Nutrition for Oral and Dental Health

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					Nutrition for Oral and Dental
Oral Health
  Diet and nutrition play a key role in
       —Tooth development
       —Gingival and oral tissue integrity
       —Bone strength
       —Prevention and management of
        diseases of the oral cavity
Effects of Nutrient Deficiencies on
Tooth Development
  Dental and Oral Health
 Teeth are made from protein matrix that is
  mineralized with collagen (requiring vitamin
  C), calcium, and phosphorus (requiring
  vitamins D and A)
Anatomy of a Tooth
Dental Caries
 Infectious disease of teeth in which organic
  acid metabolites lead to gradual
  demineralization of enamel; proteolytic
  destruction of tooth structure
 Any tooth surface can be affected.
The Decay Process
 Plaque formation: sticky mix of microorganisms,
  protein, polysaccharides
 Bacteria metabolizing fermentable carbohydrate
  produce acid
 Acid production: oral pH<5.5 allows tooth
 Saliva function: rinses away food; neutralizes
  acid; promotes remineralization
 Caries patterns:pattern depends on cause
Early Childhood Caries
   Also called ―baby bottle tooth decay‖
   Nursing bottle caries—putting baby to bed
    with a bottle of sweetened liquid (juice,
    Kool-Aid, etc.)
   Front teeth rapidly develop caries
   Common among Native Americans
   Wean children before age 2 from bottle
Early Childhood Caries

(From Swartz MH. Textbook of Physical Diagnosis, History, and Examination, 3rd ed. Philadelphia: W.B. Saunders, 1998.)
Dental Caries—cont’d

  Streptococcus mutans—most common
   bacteria involved
  Fermentable Carbohydrate
  Time
  Drop in salivary pH to below 5.5
Dental Caries—cont’d

  Cariogenicity of foods
  Frequency of consumption of fermentable
  Food form—slowly dissolving
  Food combinations
  Nutrient composition of food/beverages
  Timing (end of meal)
Medical Sequelae of Dental Caries
 Bacteria from tooth decay can enter
  bloodstream and inoculate heart valves,
  cause bacterial endocarditis
 Oral-pharyngeal secretions inoculated with
  bacteria can cause aspiration pneumonia
  Primary anticaries agent
  Water fluoridation
  Fluoridated toothpastes
  Oral rinses
  Dentrifices
  Beverages made with fluoridated water
Recommendations for
Fluoride Supplementation

(Data from American Dietetic Association: Position of ADA: The impact of fluoride on dental health. J. Am Diet Assoc. 94:1428,
1994.) * Milligrams of supplemental fluoride recommended according to fluoride concentration in drinking water.
Cariogenic vs. Cariostatic
 Cariogenic: containing fermentable
  carbohydrates that can cause a decrease in
  salivary pH to <5.5 and demineralization when
  in contact with microorganisms in the mouth;
  promoting caries development
 Cariostatic: not metabolized by
  microorganisms in plaque to cause a drop in
  salivary pH to <5.5
Cariogenic Foods
 Promote formation of caries
 Fermentable carbohydrates, those that
  can be broken down by salivary amylase
 Result in lower mouth pH
 Include crackers, chips, pretzels, cereals,
  breads, fruits, sugars, sweets, desserts
   Cariostatic Foods
 Foods that do not contribute to decay
 Do not cause a drop in salivary pH
 Includes protein foods, eggs, fish, meat and
  poultry; most vegetables, fats, sugarless
Anticariogenic Foods
 Prevent plaque from recognizing an
  acidogenic food when it is eaten first
 May increase salivation or have
  antimicrobial activity
 Includes xylitol (sweetener in sugarless
  gum) and cheeses
Other Factors that Affect Diet
 Consistency: Liquids are cleared quickly while
  sticky foods remain on the teeth
 Meal frequency: frequent meals and snacks
  increase duration of exposure
 Food composition
 Food form: liquid, solid, slowly dissolving
 Sequence of eating: cheese or milk at the end of
  the meal decrease the cariogenicity of the meal
Caries Prevention Guidelines
Periodontal Disease
 Inflammation of the gingiva with destruction
  of the tooth attachment apparatus
 Gingivitis—early form
 Nutritional care involves increasing vitamin C,
  folate, and zinc
Tooth Loss and Dentures
  Tooth loss—denture placement
  Food selections change
  Saliva production decreases
  Reduced chewing ability
  Lower calorie and nutrient intake occurs for
  Simple nutrition counseling; Food Guide
   Pyramid, etc.
Oral Manifestations of Disease
 Stomatitis:
  inflammation of oral
 Candidiasis and herpes
  simplex: fungal and
  viral infections which
  can affect mouth and
  esophagus causing
  pain and dysphagia

Oral Manifestations of Disease
 Xerostomia: Dry mouth
 Periodontal disease
 Kaposi’s sarcoma—lesions in mouth and
  esophagus; associated with AIDS

