Fig. 19.1

Definitions
The nature and extent of associations and relationships between nutrition, oral and systemic health have expanded; approaches to systemic health screening have been identified for OHCPs [914]. Several of these screening approaches include nutrition and diet parameters. Likewise strategies for nutrition risk and diet screening have been described for dental practices. For health and nutrition risk screening, the outcomes include identification of risk for disease, malnutrition, or presence of dietary factors associated with disease. Following screening, the OHCP can determine risk, oral or dental diagnosis(es) requiring intervention and provide appropriate baseline nutrition education and referral to other healthcare professionals for further assessment and management as indicated.
Global Goals for Oral Health 2020 proposed by representatives of Foreign Direct Investment (FDI), the World Health Organization (WHO), and the International Association of Dental Research (IADR) [8] and the 2012 American Dental Association (ADA) “Call to Action for Oral Health” [15] support expansion of the OHCP’s role in health screening to improve oral, systemic and nutritional well-being. The oral-systemic-nutrition health risk screening, basic intervention, and referral processes can be used to detect risk for malnutrition and nutrition related oral health risk factors requiring diet/nutrition education and or referral to a registered dietitian (RD) (Fig. 19.1). The goal of nutrition and health risk screening is early detection and intervention to reduce the incidence and severity of nutrition risk and maximize response to treatment. The screen can be completed at the patient’s initial and periodic reassessment appointments, taking less than 10 minutes. The amount of time that may be saved secondary to screening and subsequent care or referral, is not quantifiable. The outcomes of health and nutrition risk screening provide the OHCP with indication of weight status, food and nutrition access problems, dietary factors influencing oral health, oral integrity problems influencing diet intake, and any factors related to diet or nutrition that indicate risk for malnutrition or related chronic diseases (if such risk factors are assessed). The next steps to be taken should be based on individual needs. This may include diet assessment and education by the OHCP, referrals to social services for food and supplement resources in the community, a physician referral for systemic health issues or referral to a registered dietitian (RD) for medical nutrition therapy (MNT) (see Fig. 19.1 for definitions).
Table 19.1 describes possible risk factors associated with compromised nutrition and oral health for both OHCPs and RDs. This list is not all inclusive. The risk screen for OHCPs and RDs differs primarily in focus; nutrition first versus oral health first; however, the outcomes and goals should be similar. Possible interventions may include referral to the appropriate provider, either the RD or OHCP, the provision of baseline education, and a plan for future follow-up.

Table 19.1

Medical and physical risk factors for compromised nutritional and oral health status
Alterations in taste
Autoimmune disorders
Cardiovascular disease
Craniofacial anomalies
Cranial nerve dysfunction
Crohns disease
Deficiencies of vitamins, minerals, trace elements
Dental procedures altering ability to eat a usual diet
Developmental disorders
Diabetes
Disorders of taste and smell
Eating disorders
Early childhood caries
End-stage renal disease
Erosion
Extensive dental caries
Fad dieting/nutrition quackery
Gastroesophageal reflux disease
Hypertension
Immunocompromising conditions (e.g., cancer, HIV infection, AIDS)
Infectious diseases
Multiple sclerosis
Musculoskeletal disorders
Neoplastic disease
Physical/mental handicaps
Polypharmacy
Poor dentition/edentulism
Poverty
Protein-energy malnutrition/wasting
Spinal cord injury
Radiation therapy
Salivary dysfunction
Substance abuse (alcohol and/or drugs)
Transplant surgery
Ulcerations/lesions
Unhealthy body weight
Unintentional weight loss
Vesiculobullous diseases
Xerostomia

Determining Nutrition Risk: The Role of the Oral Health Care Professional

The primary aim of a nutrition risk screening tool is to identify patients who are at or may be at nutrition risk and in need of referral to a RD or other health professional for further assessment and intervention. Figure 19.2 is a sample of an oral health and nutrition risk screening tool used in an urban, northeastern U.S. dental school’s adult clinics. The parameters included on this tool were derived from a 2004 study by Radler in the dental clinic [16].

A145358_2_En_19_Fig2_HTML.gif
Fig. 19.2

Sample dental school clinic nutrition risk screening tool
Health and nutrition risk screening in the dental setting includes subjective questions (Table 19.2) relative to diet, oral health status, biting and chewing ability, and body weight history as well as objective assessment of height, weight, and the condition of the oral cavity. The extent to which these questions as well as laboratory data and other assessment components are used depends, in part, on the type of dental practice and the overall health and disease history of the patient. Practices that include diabetes screening may include a finger stick Hemoglobin A1C or use approaches previously validated in the dental literature [11, 12]. Patients with complex medical histories and/or who take multiple medications or dietary supplements may require more extensive physical and laboratory screening approaches and the OHCP may wish to use all of the questions in Table 19.2.

Table 19.2

Nutrition risk questions to ask patients about common symptoms/conditions
A145358_2_En_19_Taba_HTML.gif
Nutrition risk factors are defined as “characteristics that are associated with an increased likelihood of poor nutritional status” [17]. Risk for malnutrition is based on the type and extent of risk factors present [18]. The elderly patient who lives alone, has lost more than 10 pounds in 6 months and has difficulty chewing is at risk for weight loss and malnutrition, as is the 35-year-old woman who presents with an unintentional 10 pound weight loss and candidiasis, complains of burning mouth, and on appropriate testing has a 2 hours post prandial blood glucose of 180 mg/dl.

