CE Course 7

Diet and Nutrition Implications for Oral Health

Credit: Continuing Education Hours: 2
If you have specific questions about the CE requirements in your state, or if you're not sure if the course will be accepted, please consult your state dental board.

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Table of Contents

  • Course Goals
  • Learning Outcomes
  • Abstract
  • Introduction
  • Dietary Guidelines for Americans
  • Nutritional Factors in Tooth Development and Maintenance
  • Role of Sugars and Starches in Tooth Decay
  • Plaque Formation
  • Acid Production
  • Baby Bootle Tooth Decay
  • Saliva Flow and Composition
  • Other Factors Affecting Cariogenicity
  • Sugar Alcohols and Sugar Substitutes
  • Nutrition Screening in the Dental Office
  • Anticariogenic Foods
  • Nutrition and Periodontal Disease
  • Interrelationship between Oral Problems, Disease, and Nutritional Health
  • Key Terms
  • Supplemental Activities
  • About the Author

  • Course Goals

    The purpose of this continuing education (CE) course is to review current dietary recommendations for Americans in relation to oral health and discuss the implications of specific foods and nutrients on oral health. The role of the oral health care professional in identifying certain nutrition-related problems and counseling individuals on healthful eating will be reviewed.


    Learning Outcomes

    Upon completion of this course, the participant will be able to:

    • Identify the links between nutrition and oral health
    • Describe nutritional factors in tooth development and maintenance
    • Discuss the role of sugars and starches in tooth decay
    • Identify factors that determine the cariogenicity of foods
    • Describe the relationship between nutrition and periodontal disease
    • Discuss the effects of specific diseases and conditions on nutritional status and oral health.

    Assessment Method: Post-test only


    Abstract

    Dental hygienists are in a unique position to provide both oral hygiene instruction and basic nutrition information related to oral health. Many clients may not be aware of the effects of diet and nutritional status on the development and maintenance of a healthy mouth and caries-free teeth. It is vitally important for dental hygienists to perform basic nutrition screening to assess clients’ dietary habits for potential risk factors for dental caries and periodontal disease, and to look for potential signs of nutritional deficiencies or nutrition-related problems in clients with chronic diseases or conditions. Collaboration between dietetics professionals and oral health care professionals is essential in identifying, educating, and treating oral health problems related to nutrition. Such partnerships will encourage improved levels of oral health care. The purposes of this course are to review the links between nutrition and oral health and to discuss how oral health care professionals can integrate nutrition counseling aimed at improving the oral health of their clients into their practices.


    Introduction

    Nutrition and oral health are intimately linked. Diet and its nutritional consequences can have a profound influence on tooth development and maintenance and on the development and progression of diseases of the oral cavity. Likewise, oral infectious diseases, as well as other diseases with oral manifestations, may influence diet and nutritional status.1

    The role of diet in oral health is twofold. First, food and its nutrients contribute to the health of the mouth as well as to overall health. Eating a balanced and varied diet as recommended by the Dietary Guidelines for Americans and the Food Guide Pyramid provides a foundation for maintaining oral health and achieving overall health. Second, eating habits have a direct effect on dental caries. The ability of various carbohydrate-containing foods to contribute to dental caries depends on how well it adheres to the tooth surface and how frequently it is consumed. Since carbohydrates should provide for more than half of the total energy requirements for children and adults, it is both unrealistic and undesirable to eliminate sugars and starches. However, the types of carbohydrates and the frequency at which they are consumed can be adjusted to reduce the risk of dental caries.


    Dietary Guidelines for Americans

    The Dietary Guidelines for Americans provides sound, science-based advice about food and lifestyle choices that promote health and reduce the risk of chronic disease for healthy Americans 2 years and older. Together with the Food Guide Pyramid, the dietary guidelines are the cornerstone of federal food, nutrition education, and information policies. For health care providers and educators, the guidelines form the basis for health promotion and disease prevention efforts. From a consumer standpoint, the guidelines offer practical advice to help individuals make food choices for a healthy, active life.

