Nutrition for Oral and Dental Health

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 ToothAnatomy 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

demineralization 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 CariesEarly 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

Carbohydrate 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

Fluoride

Primary anticaries agent Water fluoridation Fluoridated toothpastes Oral rinses Dentrifices Beverages made with fluoridated water

Recommendations for Fluoride SupplementationRecommendations 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 gums

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 Carogenicity 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

many Simple nutrition counseling; Food Guide

Pyramid, etc.

Oral Manifestations of Disease

Stomatitis: inflammation of oral mucosa

Candidiasis and herpes simplex: fungal and viral infections which can affect mouth and esophagus causing pain and dysphagia

Photo: http://webpages.marshall.edu/~gain/bactnote/Image9.gif

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 cheese

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 Xerostomia

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 steak

Interventions 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 appropriate

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 swallowing

Mechanical causes– Trauma to esophagus with scar tissue– Inelasticity due to repeated inflammation– Tumor of esophagus– Aneurism of aorta

Dysphagia = difficulty swallowing

Neuromuscular causes CVA, brain tumors Head injury Parkinson’s disease, MS, ALS Achalasia (cardiospasm) Spinal cord injury

Dysphagia Oral phase problems

Pocketing foodDrinking from cup or strawDrooling

Pharyngeal phaseGaggingChokingNasal regurgitation

Esophageal phaseObstruction

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

Aspiration 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 patients

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 starches

NDD Level 2 – Mechanically Altered Foods are soft-textured and moist so they easily form a

bolus 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

pieces 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 Acceptance

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 weight

Patients on thickened liquids are at risk for dehydration

Re-evaluate patients and advance diet as quickly as possible