Nutrition in Orthodontic Practice
Maintenance of good general dental health and optimal orthodontic outcomes are greatly dependent on adequate nutrition. The development of the oral cavity and its structures is influenced by the nutritional state of an individual and both deficiencies and toxicities may cause malformations. After tooth eruption, nutritional factors influence the teeth topically and have great impact on both the prevention and development of dental caries. Good nutrition can maximize while poor nutrition can undermine the appropriate biological response of the periodontal ligament and alveolar bone to orthodontic forces.
Orthodontic practitioners, by virtue of patient contact at a nutritionally sensitive period, are in a good position to screen/assess for inadequate nutrition and poor eating behaviors. Simple, quick, and routine diet risk assessment tools (which are different from the more extensive nutritional assessments done by dietitians and nutritionists) can be used during the office visit. Depending on the results of this assessment, the practitioner can either choose to provide simple dietary recommendations and guidance to patients or, if more complex nutritional issues or disease is uncovered, refer them to specialists such as physicians, registered dietitians, and/or therapists. The key to effective diet education in the orthodontic office is a logical, ordered approach, which includes patient education, data collection, data evaluation/diagnosis, providing nutrition guidance, follow-up and re-evaluation, and a few key personalized recommendations.
A basic understanding of nutrition as well as good guidance and communication skills, will help orthodontic practitioners to improve their orthodontic outcomes in addition to helping improve the quality of life of their patients.
Introduction: the Role of the Orthodontist in Nutrition
Nutrition, oral health, and general health are inextricably linked. In his 2000 report on Oral Health in America, the Surgeon General of the United States emphasized the need for ‘all healthcare providers’ to play an ‘active role in promoting healthy lifestyles … by incorporating nutrition counseling into their practices’ (US Department of Health and Human Services et al., 2000). This is particularly important for dental professionals, as oral health plays an important role in nutrition and vice versa. The health of the oral cavity can facilitate or impede the desire and ability to eat. Conversely, diet and nutrition play important roles in oral health promotion and caries prevention.
The orthodontist is well positioned to help screen for dietary issues, as well as provide meaningful dietary advice. Many orthodontists report regularly engaging in dietary discussions with their patients (Huang et al., 2006). Nutrition and diet are relevant topics between practitioner and patient as good nutrition maximizes orthodontic outcomes. Orthodontists usually see patients in childhood or early adolescence. This allows for early detection of and intervention for dietary problems. When nutrition issues relate directly to dental or orthodontic issues, the orthodontist can assist in promoting behavior change for oral health. When nutrition issues are beyond the orthodontic scope of practice, referral can be made to a physician or registered dietitian.
This chapter will review the relevance of nutrition to orthodontics and how the orthodontist can assist in facilitating good nutrition for good oral health. Additionally, this chapter will provide practical advice about delivering patient education designed to promote positive dietary behavior change. A point to note before considering this in more depth is that in casual conversation the terms diet and nutrition are often used interchangeably. However, particularly in an oral health context, the difference between the two is important. Diet is the pattern of food intake, the ways in which people eat. This includes their individual food choices, the frequency of eating, and the underlying values that determine what foods are eaten or avoided. This is particularly important in dental caries etiology and prevention. Nutrition is the systemic effect of food on the body. Malnutrition can mean undernutrition, overnutrition, or nutrition that contributes to ill health such as in cardiovascular disease.
What Is an Adequate Diet?
An adequate diet is a diet that meets all of the known nutritional requirements for health. As knowledge is ever increasing about human nutritional requirements, dietary standards and guidelines are continuously updated to reflect these changes. Known human nutrient requirements are documented in the dietary reference intakes (DRIs) in the United States, and are available in table form (fnic.nal.usda.gov). Most countries have similar standards, however, as the standards are listed in physiologically needed amounts (e.g. grams, milligrams, micrograms/day etc.) and not in commonly consumed foods, they are not useful for educating the public. Thus, dietary guidelines and food grouping systems have been devised, as translations of the DRIs into the foods that provide them. Foods are grouped by similar nutrient content. The most recent and most comprehensive food grouping system for the United States is called MyPlate (www.choosemyplate.gov Figure 5.1), which not only provides the general diet guidelines for health but also provides specific recommendations based on age, gender, weight, and exercise level. Table 5.1 shows examples of the recommended daily food intake for two teenagers and two adults. The most useful approaches to diet assessment and education in dental practice compare the patient’s usual food intakes with these standards to determine general adequacy/potential concerns. The MyPlate website may be appealing for the tech-savvy adolescent age group. See Table 5.2 for a summary of the diet recommendations for adolescents and adults along with practical recommendations for meeting these guidelines.
