a good oral hygiene, both patients and caregivers should be made more aware about the importance to check dental status as well as oral hygiene.

The oral health-care professionals should develop a personalized program, in order to prevent all the problems related to the aging process. In some cases, it is di fficult to provide dental care in the hospital setting in a short time, since in many countries there are long waiting lists (especially in publicly funded hospitals) [149]. Therefore, private dentists also need better awareness concerning the complexity of older people. There is, first and foremost, a need to understand the level of dependency, the medical condition, and the physical or cognitive impairment of the patient. Secondly, it is important to establish an oral healthcare plan that includes both professional and self-care elements [150].

The oral managemen<sup>t</sup> of older people usually involves di fferent aspects:


#### *4.2. Nutritional Interventions*

As discussed above, nutrition is an important determinant of health in older people. Thereby, it is pivotal to provide adequate amounts of energy, proteins, fluid, and micronutrients in order to prevent or treat excess or deficiencies, and therefore improve several health-related outcomes in terms of morbidity and mortality. A personalized approach is pivotal in order to respect individual

preferences, needs, and to increase compliance to the diet. Nutritional status should be assessed before each intervention, and the amount of energy and proteins should be individually adjusted with regard to nutritional status, physical activity level, disease status, and tolerance [152]. The European Society for Clinical Nutrition and Metabolism (ESPEN) [152], in its guidelines on clinical nutrition and hydration in geriatrics, recommends a guiding value for energy intake of 30 kcal/kg of body weight/day. However, as stated above, it should be adapted individually. Both ESPEN [153] and the PROT-AGE study group [147] recommend providing a protein intake of at least 1.0 g/kg body weight/day in older people to maintain muscle mass, increasing the intake up to 1.2–1.5 g/kg body weight/day in presence of acute or chronic illness. Additionally, it seems that the per-meal anabolic threshold of protein intake is higher in older individuals (i.e., 25 to 30 g protein/meal, containing about 2.5 to 2.8 g leucine) than young adults [147]. However, since older people may experience di fficulty of ingesting large amounts of proteins in a single meal, supplementation should be considered. Since serum vitamin D levels decline gradually with aging [154,155] and have been associated with reduced muscle mass and strength, supplementation should thus be considered in those who are deficient.

Food texture should be adapted depending on the chewing and swallowing condition in order to avoid choking risk [10]. Harder foods may be modified to soft consistencies (i.e., bite-sized, minced, pureed) requiring little chewing, as well as liquids, which may be thickened to render the swallowing process slower and safer [10,156,157]. Controlling the intake of simple sugars is pivotal to prevent both dental caries [101] and metabolic complications [158]. World Health Organization recommends to limit the intake of free sugars to less than 10% of total energy intake to minimize the risk of dental caries [159].

Fruit and vegetables are major sources of minerals and vitamins with antioxidant properties; therefore, their consumption should be promoted both for oral and general health. It has been documented that excessive antioxidant supplementation could compromise both the mechanism of adaption to exercise and have even pro-oxidant e ffects. Thus, supplementation in people who are not deficient should be regarded carefully [160]. Dietary consumption of fatty fish (i.e., salmon, mackerel, herring, lake trout, sardines, albacore tuna, and their oils), which are a major source of omega-3 fatty acids, has been associated with a greater fat-free mass [161]. Given their antioxidant role, omega-3 fatty acid supplementation has been suggested to improve inflammatory status both in periodontal disease [162] and sarcopenia [163]. However, more studies are needed to further elucidate the exact time and dosage of supplementation as well as long term e ffects [164]. Nevertheless, consumption of foods rich in omega-3, such as as fatty fish, should be promoted.

#### *4.3. Exercise and Rehabilitative Strategies*

Physical inactivity is considered one of the main causes of sarcopenia [165] because it determines a resistance to muscle anabolic stimuli [166]. Moreover, it has been proposed that physically inactive individuals may have a greater risk of periodontal disease [167]. In particular, resistance training seems to be the most e ffective type of exercise to counteract sarcopenia [168]. Furthermore, since sarcopenia is a systemic process [15,21], it has been recommended to perform a holistic training involving all muscle groups [15]. In fact, it has been documented that both masticatory and swallowing functions can be improved through muscle-strengthening exercises [169,170]. Several studies reported enhancements in subjective chewing ability, swallowing function, salivation, relief of oral dryness, and oral-health quality of life. Indeed, the synergistic e ffect of nutritional interventions coupled with physical exercise may improve both muscle [164] and oral health [167]. Recently, Kim et al. [171] reported an improvement in oral function following an exercise program which included stretching of the lip, tongue, cheek, masticatory muscle exercise, and swallowing movements. Several studies have been focused on swallowing rehabilitation. To date, a positive e ffect of expiratory muscle resistance training has been documented in improving suprahyoid muscle activity [172,173]. Furthermore, head lift exercises showed a beneficial impact on swallowing movements [174,175], and tongue strengthening exercises have been reported to enhance tongue strength [176,177]. Yeates et al. [178] demonstrated that isometric tongue strength exercises and tongue pressure accuracy tasks improved isometric tongue

strength, tongue pressure generation accuracy, bolus control, and dietary intake by mouth. It has also been reported that tongue exercises prevented general sarcopenia [178,179]. Indeed, swallowing muscles training, despite its focus on swallowing function, may exert its beneficial effects systemically.