    The guidelines are developed jointly by the Departments of Health and Human Services (DHHS) and Agriculture (USDA) and play a key role in setting the standards for healthful diets for American age two and older. These guidelines are updated and released every five years.

    The current edition of the Dietary Guidelines, released in 2000, presents 10 guidelines (Table I). They are grouped under three key messages—Aim for Fitness, Build a Healthy Base, and Choose Sensibly— and focus on the many ways to build a healthy diet and lifestyle. By following these guidelines, individuals can maintain good health and reduce risk for developing chronic diseases, such as heart disease, certain types of cancer, diabetes, stroke, osteoporosis, and dental caries.

    Food Pyramid


    Nutritional Factors in Tooth Development and Maintenance

    At two months of gestation, primary tooth development begins. Permanent teeth begin to form several months before birth. Apregnant woman’s nutrient intake must therefore supply the pre-eruptive teeth with the appropriate building mate-rials. Severe nutrient deficiencies during pregnancy may result in mouth malformations in the child and teeth that are more susceptible to dental caries.2
    Likewise, chronically malnourished children may have delayed tooth eruption, compromised tooth integrity, and increased dental caries.3,4 However, the degree of malnutrition known to cause these aberrations is not commonly seen in the United States or other developed countries.

    Once the teeth have erupted into the oral cavity, many severe and even moderate nutritional deficiencies or excesses can result in defective tooth development. Table II describes the potential effects of specific nutrient imbalances on tooth development and salivary flow and composition.

    Teeth are formed by mineralization of a protein matrix. The mineralization process begins as early as four months of gestation and continues into late adolescence as the root structures are completed. Once teeth have erupted, diet and nutrient intake continue to affect permanent tooth development and mineralization, enamel development and strength, as well as the timing of eruption of the remaining teeth.5 For example, nutrient imbalances during early childhood can interfere with enamel formation, causing hypoplasia or hypocalcification. Additionally, teeth subjected to nutritional insult during critical stages of growth and development show a diminished ability to withstand caries.5

    Nutrients essential for tooth development and maintenance include vitamins A, C, and D, as well as calcium, phosphorus, and fluoride. The protein in dentin is collagen, which is dependent on vitamin C for normal synthesis. A tooth’s enamel contains keratin, a type of protein, and requires vitamin A for its formation. Vitamin D is essential to the process by which calcium and phosphorus are deposited into crystals of hydroxyapatite, the structural matrix of bones and teeth.

    During tooth development, fluoride is incorporated into the pre-eruptive tooth’s mineralized structure, along with calcium and phosphorus to form fluorapatite, a compound more resistant to erosion than hydroxyapatite. After the tooth erupts, fluoride is no longer involved systemically in tooth formation. However, the topical effects of fluoride continue to impart protection against tooth decay by decreasing demineralization when the tooth is exposed to organic acids and by increasing the rate of remineralization following erosion by plaque acids.6 Fluoride in saliva also inter-feres with acid production in the bacterial cells that cause oral plaque.7,8 Fluoride can be provided topically to teeth in rinses, dentifrices, gels, varnishes, chewable dietary fluoride supplements, or by fluoridated water.

    Fluoride supplementation is no longer recommended at birth. Fluoride should not be administered to infants during the first six months after birth, whether they are breast-or formula-fed. During the period from six months to three years of age, infants (both breast-fed and formula- fed) require fluoride supple-mentation only if the water supply is severely deficient in fluoride (9 (A dietary fluoride supplementation schedule is provided in Table III. Because of the ingestion of foods with natural fluoride content (e.g., tea) or those reconstituted with fluoridated water (e.g., baby formula, juices) as well as unintentional swallowing of fluoridated oral care products, children are ingesting more fluoride, which may explain the current increase in cases of mild dental fluorosis.9 For this reason, the guidelines for fluoride supplementation reflect more conservative levels at which supplementation is recommended. Parents should be encouraged to monitor the fluoride intake of children younger than six to ensure adequate intake for tooth development, yet prevent overuse.