 Kaposi’s Sarcoma
 in AIDS
 MNT for Mouth Pain/
 Oral Infections
 Avoid acidic and spicy foods
 Offer soft, cold, nutrient dense foods such
  as canned fruit, ice cream, yogurt, cottage
 Try oral supplements
 Use PEG or NG feeding if oral
  supplementation is unsuccessful
 For xerostomia, try artificial salivas, citrus
  beverages, sugar free candies or gums
Medications That May Cause
Dental Health Affects Nutrition
 Tooth loss may affect ability to chew
  (relationship between loss of teeth and
  reduced intake of fruits and vegetables
 Dentures are often ill-fitting (especially
  common after weight loss); problem foods
  include fresh fruits and vegetables, chewy
  and crusty breads and chewy meat like
 Obtain a dental consult: if dentures are
  missing, find them. If they are loose,
  replace or reline them
 Modify diet consistency: mechanical soft,
  ground, pureed
 Use least restrictive diet possible;
  individualize; mix consistencies if
MNT for Wired or Broken Jaw
 Provide pureed, strained, or blenderized foods
  as appropriate
 Encourage nutrient-dense foods such as
  blenderized casseroles
 Recommend small, frequent meals with oral
  supplements such as milkshakes, Instant
  Breakfast, medical nutritionals
 Use liquid vitamin supplement if necessary
 Recommend patient weigh self to monitor
  weight status
Dysphagia = difficulty

  Mechanical causes
   – Trauma to esophagus with scar tissue
   – Inelasticity due to repeated inflammation
   – Tumor of esophagus
   – Aneurism of aorta
Dysphagia = difficulty
 Neuromuscular causes
  CVA, brain tumors
  Head injury
  Parkinson’s disease, MS, ALS
  Achalasia (cardiospasm)
  Spinal cord injury
  Oral phase problems
      Pocketing food
      Drinking from cup or straw
  Pharyngeal phase
      Nasal regurgitation
  Esophageal phase
Symptoms of Dysphagia
  Drooling, choking, coughing during or
   after meals
  Inability to suck from a straw
  Holding pockets of food in cheeks (pt
   may be unaware)
  Absent gag reflex
  Chronic upper respiratory infections
  Gargly voice quality or moist cough
   after eating
Diagnosis of Dysphagia
  Nerve assessment
  X-rays
  Fluoroscopic swallow study: barium
   swallow/cookie swallow
  Measurement of esophageal sphincter
   pressure and peristalsis
  Inhalation of food, liquid into lungs
  Can cause aspiration pneumonia
  Appears to be dose-dependent
  A major cause of aspiration pneumonia
   is thought to be aspiration of
   oropharyngeal secretions, particularly if
   contaminated by bacteria
MNT for Dysphagia
(National Dysphagia Diet)
 Intervention depends on severity of deficit
  Mealtime supervision, cueing
  Thickened liquids: thin » nectarlike »
    honeylike » spoon thick
  Altered consistency:
    – Level 1: pureed
    – Level 2: mechanically altered
    – Level 3: advanced
Thickened Liquids
MNT for Dysphagia
 In severe cases, patient may
  be made NPO and enteral
  feedings initiated
National Dysphagia Diet
  NDD diets are more restrictive than
   dental consistency diets; may wish to
   use more liberal diet for edentulous
  Developed by consensus committee; no
   evidence as yet that it is effective in
   preventing aspiration
  Provides much-needed standardization
NDD: Level 1 -- Pureed
 Foods are totally pureed; no coarse textures or
  lumps of any kind
 Breads must be pureed or pregelled, slurried
  through entire product thickness
 Cereals should be homogeneous or ―pudding-
  like;‖ such as cream of wheat, cream of rice,
  farina; avoid oatmeal
 Fruits pureed without pulp, seeds, skins; juice
  should be thickened to desired consistency
 Soups should be pureed, strained, and thickened to
  desired consistency
 Mashed potatoes and pureed pasta are main
NDD Level 2 – Mechanically
 Foods are soft-textured and moist so they easily form a
   Breads must be slurried, pre-gelled through entire
    thickness, but well-moistened pancakes are allowed
   Cooked cereals may have some textures and some try,
    well-moistened cereals allowed
   Soft canned or cooked fruits, no seeds or skins
   Ground or minced tender meats with no larger than ¼ inch
    pieces, well-cooked casseroles, cottage cheese; avoid
    peanut butter, sandwiches, pizza
   Most soups
   Soft, well-cooked vegetables with less than ½ inch pieces;
    no corn, peas, fibrous varieties
NDD Level 3 -- Advanced
 Nearly normal textures, but exclude crunchy,
  sticky, hard foods
 Foods should be bite-sized and moist
 Moist, tender meats and casseroles with small
 Most vegetables except corn
 Potatoes, rice, stuffing allowed
 All beverages if they meet ordered consistency
 Moist breads allowed; no tough, crusty bread
 Most desserts allowed, no nuts, seeds, pineapple,
  coconut, dried fruit
Strategies for Improving
  Thickened liquids: commercial products
   can improve quality and consistency of
   thickened liquids
  Seasoning: persons with dysphagia often
   have dulled sense of taste. Serve
   seasoned foods such as spaghetti, chili,
   apple pie
  Piping and molding: pureed foods can
   be thickened and molded for more
   attractive appearance
Piped and Molded Pureed Foods
Dysphagia Diet Issues
  Patients on altered
   consistencies tend to
   eat less and often lose
  Patients on thickened
   liquids are at risk for
  Re-evaluate patients
   and advance diet as
   quickly as possible

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