Source: US Department of Agriculture (2010).
Adapted from US Department of Health and Human Services and US Department of Agriculture, 2005. (US Department of Health and Human Services, US Department of Agriculture (2005) Dietary Guidelines for Americans, 2005. Washington DC: Government Printing Office.)
|Categories||Key recommendations for adults and adolescents||Practical recommendations for patients for improving diet quality|
|Fruit||2+ cups of fruit per day||Add fresh fruit to cereal, granola, oatmeal, waffles, pancakes, toast, or yogurt|
|Eat fruit for snacks|
|Eat fruit for dessert with frozen yogurt or whipped topping|
|Fresh, canned, frozen, and dried fruits all count, but choose those without added sugar or heavy syrup|
|Vegetables||2.5+ cups of vegetables per day||Eat fresh vegetables with a dip or hummus for snacking|
|Add vegetables to pasta dishes, casseroles, pizza, or stir-fries, sandwiches|
|Start meals with a small salad|
|Fresh, canned, or frozen vegetables all count, but choose those without add salt or butter or creamy sauces|
|Dairy||3 cups of low-fat or fat-free dairy per day||Use low-fat or fat-free milk on your cereal|
|Snack on low-fat or fat-free yogurt or cheese|
|Add low-fat or fat-free cheese to sandwiches or salad|
|Starches and grains||3–6 28 g (1 oz) servings of whole grains per day with the rest of grains coming from enriched grain products||Choose wholegrain bread products, wholegrain pasta, brown rice, barley, and bulgar for meals|
|Choose wholegrain crackers, plain popcorn, or oatmeal cookies for snacks|
|Fat||Adults: Total fat should comprise 20–35% of the total calories with most coming from monounsaturated fats and polyunsaturated fats
Adolescents: Total fat should comprise 25–35% of the total calories with most coming from monounsaturated fats and polyunsaturated fats
|Vegetables oils, fatty fish, avocados, nuts, and nut butters are all good sources of mono- and polyunsaturated fats|
|Serve salmon for dinner or add it as a protein to a salad|
|Add avocado to sandwiches, salads, or eat it as a snack with lemon|
|Cook with vegetable oil instead or lard or butter|
|Snack on nuts or make a nut butter sandwich|
|Saturated fats should be limited to less than 10% of total calories||Limit red meat, lard and full-fat dairy including milk, yogurt, cheese, sour cream, butter, cream, ice cream|
|Limit trans fat to as low as possible||Limit fried fastfood, commercially prepared bakery goods (pies, donuts, cookies crackers), and shortenings|
|Protein||114 g (4 oz)/day. Choose lean protein||Lean flesh proteins include: lean cuts of beef (tenderloin, flank steak, roast beef, or London broil); lean cuts of pork (tenderloin or fresh ham); lean cuts of veal and lamb (roast or chop); chicken and turkey meat with skin removed; fish and shellfish, tuna canned in water; sardines; and low-fat luncheon meats|
|Lean vegetarian proteins include: tofu, beans, low-fat cheese or cottage cheese, egg whites, and egg substitute|
|Added sugars||Limit added sugars||Limit general sweets such as cookies, candies and chocolate|
|Limit drinking sugar-sweetened beverages including regular soda, sweetened coffee or tea, energy drinks, sports drinks, or imitation fruit drinks|
|Practice good dental hygiene and consume sugar- and starch-containing foods less often to reduce the risk of dental caries||Limit sugar-containing foods in between meals|
|Limit sucking on hard candies, breath mints or cough drops|
|Avoid constantly sipping on sugar sweetened beverages including regular soda, sweetened coffee or tea, energy drink, sports drinks, or imitation fruit drinks|
|Physical activity||Adults: 30 minutes of moderate- intensity physical activity to reduce the risk of chronic disease and 60 minutes to prevent gradual weight gain into adulthood
Adolescents: 60 minutes of physical activity most days of the week
|Take the stairs, park further from the store in a parking lot, limit time in front of the television and computer, join a sports team or a gym or walk outside|
|Minerals||Limit sodium to 2300 mg/day||Limit processed foods such as frozen meals or partially prepared boxed meal starters|
|Choose low-sodium or no-salt-added canned foods or rinse regular canned foods|
|Avoid adding extra salt during cooking or at the table|
(from US Department of Agriculture, 2011)
Nutrition and the Orthodontic Patient
Importance of Nutrition During Development and for Maintenance of Oral Tissues
Growth and development of all tissues and structures, including that of the oral cavity, directly depend on adequate nutrition. Tooth development begins in utero and continues until the third decade of life, when the third molars emerge into the oral cavity, and all teeth complete root formation. Following their emergence into the oral cavity the dental crowns become exposed to the oral environment. At the time of emergence, the dental roots are incomplete, and while the eruptive movement continues, the tissues surrounding the teeth model and remodel, as part of overall growth, and this activity continues in adult life. In both young people and adults, nutrition plays a pivotal role in determining the nature of tissue growth, remodeling, and the individual response to physical and chemical challenges. Thus, all age groups are dependent on consistent good nutrition (Romito, 2003).