    Once teeth are fully formed, there is little change in their composition throughout life. Unlike bone tissue, teeth do not readily release minerals, such as calcium or phosphorus, when the body’s need for these minerals are not met by the diet.5

    Clearly, proper oral tissue development depends on adequate nutri-tion. For expectant mothers, lactating women, infants and young children, dietary advice provided during these critical development times can have profound implications on the health and well being of a growing child’s teeth and oral cavity. Thus, it is important to identify individuals at risk for poor nutrition and provide nutrition counseling or a referral to a registered dietitian to ensure adequate intakes of essential nutrients that are necessary for optimal oral health.


    Role of Sugars and Starches in Tooth Decay

    Dental caries is an infectious disease in which bacterial by-products (i.e., acids) dissolve the hard surfaces of teeth. Unchecked, the bacteria can penetrate the dissolved surface, attack the underlying dentin, and reach the soft pulp tissue. Dental caries results from the interaction of four factors in the mouth.10 These factors must be present simultaneously for a long enough time in order to interact.

    • Cariogenic plaque bacteria
    • Fermentable substrate (i.e., sugars and starches)
    • Host and tooth factors, including fluoride and other minerals
    • Saliva flow and composition.


    Plaque Formation

    Plaque is a sticky, gelatinous mass that adheres to the teeth and gingiva. It is composed of bacteria, salivary proteins, polysaccharides, and lipids. Plaque harbors acid-forming bacteria, which are capable of fermenting dietary carbohydrates. The type of carbohydrate in the diet encourages proliferation of specific bacteria, the most common of which is Streptococcus mutans. This type of bacteria prefers sucrose (table sugar), the most common sugar consumed in the diets of children and adults. Other bacteria are also able to metabolize carbohydrates and produce acids at levels sufficient to cause tooth decay.


    Acid Production

    When food or drink containing fermentable carbohydrate is consumed, the pH of plaque begins to drop. Fermentable carbohydrates include both sugars and starches. Sugars may be sucrose, fructose, lactose, maltose, and glucose. Of these, lactose is the least cariogenic. Acids are produced when plaque bacteria metabolize carbohydrate. At a pH below 5.5 (the critical pH), the acids can begin to demineralize enamel and dissolve tooth structure.5 This may last for 20 to 30 minutes until the buffering action of saliva neutralizes the acidity of plaque. In areas between teeth or in fissures on occlusal surfaces of teeth, the pH may drop to as low as 4.0 and may persist for one or more hours.

    Starches found in breads, cereals, pastas, rice, and some vegetables are also fermentable. However, the effect of starch-containing foods on teeth depends on whether the starch is raw, cooked, or refined and whether sucrose is present. Compared to sugars, the time required to initiate the caries process is somewhat longer for starches as salivary amylase, an enzyme, must first hydrolyze large starch molecules into maltose. Fermentation of maltose yields acids that demineralize enamel rapidly. Cereal grains, which are refined and cooked in the production of breads or crackers, are more easily hydrolyzed by salivary amylase. Starch and sugar mixtures, as found in ready-to-eat breakfast cereals, some breads, pastries, and many convenience foods, are retained in the plaque that lodges between teeth, making these foods even more cariogenic than sugars alone.11,12 In fact, foods with a higher content of sugar are removed more rapidly and depress the pH of plaque for a shorter time than starchy foods.13

    Raw starches found in vegetables have low cariogenicity. Fruits on the other hand contain both raw starches and sugars. Despite the sugar content, fresh fruits also have a low cariogenic potential, especially when eaten with meals. This is attributed to the high water content of fruits and the presence of citric acid, which stimulates saliva secretion. Sugars in soft drinks, fruit drinks, fruit juices, and sports drinks are less cariogenic to teeth than solid sweets because beverages clear the mouth more quickly. However, frequent between-meal intake of sweetened beverages or slowly sipping sugar-sweetened drinks, such as soda, coffee, or tea, bathes the teeth with sugars that are easily fermentable and increases caries risk.14 (Early child-hood caries caused by inappropriate feeding practices is discussed in more detail below in, Baby Bottle Tooth Decay.)


