Interrelationship between Oral Problems, Disease, and Nutritional Health

The links between oral problems, specific diseases and conditions, and nutritional health are becoming clearer, allowing for early and more effective intervention.

Osteoporosis
Aging is associated with a loss of bone mass and an increased risk of oral and systemic bone loss. Systemic osteoporosis can result in bone fractures, especially of the spine and hip, with the characteristic spinal curvature and loss of height often seen in osteoporotic postmenopausal women. Oral signs of osteoporosis include loss of teeth due to resorption of toothsupporting alveolar bone. Because alveolar bone of the jaws is thought to undergo resorption prior to other bones, changes in jaw structure and loose teeth may be early signs of osteoporosis.5 Evidence suggests that calcium and vitamin D supplementation aimed at slowing the rate of bone loss from various parts of the skeleton can also affect oral bone and, in turn, support tooth retention.30

It has been suggested that factors responsible for osteoporotic bone loss may also combine with local factors, such as periodontal diseases, to increase rates of alveolar bone loss.31-33 However, additional studies are needed to confirm this and the potential implications of this association in identifying individuals at risk. A closer look at the therapies designed to enhance bone mineral density, such as hormone replacement and biphosphonate therapy, will help to determine if these therapies can also aid in tooth retention and a slower loss of alveolar bone.32

Eating disorders
Eating disorders such as anorexia nervosa, bulimia nervosa, and binge-eating disorder are a serious concern in women's oral health and present unique challenges to oral health care professionals.34 Each type of eating disorder presents with unique patterns of psychologic, medical, and oral characteristics. Oral signs of eating disorders may include erosive tooth wear, low unstimulated salivary flow, and moderate to severe dental caries.35 Clients may also complain of sensitivity to hot and cold temperatures and dental pain, and may express concern about the appearance of their teeth.5 The extent of oral tissue damage depends on the frequency of purging—as seen in bulimia, binge-eating disorder, and in some cases of anorexia—and the cario-genicity of the diet. Because oral health professionals are often the first health care providers to see these clients, early diagnosis and intervention may be possible.

Appropriate dental treatment should be coordinated with the primary health care provider, which may include psychological, nutritional, and medical treatment. Clients should be informed about the effects of purging on the mouth and teeth. They should be cautioned against brushing immediately after vomiting to prevent further erosion of enamel. Instead, a sodium bicarbonate or magnesium hydroxide rinse is recommended to neutralize mouth acids.5 Clients should also be counseled to limit intake of acidic fruit juices, such as orange, grapefruit, and cranberry juices, and to avoid sticky, sweet foods between meals. If dry mouth is a problem, clients can be instructed to try sugarless chewing gum or sugar-free lemon drops to help stimulate saliva flow.

Diabetes
Diabetes is a chronic metabolic disease with oral health implications, including dental caries, periodontal disease, and tooth loss.36-38 Dry mouth is a common complaint among clients with diabetes, especially among those who also smoke. The decreased salivary flow is associated with poorly controlled diabetes and the subsequent development of neuropathy.39 Xerostomia and its consequent reduced salivary flow is also linked to an altered sense of taste and burning mouth syn-drome. When diabetes is poorly controlled, hard candies may be used frequently to treat hypoglycemia. This habit, combined with reduced salivary flow common to diabetes, can significantly increase risk for dental caries and periodontal disease. Because of the importance of saliva in maintaining oral health, clients with diabetes should be evaluated for reduced salivary flow and treated accordingly, along with a regimen of controlled diet, oral hygiene, and topical fluoride when indicated.40

HIV Infection
The evaluation of oral health is an important, but often overlooked, part of the care of clients with HIV and AIDS. Oral infections, mouth ulcers, and other severe dental problems are associated with HIV infections.41 These conditions can impair the desire and ability to eat, limiting the intake of nutrients at a time when nutrition is essential. Usually, palliative oral care and appropriate food choices, such as bland, soft foods and nutrition supplement beverages, can help to maintain adequate nutrition. However, when oral conditions are not treated either pro-phylactically or when problems first arise, nutritional status can be undermined, thus contributing further to progression of the disease as well as the oral manifestations.5 Oral health care professionals are in a position to identify and help treat problems early on that may interfere with nutrient intake. Dental intervention in conjunction with nutrition management is an essential component of care at the earliest stages of HIV infection.

Oral and pharyngeal cancer
From a diet perspective, the most consistent factors in the development of oral and pharyngeal cancer are the protective effect of high fruit and vegetable consumption and the carcinogenic effect of alcohol intake. Although use of vitamin supplements in reducing risk for oral cancers has been explored, evidence is lacking that specific nutrients in isolation can prevent development of oral cancer. More likely, the protective effects of fruits and vegetables stem from the interaction of nutrients, including vitamins, minerals, and phytochemicals that occur naturally in these foods.

Cancer treatment, including radiation therapy and surgical intervention, can have significant oral implications. Radiation to the oropharyngeal area can lead to painful stomatitis, xerostomia, fibrosis of the muscles used for chewing, taste changes, and tooth loss.1 These side effects often lead to reduced nutrient intake at a time when nutritional intake is essential to fight disease and promote healing. Surgical treatment, including reconstruction, may result in changes in chewing and swallowing ability and increased energy and nutrient needs for healing.42

Integrating Oral Health and Nutrition in Dental Practice
It is clear that there is a lifelong synergy between nutrition and oral health status in health and disease. The trend toward a coordinated team care approach that involves collaborative efforts among health care providers suggests that dietetics and oral health care professionals can improve their levels of practice by integrating oral health and nutrition services. The American Dietetic Association’s position on oral health and nutrition outlines collaborative efforts that dietetics and oral health care professionals can implement in clinical, community, and research settings.1 (The activities recommended for professionals are pre-sented in Table VI.)