Nutrient deficiencies associated with nutrition-focused physical findings of the oral cavity Diane Rigassoi Radler, PhD, RD Tracy

Lister, MHS, RD Nutrition in Clinical Practice December 2013 28(6): 710-721

BACKGROUND: NUTRITION-FOCUSED PHYSICAL EXAMINATION

The goal: Early detection and correction of deficiencies An assessment tool to enhance/complement evaluation of biochemical markers and information received during patient interviews

End result: Comprehensive understanding of patients nutritional status

NUTRITION-FOCUSED PHYSICAL EXAMINATION: ORAL CAVITY

Tool for:
Early detection of deficiencies Monitoring the results of interventions

Due to rapid cells turn-over evidence of deficiency may be present earlier

GOAL OF ARTICLE:

Outline the process of conducting an effective nutritionalfocused oral exam with particular attention on :

Lips Oral Mucosa Teeth and Gums Tongue

Present information on how to:

Identify Confirm Treat Monitor nutrient deficiencies.

CONDUCTING ORAL EXAMINE

Obtain informed consent from patient

Explain purpose of and ask permission to conduct examine

Pen light Tongue Depressor Gloves Is the patient currently or has recently experienced :
Changes

Recommended Equipment:

Relevant Questions:

in taste Sensations of burning or pain Bleeding

NUTRITIONAL-FOCUSED ORAL EXAM: LIPS

Observe the lips for:

Dryness Cracks Color Angular Cheilosis - fissures at corners of mouth Cheilosis -dry, swollen, ulcertated or chapped lips

Identification of possible deficiency:

Sign/Symptom Possible Deficiency B6, Folate, Riboflavin, Niacin, B12, Iron Confounding Factors Herpes, Renal Disease, Rheumatoid Arthritis Alcoholism, Obesity, Pregnancy

Cheilosis
Angular cheilosis

NUTRITIONAL-FOCUSED ORAL EXAM: ORAL MUCOSA

Normal inside of mouth will be pink and moist If present, request patient remove dentures Utilizing tongue depressor and pen light observe mouth for:

Presence of lesions Color Bleeding Swelling/inflammation Ulcers Nodules

IDENTIFICATION OF POSSIBLE DEFICIENCY: ORAL MUCOSA

Possible Deficiency
Zinc

Sign/Symptom
Xerostomia (dry mouth) Apthous Stomatitis (canker sores)

Confounding Factors
Poor intake, Alcoholism Cancer, Dehydration Poor intake, Alcoholism, Cancer, Altered absorption/metabolism Renal, Diabetes

B12, Folate

Candidiasis (thrush)

Vitamin C, Iron

Poor intake, Antibiotics, Corticosteroids, HIV Reduced immunity, Cancer Renal, Malabsorption
Poor intake, Blood loss Malabsorption, Renal

Pale tissue

Iron

Stomatopyrosis (painful, inflamed mouth) Dysethesia (burning mouth syndrome)

Iron, B12, Folate, Magnesium

Poor intake, Alcoholism Menopause, Diabetes,

NUTRITIONAL-FOCUSED ORAL EXAM: TEETH AND GUMS

Utilizing tongue depressor and pen light observe for:

Color

Bleeding
Missing/broken teeth Dental Caries (cavities)

Identification of possible deficiency:

Sign/Symptom Bleeding Gums Tooth Loss Dental Caries Vitamin C B12 Possible Deficiency Confounding Factors Diabetes, Smoking H. Pylori, Infections, Malabsorption, Alcoholism Increased Requirements, Delayed wound healing, Eating disorders, Radiation Therapy

NUTRITION-FOCUSED ORAL EXAM: TONGUE

Request patient stick out tongue Note:

Surface

Rough texture is normal Abnormal might include: pale, bright red, purple, furry white Any enlargement or deteriorate

Color

Papillae

To observe underneath the tough, request patient touch roof of mouth with tongue

Note:

Presences of ulcers, red or white patches

IDENTIFICATION OF POSSIBLE DEFICIENCY: TONGUE

Sign/Symptom
Glossitis (inflammation)

Possible Deficiency
Riboflavin

Confounding Factors
Poor intake, Malabsorption Uremia, Infections, Alcoholism, Poor hygiene, Poor intake, Malabsorption Poor intake, Malabsorption Alcoholism, Kidney disease

Magenta Color
Edema

Niacin
Folate

Atrophic Filiform Paillae (flattened protrusions: results in smooth, slick appearance)

B6

Poor intake, Malabsorption Uremia, Infection, Alcoholism, Poor hygiene

B12
Poor Intake, Malabsorption, Alcoholism, Menopause, Poor mouth care, Depression, Diabetes Mellitus,