    Baby Bootle Tooth Decay

    Early childhood caries, often referred to as baby bottle tooth decay or nursing bottle caries, results from allowing infants to drink from a bottle containing fermentable carbohydrates, such as juice or milk, for prolonged periods of time. This preventable disease occurs between one and three years of age, develops rapidly, and can cause severe dental pain and infection.

    In children allowed to fall asleep while sucking on a bottle, the sweetened liquid pools around the teeth, initiating the demineralization of enamel. This action, combined with diminished salivary flow during sleep, leads to decay of the primary teeth. Early childhood caries also puts a child at greater risk for future dental caries.15

    Early signs of baby bottle tooth decay are white spot lesions on the gingival one-third of the maxillary front teeth.5 Within six months, these lesions may progress to a dull white band of demineralization along the gingival margins of the upper incisors and, if the disease advances further, the four maxillary incisors may be completely destroyed. In advanced stages, the maxillary and mandibular molars and canines also may be involved.

    Prevention involves educating parents before the child’s primary teeth erupt. Education in the dental office can begin when a pregnant woman receives her routine dental care. All caregivers of infants— parents, grandparents, day care providers—should be counseled on appropriate feeding practices. Nap or nighttime bottle feeding in bed should be discouraged. If a child is offered a bedtime bottle, the only safe liquid is water. Similarly, breast-fed infants should be removed from the breast when they fall sleep.

    Fruit juices should not be offered before six months of age and should only be offered in a cup.16 When fruit juice is served, it should be part of a meal or snack. Younger children should not be allowed to sip juice throughout the day. Fruit juice can be offered as one serving (four to six ounces) of the recommended two servings from the fruit group for young children (one to four years) each day. Besides promoting dental caries, high intakes of juice in young children can contribute to diarrhea, malnutrition, and short stature.16


    Saliva Flow and Composition

    Saliva is a protective fluid in the mouth. The amount, flow, and composition of saliva is influenced by the aroma, taste, and chewing of foods. Saliva flow clears food debris from the mouth and helps neutralize the action of plaque acids. As it buffers the plaque acids, the calcium, phosphorus, and fluoride molecules in saliva promote the remineralization of eroded areas on teeth. However, if the acid challenge is too frequent or continues for too long, saliva may not be able to protect enamel from demineralization.

    Risk for dental caries increases as saliva production decreases, as seen during sleep, as a symptom of disease, or as a side effect of fasting or medication. Nutritional insults early in development and chronic effects of malnutrition can impair the salivary gland’s secretory function.17 Salivary function also may be damaged by radiotherapy for oral cancer.


    Other Factors Affecting Cariogenicity

    Besides sugars and starches, other factors also influence the cariogenic potential of foods. These factors include frequency of intake, form and consistency, retention time, and position of a food in the meal.

    The frequency of meals and snacks determines the number of opportunities for bacterial plaque to feed on carbohydrates. Acid production occurs as a result of carbohydrate exposure and is not necessarily dependent on the amounts of sugars or starches consumed. Thus, a single exposure to a large amount of sugary foods is less cariogenic than multiple exposures of small amounts of sugar spread throughout the day.

    The consistency of foods, such as stickiness, also determines the length of time that carbohydrates are exposed to bacterial plaque. Foods that adhere to the surfaces and crevices of teeth include sticky candies, dried fruits, and sweetened flour products. The form of foods also influences the retention time of carbohydrates in the mouth. Liquids are cleared from the mouth more quickly than solids, and foods with coarse particles are preferable to finely divided particles that become lodged in the fissures and crevices of teeth. Foods that stimulate saliva secretion, including cheese, salt, and raw fruits and vegetables, help to limit oral retention of cariogenic foods.

