The concept of Health Cookies for people with chewing difficulties has been demonstrated through a clinical trial in Nice University Hospital.

A solid nutritional supplement,  even for people with chewing difficulties

With their adapted texture and their small thickness, the health cookies can be eaten even when there are no or very few teeth left. They are easy to dip in a drink, without crumbling too fast.

During their development phase, Protibis® Health Cookies were made by the pastry chef at the Hospital of Nice, to be used as a test to detect dry mouth syndrom. Principle for this experimental prototype : the baker made small cookies with flour, vegetal oil, and egg whites. A person can masticate and swallow these cookies when they are soaked in enough saliva: a person who produces little saliva will take more time to eat a cookie than a person who has a normal level of saliva. This simple test relies on strong neurophysiology basis, as the reflex to swallow the food intake is extremly reproducible for a specific piece of food. The time that is necessary to masticate and swallow a specific piece of food is directly linked to its volume, its texture, and the hydration level of the food intake.

The "cookie test" was compared to the reference test to detect a lack of saliva, for instance sialometry. Sialometry consists in making a person masticate a few grams of paraffin wax for 10 to 15 minutes, and collecting the saliva in a  bottle to measure the quantity of produced saliva. (SSFR test: stimulated salivary flow rate). In these conditions, a person who produces more than 1 mL of saliva per minute has a normal salivation. A person who produces 0,5 to 0,7 mL of saliva per minute does not produce enough saliva. A person who produces less than 0,5 mL of saliva per minute suffers from severe hyposalivation. This paraffin test is not often carried out,  as it takes a long time and is often too tiring for the patients who are not able to masticate a sizeable solid item for 10 minutes or more. In comparison, it takes less than one minute to eat a small 7 g cookie in a single bite.

A clinical trial has been carried out with 60 patients to compare the efficiency of the two screening tests for lack of saliva : in measuring the time necessary to eat one cookie, and in measuring the amount of saliva produced with the paraffin test.

30 gerontology hospital patients in short stay took part in this trial (7 men, 23 women, average age 84), with 30 patients with chronic illnesses from the department of infectious diseases (19 men, 11 womens, average age 47). This trial allowed to confirm the correlation between the time taken to masticate-swallow cookies and the amount of saliva produced with the stimulation. The time taken to masticate-swallow was significantly higher in case of drymouth (average 51,9 seconds versus 30,7 seconds, p<0,01).

This clinical trial has demonstrated the test's sensitivity and specificity, which allows to screen and detect drymouth by measuring the time necessary to masticate and swallow a 7g cookie. This test is enabled by the specific composition and texture of the cookies. Compared to sialometry, this test is easy to carry out with elderly people and ill people, as in average it does not take more than 40 seconds instead of 10 minutes. Besides, this test is clean and the patients prefer to swallow a small cookie rather than spitting in a bottle for 10 minutes.

This trial has also highlighted that people who suffer from mouth or tooth pain did not take more time to eat a cookie than people who did not (39,5 seconds versus 39,9 seconds, p<0,01).

Finally, this trial has shown that the cookies can be eaten whatever the oral status. The time necessary to masticate and swallow the cookies depends only on the quantity of produced saliva, whatever  the chewing capacity, that is to say the number of antagonist teeth. In other words, a person who does not have many teeth left, or is toothless, eats with as much ease as a person who has all their teeth (after adjustment of the chewing capacity, SSFR < 1 mL/mn, AUC = 0,921; SSFR < 1,5 mL/mn, AUC = 0,950; AUC : area under curve).

In conclusion, for this trial aimed at validating the screening test for the lack of saliva, we have made small cookies that can be eaten by the patients, whatever oral state they present, thanks to their specific texture. We have used the basics of this experimental prototype, and added milk proteins, butter, sugar, a bit of salt, and vanilla, to make high protein and high energy cookies. These cookies are pleasant to eat, and designed for malnourished people and people with a risk of malnutrition. Thanks to their flavour and specific texture, these butter cookies are particularly well appreciated by people with inappetence or difficulties to masticate.

Researchers, Nice University Hospital:
Pr. Isabelle MADINIER, odontology department UF7647                                           
Pr. Patrice BROCKER, gerontology department UF3310

References :

• Etude 03-PP-03 UF 731 promotor Nice University Hospital, France, 2004.

• Madinier et al. Detection of mild hyposalivation in the elderly based on the chewing time of specifically-designed disc-tests: diagnostic accuracy. Journal of the American Geriatrics Society 2009.