1. Nutrition for Oral and Dental Health

2. 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

3. Effects of Nutrient Deficiencies on Tooth Development

4. 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)

5. Anatomy of a Tooth

6. 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.

7. 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

8. 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

9. Early Childhood Caries
(From Swartz MH. Textbook of Physical Diagnosis, History, and Examination, 3rd ed. Philadelphia: W.B. Saunders, 1998.)

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

11. 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)

12. 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

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

14. 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.

15. 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

16. 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

17. 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

18. 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

19. 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

20. Caries Prevention Guidelines

21. 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

22. 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.

23. 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:

24. 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

25. 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

26. Medications That May Cause Xerostomia

27. 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

28. 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

29. 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

30. Dysphagia = difficulty swallowing
Mechanical causes
Trauma to esophagus with scar tissue
Inelasticity due to repeated inflammation
Tumor of esophagus
Aneurism of aorta

31. Dysphagia = difficulty swallowing
Neuromuscular causes
CVA, brain tumors
Head injury
Parkinson’s disease, MS, ALS
Achalasia (cardiospasm)
Spinal cord injury

32. Dysphagia
Oral phase problems Pocketing food Drinking from cup or straw Drooling
Pharyngeal phase Gagging Choking Nasal regurgitation
Esophageal phase Obstruction

33. 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

34. Diagnosis of Dysphagia
Nerve assessment
X-rays
Fluoroscopic swallow study: barium swallow/cookie swallow
Measurement of esophageal sphincter pressure and peristalsis

35. 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

36. 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

37. Thickened Liquids

38. MNT for Dysphagia
In severe cases, patient may be made NPO and enteral feedings initiated

39. 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

40. 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

41. 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

42. 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

43. 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

44. Piped and Molded Pureed Foods

45. 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