Oral development (including tooth mineralization) begins in utero and prenatal nutrition of the mother is the first important factor that affects the ultimate oral development of the child (Tinanoff and Palmer, 2000). Maternal deficiencies of folic acid, riboflavin, and zinc during pregnancy can lead to severe craniofacial abnormalities such as cleft lip and palate in the child. General malnutrition and specific nutrient deficiencies (as well as nutrient toxicities) during tooth development can adversely affect tooth size, formation, and eruption pattern. For example, protein deficiency during early childhood can affect the tooth size and eruption sequence. Vitamin C deficiency may alter collagen formation and bone development. In developing countries where malnutrition is rampant, such nutrition-related defects are commonly observed. In developed countries, however, overt malnutrition and specific nutrient deficiencies are less common (Romito, 2003). However, issues related to nutrient toxicity do occur. A few years ago, the accidental over-fortification of milk with vitamin D by a commercial dairy resulted in malformation defects in erupted dentition in a young child (Giunta, 1998). Thus, orthodontists should be aware of the importance of nutrition during oral growth and development, and should counsel pregnant women about the importance of optimal nutrition for the wellbeing of their unborn child as well as for their own health. They should caution against the random use of nutritional supplements other than multivitamins or calcium/vitamin D supplements, unless they are prescribed by a physician.
Role of Diet in Dental Caries
The orthodontist is in an ideal position to educate patients about diet and dental caries, since orthodontic appliances increase the available surfaces for plaque accumulation, resulting in more areas for caries to occur. Following eruption, teeth are most susceptible to dental caries (2–5 years for deciduous teeth and early adolescence for permanent teeth). Caries is the result of demineralization of tooth enamel and dentin by organic acids formed by bacterial metabolism of dietary sugars. The development of dental caries is influenced primarily by the total amount of time fermentable carbohydrates (simple sugars: mono and disaccharides) are in contact with cariogenic plaque. Thus, the frequency of consumption, form of sugar (indicating retention of sugar in the mouth), and timing of consumption (at or in-between meals) are the important factors in determining caries risk. It is important to remember that the total amount of sugars consumed does not seem to be the most important factor in the cariogenic potential of the diet. Dietary patterns that include frequent snacking/ sipping on foods or beverages that contain simple sugars are more conducive to caries development than infrequent snacking (Moynihan and Petersen, 2004). Table 5.3 shows the relative cariogenicity of various foods.
|Cheese sticks||Chocolate||Dried fruit|
|Cheese and crackers||Yogurt||Candy, lollipops, hard candy|
|Vegetables with dip||Soda|
|Pieces of meat||Cake, cookies, pie|
For the general public, the term sugar that is associated with dental caries is often equated with the disaccharide sucrose, or table sugar. However, all monosaccharides (glucose, fructose, galactose) and disaccharides (sucrose, maltose, lactose) have cariogenic potential. In the realm of dental health, the term fermentable carbohydrates is often used for those carbohydrates that can be metabolized by bacteria to produce acid and as a result, increase caries risk (Kandelman, 1997). These are primarily the mono- and disaccharides, but starches can also be cariogenic when held in the mouth long enough for salivary amylase to hydrolyze them to simple sugars.
For simplicity in making recommendations to patients, it is important to communicate that protein, fats, and food fibers are not cariogenic. The only cariogenic foods are those that are composed of one or more of the simple sugars. These include sugars added during manufacturing (formerly sucrose, now primarily high-fructose corn syrup) as well as table sugar added in cooking or at the table and naturally occurring sugar found in fruit, juice, honey, and molasses (Moynihan and Petersen, 2004).
How Diet Can Help Protect the Teeth Against Caries
Saliva plays a major role in preventing dental caries by promoting enamel remineralization, cleansing the mouth, and helping neutralize acids. The act of chewing facilitates salivary flow. Many medications, including common over-the-counter ones such as antihistamines, can cause decreased salivary flow or xerostomia. Xerostomia increases the caries risk associated with the diet, due to the loss of the acid-mitigating effects. Thus hydration to maintain salivary flow is vital for caries prevention.
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