    The position of cariogenic foods consumed in a meal affects caries risk by influencing the magnitude of a decrease in plaque pH. For example, if a piece of aged cheese is eaten after an acid-producing food such as canned peaches in heavy syrup, the plaque pH rises above the critical pH very quickly.18 Likewise, a sugared beverage causes a rapid drop in pH, but it will rise if followed by an unsweetened food. Therefore, placing foods that stimulate a drop in pH between other foods or ending a meal with a low cariogenic food lessens the risk of tooth demineralization.5


    Sugar Alcohols and Sugar Substitutes

    Sugar alcohols, also referred to as polyols, are sweeteners used in reduced calorie foods. Chemically, they are neither sugars nor alcohols. Scientists refer to them as sugar alcohols because part of their structure chemically resembles sugar and part is similar to alcohols. Sugar alcohols approved for use in the United States include sorbitol, mannitol, xylitol, lactitol, maltitol, and isomalt. Their most common use is in “sugar-free” candies, gums, and syrups. The sweetness of different types of sugar alcohols varies , ranging from about half as sweet as sugar to roughly as sweet.

    Sugar alcohols are best known for their modest effect on blood glucose levels. They are slowly and incompletely absorbed from the small intestine and are converted to energy by processes that require little or no insulin. Extensive studies of sugar alcohols show that they result in limited acid production by plaque bacteria. In fact, frequent use of chewing gum sweetened with xylitol or xylitol/sorbitol mixtures has been found to reduce plaque as well as levels of S. mutans in plaque and saliva.19 This may be explained by the stimulatory effect of chewing on saliva flow coupled with the noncariogenic effects of these reduced-calorie sweeteners. However, in individuals with impaired salivary gland function, the limited acid production seen with sorbitol-and mannitol-sweetened gums and candies may be enough to stimulate tooth erosion.20

    Non-caloric sweeteners, including aspartame, acesulfame potassium, and saccharin, do not promote dental caries because oral bacteria do not metabolize these sweeteners. Therefore they do not convert them into plaque or the acids that cause tooth decay.5,11

    Nutrition Screening in the Dental Office

    The following information related to nutrition and oral health can be collected by the dental hygienist to screen for clients needing nutrition information or, if necessary, further intervention by a registered dietitian. These facts can be recorded as part of the client’s initial medical/dental history form. Questions can also be incorporated into the interview time before or after the oral exam and prophylaxis.

    • Fluoride intake—systemic and topical
    • Frequency of snacking
    • Types of foods consumed between meals
    • Intake of sweetened beverages, including juice, soda, coffee, or tea
    • Gastric reflux or frequent vomiting (eating disorders)
    • Saliva flow—medications or conditions that may reduce saliva flow
    • Chronic diseases or conditions (diabetes, heart disease, HIV infection, eating disorder)
    • Overall diet quality—variety of foods from each food group each day
    • Use of vitamin and/or mineral supplements
    • In infants, use of baby bottle (with juice or milk) as pacifier or


    Anticariogenic Foods

    Components of foods can have protective effects on tooth enamel that decrease cariogenic potential. Some foods decrease the solubility of enamel and chances of demineralization while others stimulate salivary secretions that help to remineralize tooth enamel. Substances that make the enamel less susceptible to demineralization include fluoride, cocoa, phytate, oxalate, and proteins in milk. Citrus fruits, which contain citric acid, are known to stimulate saliva production.5

    Studies indicate a protective effect of cheese against dental caries. Cheeses such as aged Cheddar, Swiss, blue, Monterey Jack, mozzarella, Brie, Gouda, and Amer-ican processed cheese have been shown to prevent plaque pH from dropping to a level conducive to caries formation, even in the presence of sucrose.21 The protective properties of cheese are attributed to several factors. The texture of cheese increases the salivary secretion rate, while the nutrient content (protein, calcium, and phosphorus) neutralizes plaque acids. Evidence also suggests that some cheeses enhance remineralization of enamel.22,23 Eating cheese can be an effective strategy for preventing dental caries when oral hygiene is not feasible, especially when consumed at the end of a meal or in combination with caries-promoting foods.