History

The patient history reveals information about acute, chronic, and terminal diseases that may impact oral and nutritional well-being. In addition to asking patients about their medical, surgical, and drug history, diet and nutrition history questions may also be asked as outlined in Table 19.2.
Unintentional weight change may signal potential nutrition deficits, lack of money for food, or evidence of systemic disease. Weight screening is an inexpensive, noninvasive, rapid health risk assessment measure. Weight loss is characterized by loss of body-fat stores and lean body mass. Patients should be weighed during initial visits and subsequent checkups. The initial-visit weight provides a baseline for comparison for future reference. Although the weight history will be based on self-report, it is valuable to establish an objective ‘first visit’ weight as a basis for comparison on future visits. Weight change is typically associated with either a change in eating habits or evidence of a possible systemic disease. Eating habit changes may be intentional with a goal of weight loss or gain or caused by oral or systemic health issues influencing appetite or functional ability to eat. In either case, the result is a change in nutrient intake. Percent weight change can be calculated using actual and usual weight (Table 19.3). OHCPs should question patients as to whether the weight change was intentional or unintentional. An unintentional weight loss of 5% or more in 3 months or less or of 10% or more in 6 months or less indicates risk for malnutrition. Body mass index (BMI) represents body weight in proportion to height; weight classifications based on BMI are underweight, normal, overweight, obesity (class I or II) and extreme obesity (class III). A BMI below 18.5 reflects underweight, 18.8–24.99 reflects normal weight; 25–29.99 represents overweight and a BMI value of 30 or greater indicates obesity. BMI is used to identify chronic disease and mortality risk due to overweight and or obesity in adults; an online BMI calculator is available at “www.​nhlbisupport.​com/​bmi/​bmi-m.​htm”. It should be interpreted with caution since it does not measure body fat distribution or variation in fatness due to race, age or fitness level. Once measurements are completed, OHCPs may wish to use one of several web-based programs available to calculate weight change and BMI [19] (​www.​nhlbi.​nih.​gov/​guidelines/​obesity/​BMI/​bmicalc.​htm, ​www.​cdc.​gov/​healthyweight/​assessing/​bmi/​). Equations for calculating and interpreting anthropometric data are in Table 19.3.

Table 19.3

Formulas for weight and body mass index and other anthropometric calculations
Wt change is calculated based on usual body wt:
$$ \frac{\text{today's wt}}{\text{usual wt}}\; \times \;100\; = \;\% $$ weight change
Current (today’s) wt < usual wt = negative wt change
Current (today’s) wt > usual wt = positive wt change
Ranges of desirable height and weight for adults: rule of thumb
Men = 106 ilbs for the first 5 ft + 6 lbs/in
Ex: 5′6″ man = 106 + (6 inches × 6 lbs/in) = 106 + 36 = 142 lbs ± 10% desirable wt
Women = 100 lbs for the first 5 ft + 6 lbs/in
Ex: 5′2″ woman = 100 + (2 inches × 5 lbs/in) = 100 +10 = 110 lbs ± 10% desirable wt
Note: ±10% = based on frame size; weight range may be 10% greater or less than the calculated wt
Body mass index
Body wt in kilograms (kg) (height in meters)2 or Wt (in lbs) × 703 divided by (height in inches)2
If patient does not know his usual weight, desirable weight can be used to calculate % desirable weight. This will also give an indication of body stores. Weight alone does not differentiate between body fat versus muscle mass

Medical History

The medical history reveals information about acute or chronic diseases that are risk factors for individuals with concurrent oral or dental problems that affect their ability to consume their usual diet. The medical history, when combined with questions noted in Table 19.2 provides the OHCP with insights into disease control and the need for diet intervention. This intervention, if focused solely on dietary strategies as a result of masticatory or soft tissue problems, can be done by the OHCP. Patients who need more in-depth nutrition assessment and diet counseling related to their systemic disease should be referred to an RD for medical nutrition therapy (MNT). Diabetes is associated with oral manifestations.
These manifestations vary and may include periodontal disease, dysgeusia, increased caries risk, candidiasis, burning tongue, xerostomia, and poor wound healing which may in turn impact appetite, eating ability, and, finally, oral intake [10, 20]. Neuropathies and opportunistic microbial infections in the oral cavity affect oral health, nutrition status, and inevitably diabetes control. Chapter 11 provides further information on screening, risk factors and management of patients presenting with risk for diabetes or with a diagnosis of diabetes.
Autoimmune diseases such as pemphigus vulgaris increase nutrition risk by virtue of the oral and systemic sequellae of the disease and the medications used to manage the disease [1, 2]. Inflammatory arthritides have associated medication side effects, and joint pain or mechanical limitations may compromise eating ability. Steroid medications often used to manage these diseases increase risk of diabetes and nitrogen (protein) and calcium losses, thus increasing protein and calcium needs. The xerostomia associated with Sjögren’s syndrome increases risk for dental caries, periodontitis, and oral mucosal injury or pain, which may make eating difficult or painful. Temporomandibular joint pain may result in limited opening of the mouth and compromised masticatory ability. Chapter 15 on autoimmune disorders provides further information on detection, systemic and nutritional issues and management.
Head and neck and oral cancers affect nutrition and oral health status. Surgery to remove tumors in the oral cavity may have severe functional effects on eating ability. Radiation to the oral cavity can destroy taste as well as the quality and quantity of saliva. Chemotherapy can cause anorexia, stomatitis, nausea, and vomiting, ultimately compromising nutrition status [21]. Chapters 12 and 13 provide further information on screening, risk factors and management.
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Nov 6, 2015 | Posted by in General Dentistry | Comments Off on
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