Iron

ASSESSMENT OF DEFICIENCIES
Supporting Evidence
Sore red tongue Shiny red lips Fungiform papillae atrophy/enlargement Plasma EGRac Red tongue Pigmented sun develops rash w/sun exposure Vomiting/Diarrhea/Constipation Depression, Headaches, Fatigue, Memory loss Plasma pyridoxal 5 phosphate level Microcytic Anemia Glossitis, Stomatitis, Sore Burning Mouth Peripheral Neuropathy Depression, Confusion Pernicious Anemia Fatigue, Weakness, Weight loss Loss of appetite Numbness/tingling in hands/feet Poor balance Depression, confusion, dementia, poor memory Sore tongue/mouth Low serum folate level High homocysteine level Mucositis, Stomatitis, Sore Burning Mouth, Candidiasis Aphthous ulcers Bald tongue w/red tip/border

Drug/Nutrient , Nutrient/Nutrient Interactions

None Noted

Riboflavin Niacin

None Noted

B6

Cycloserine increases B6 catabolism Theophylline decreases Plasma pyridoxal 5 phosphate Riboflavin can interfere with metabolism

B12

Proton pump inhibitors Histamine receptor antagonists Metformin All decrease B12 absorption

Folate

Anticonvulsants, sulfazalzine, triameterene, barbiturates Negatively affect absorption and metabolism

ASSESSMENT OF DEFICIENCIES CONT

Suspected Deficiency Supporting Evidence
Weakness, fatigue, slow cognition Difficulty regulating body temp Inflamed tongue Low Hgb = iron deficiency Low ferritin = iron deficiency anemia (Inflammation can negatively impact values) Serum zinc is not a reliable indicator Deficiency based on nutritional assessment May have altered taste

Drug/Nutrient , Nutrient/Nutrient Interactions

Tannins, Calcium, Soybean, Protein, Polyphenols, Phytates can interfer with absorption Vitamin A deficiency limits iron storage Zinc can impair iron absorption Affected by Antibiotics and Diuretics

Iron

Zinc

Vitamin C

Plasma ascorbic acid Physical signs: bleeding gums, tooth loss, weakness, irritability, hyperkerratosis, hemorrhaging, peripheral edema Concurrent anemia
Early signs: loss of appetite, nausea, fatigue, weakness Late signs: numbness, tingling, muscle cramps, seizures, personality changes, abnormal heart rhythms, hypocalcemia, hypokalemia

None Noted

Magnesium

None Noted

INTERVENTION AND MONITORING

Intervention Riboflavin
Poorly absorbed and stored. Required daily from diet. If supplementation is required suggest: Multivitamin Risks greater in diets high in corn and limited in variety 500 mg niacinamide daily for 7 days then 100-300 mg daily for 3-4 weeks Single oral dose of 30 mg Prophylaxis supplementation with Isoniazid: 50-100 mg daily

Monitoring
Signs/Symptoms of deficiency Blood work Repeat physical assessment every 1-2 weeks to assess response to supplementation Signs/Symptoms of deficiency Blood work Repeat physical assessment every 1-2 weeks to assess response to supplementation Signs/Symptoms of deficiency Blood work Repeat physical assessment every 1-2 weeks to assess response to supplementation

Niacin

B6

INTERVENTION AND MONITORING CONT

Suspected Deficiency Intervention
Deficiency caused primarily by maldigestion or absorption Exception: individuals who consume no animal products (vegans) 1000 mcg/day orally has been shown to be as effective as IM injection IM injections 1000 mcg/week may be used until serum levels normalize. Maintain with oral supplementation

Monitoring

B12

Blood work every 3-4 weeks to monitor oral doses B12 from IM injections can be depleted in 3 weeks

Folate

Do not exceed 1 mg/day to prevent interference with B12

Signs/Symptoms of deficiency Blood work Repeat physical assessment every 1-2 weeks to assess response to supplementation
Serum levels checked every 3 months Supplementation frequently required for 6 months or more to replete No more than 10-20 g increase in Hgb is to be anticipated for first month Monitor men/post menopausal women for iron overload

Iron

Supplementation required if clinical symptoms present 2-3 smaller doses preferably to 1 large dose 300 mg ferrous sulfate twice daily If supplements are not tolerated switch to 150 mg once daily and gradually increase dose

INTERVENTION AND MONITORING CONT

Suspected Deficiency
Zinc

Intervention
Elemental zinc: 50 mg/daily for 6 months Absorption is maximized with daily intake of 30-180 mg (2 servings of high vit c foods) Above this level only 50% of intake is absorped Therapeutic dose: 1000 mg daily for 2 weeks Maintenance: 250 mg weekly Supplementation contraindicated with Renal disease Variable bioavailability: Magnesium oxide: 60% Magnesium sulfate: 10% IV therapy 2mg magnesium sulfate will replete quicker than oral Safe Upper Limit: 350 mg /day

Monitoring
Signs and symptoms weekly

Vitamin C

Signs/Symptoms of deficiency Blood work Repeat physical assessment every 1-2 weeks to assess response to supplementation

Magnesium

Serum levels may not be good indicator as supplementation does not always improve levels Oral supplement may cause diarrhea and cramping

CONCLUSION

The information obtained from oral cavity examination must be integrated along with information obtained from:

Patient interview Past medical history Medications Results of laboratory tests (biochemical markers)

Taken as a whole the information can used to identify nutrient deficiencies Once an appropriate intervention is undertaken, the physical observations used to identify the deficiency can also be monitor for effectiveness of the intervention