    Milk is also considered noncariogenic. Its nutrients, including calcium, phosphorus, magnesium, vitamin D, and others, may offer protection against dental caries. Studies have demonstrated that phosphoproteins in milk inhibit acid demineralization of enamel and that milk enhances remineralization of tooth enamel surfaces previously softened with a cola-type beverage.24,25 Despite concerns that chocolate milk may contribute to dental caries, no scientific evidence supports this belief.26 In fact, there is evidence that foods containing milk protein, calcium, phosphorus, and cocoa—all of which are found in chocolate milk—may be less likely to contribute to dental caries than sucrose alone or snack foods, such as potato chips, cookies, and raisins.26,27 Furthermore, since chocolate milk is a liquid, it clears the mouth more quickly than carbo-hydrate-containing solids. Thus, it is less likely to cause tooth decay.


    Nutrition and Periodontal Disease

    Adequate nutrition, along with other host factors, is necessary to maintain resistance to periodontal disease. Although the role of diet and nutritional factors in development of periodontal disease is unclear, it is known that the defense mechanisms of the gingival tissues and saliva can be affected by nutritional intake and status. For example, healthy gum tissue normally prevents penetration of bacteria that can lead to gingivitis. Deficiencies of vitamin C, folic acid, and zinc may increase the permeability of gingival tissue, making these clients more susceptible to bacterial plaque that causes periodontal disease. Studies examining vitamin C and calcium intake found that individuals with low intakes of vitamin C and calcium are at increased risk for periodontal disease.28,29 This effect is accentuated in current and former tobacco users with suboptimal vitamin C intakes who show an even greater risk of periodontal disease.28

    Nutritional status is also linked to immune response. With periodontal infection, the ability of the oral tissues to utilize nutrients is altered, thus interfering with normal healing and repair. At the same time, nutritional deficiencies can weaken the resistance of oral tissues to plaque bacteria, causing increasing inflammation. Oral health care professionals are in a position to identify possible nutrient deficiencies by looking for certain signs and symptoms, including stomatitis, glossitis, soreness, tingling, or burning of the tongue, bleeding gingiva without the obvious presence of periodontitis or gingivitis, angular cheilosis, and oral ulcerations. (See Table V for oral signs and symptoms of possible nutrient deficiencies.) If a nutritional deficiency is suspected or if a person’s oral health puts them at risk for a deficiency, a referral to a registered dietitian or physician may be helpful to evaluate the person’s nutritional intake and status, and ultimately prevent serious consequences resulting from nutritional deficiencies.

    Prior to and following periodontal surgery, it is important to ensure adequate nutrients for wound healing and to maintain a healthy immune response to prevent infection. Adequate intakes of vitamins Aand C, zinc, and protein are essential. If the procedure or the wound prevents normal intake of foods for an extended period, a soft or liquid diet and multivitamin supplementation may be recommended by a registered dietitian.


    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.


    Key Terms

  1. Angular cheilosis: cracking at corners of the mouth
  2. Carbohydrate: sugars and starches used by the body as a source of energy
  3. Fructose: natural sugar found in fruits
  4. Glossitis: inflammation of the tongue
  5. Glossodynia: soreness, tingling, or burning of the tongue
  6. Glucose: the main sugar in blood and an important source of energy; found in fruits, sweet corn, corn syrup, and honey
  7. Lactose: natural sugar found in milk
  8. Maltose: natural sugar found in some cereal grains; a sugar unit consisting of two glucose units
  9. Stomatitis: inflammation of oral tissues
  10. Sucrose: table sugar
  11. Xerostomia: dry mouth


Supplemental Activities

View the following Web sites for additional information on nutrition topics related to oral health.

American Cancer Society
www.cancer.org

American Dietetic Association
www.eatright.org

American Diabetes Association
www.diabetes.org

American Institute for Cancer Research
www.aicr.org

Dietary Guidelines for Americans
www.health.gov/dietaryguidelines/

National Dairy Council
www.nationaldairycouncil.org

HIV Nutrition Resources
www.hivresources.com


Author

Betsy Hornick, MS, RD, LD, is a registered dietician and freelance nutrition writer in Poplar Grove, Illinois.