Nutrition for Oral and Dental

Health
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
Effects of Nutrient Deficiencies on
Tooth Development
 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)
Anatomy of a Tooth
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.
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
Early Childhood Caries
Also called baby bottle tooth decay
Nursing bottle cariesputting 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
Early Childhood Caries

(From Swartz MH. Textbook of Physical Diagnosis, History, and Examination, 3rd ed. Philadelphia: W.B. Saunders, 1998.)
Dental Cariescontd

Streptococcus mutansmost common

bacteria involved
Fermentable Carbohydrate
Time
Drop in salivary pH to below 5.5
Dental Cariescontd
Cariogenicity of foods
Frequency of consumption of fermentable
Carbohydrate
Food formslowly dissolving
Food combinations
Nutrient composition of food/beverages
Timing (end of meal)
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
Fluoride
Primary anticaries agent
Water fluoridation
Fluoridated toothpastes
Oral rinses
Dentrifices
Beverages made with fluoridated water
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.
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
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
 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
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
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
Caries Prevention Guidelines
Periodontal Disease
Inflammation of the gingiva with destruction
of the tooth attachment apparatus
Gingivitisearly form
Nutritional care involves increasing vitamin C,
folate, and zinc
Tooth Loss and Dentures
Tooth lossdenture 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.
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: http://webpages.marshall.edu/~gain/bactnote/Image9.gif
Oral Manifestations of Disease
Xerostomia: Dry mouth
Periodontal disease
Kaposis sarcomalesions in mouth and
esophagus; associated with AIDS

Kaposis Sarcoma
in AIDS
 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
Medications That May Cause
Xerostomia
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
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
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
Dysphagia = difficulty
swallowing
Mechanical causes
Trauma to esophagus with scar tissue
Inelasticity due to repeated inflammation
Tumor of esophagus
Aneurism of aorta
Dysphagia = difficulty
swallowing
Neuromuscular causes
CVA, brain tumors
Head injury
Parkinsons disease, MS, ALS
Achalasia (cardiospasm)
Spinal cord injury
Dysphagia
Oral phase problems
Pocketing food
Drinking from cup or straw
Drooling
Pharyngeal phase
Gagging
Choking
Nasal regurgitation
Esophageal phase
Obstruction
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
Diagnosis of Dysphagia
Nerve assessment
X-rays
Fluoroscopic swallow study: barium
swallow/cookie swallow
Measurement of esophageal sphincter
pressure and peristalsis
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
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
Thickened Liquids
MNT for Dysphagia
In severe cases, patient may
be made NPO and enteral
feedings initiated
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
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
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 inch
pieces, well-cooked casseroles, cottage cheese; avoid
peanut butter, sandwiches, pizza
Most soups
Soft, well-cooked vegetables with less than inch pieces;
no corn, peas, fibrous varieties
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
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
Piped and Molded Pureed Foods
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