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Practice Paper of the Academy of Nutrition and Dietetics:

Oral Health and Nutrition


June 2014

ABSTRACT
This paper supports the Position of the Academy of Nutrition Nutrition assessment is vital to identifying dietary intake
and Dietetics: Oral Health and Nutrition published in the and nutritional factors impacting oral health. Conversely,
May 2013 Journal of the Academy of Nutrition and Dietetics. decreased salivary flow, compromised oral integrity, tooth
It is the position of the Academy of Nutrition and Dietetics decay, or poor periodontal health can impact an individuals
that nutrition is an integral component of oral health. ability to consume an adequate diet. A poor diet can result
The Academy supports integration of oral health with in limited intake of nutrients crucial to systemic health and
nutrition services, education, and research. Collaboration well-being. The provision of medical nutrition therapy that
between registered dietitian nutritionists (RDNs); dietetic incorporates total health, including oral health is a component
technicians, registered (DTRs); and oral health care of the Standards of Practice for RDNs and DTRs. Inclusion of
professionals is recommended for oral health promotion and didactic and clinical practice concepts that illustrate the role
disease prevention and intervention. There is a synergistic of nutrition in oral health is essential in education programs
multidirectional association between diet, nutrition, and oral for both professional groups. The multifaceted interactions
health. Given that the mouth is the portal of entry into the between diet, nutrition, and oral health in practice, education,
body, it is essential that RDNs and DTRs include the oral cavity and research in both dietetics and dentistry merit the need for
in their assessment for nutritional risk factors and deficiencies. collaborative efforts to ensure comprehensive patient care.

In 2000, Surgeon General David Satcher released a diet counseling and health education aimed at pregnant
landmark report, Oral Health in America: A Report of the women and new mothers. The Institute of Medicines
Surgeon General (Oral Health in America), that states that consensus report, Improving Access to Oral Health Care
the mouth is the window to all the diseases of the body.1 for Vulnerable and Underserved Populations, provides
In 2003, Surgeon General Richard Carmona released A several recommendations for improving the nations oral
National Call to Action to Promote Oral Health: A Public- health. One recommendation addresses the need to provide
Private Partnership (National Call to Action) as a continued education to prevent oral disease including the role of diet
effort to improve oral health disparities identified in Oral and nutrition in oral disease.5
Health in America.2 A National Call to Action is directed to
professional organizations and individuals concerned about
oral health in the United States to encourage programs and SCOPE OF PRACTICE
activities to promote oral health and prevent oral disease.2
This goal reflects the Healthy People national objectives for Registered Dietitian Nutritionists (RDNs) and Dietetic
the nation to improve quality and years of life and eliminate Technicians, Registered (DTRs)
health disparities.3 Healthy People 2020 addresses the RDNs work in collaboration with other health care team
following areas for public health improvement: members with the RDNs scope of practice concentrated
on food, nutrition, and those related services that are
increase awareness of the importance of oral health to developed, directed, and provided by RDNs to protect the
overall health and well-being; public and populations; enhance the health and well-being
increase acceptance and adoption of effective preventive of patients/clients; and deliver quality products, programs,
interventions; and and services including medical nutrition therapy (MNT)
reduce disparities in access to effective preventive and across all focus areas.6
dental treatment services.4
Nutrition assessment is the first of four steps of the
The National Call to Action identifies five action strategies, Nutrition Care Process. Standard 1.3 indicates that RDNs
one of them focused on increasing collaboration, including should perform a nutrition-focused physical assessment
1
of body systems, muscle and subcutaneous fat wasting, Saliva. Healthy salivary glands produce saliva
hair, skin and nails, signs of edema, sucking/swallowing/ supersaturated with calcium and phosphorus to aid in
breathing ability, appetite, affect, and oral health.68 The buffering acids (see Figure 1). Calcium and phosphorus
DTRs role is to assist the RDN in gathering assessment can remineralize areas of the tooth surface during the early
data. The nutrition-focused physical assessment is used to phase of tooth decay.15 Certain conditions (eg, Sjgrens
determine clinical signs or symptoms of nutrient deficiencies syndrome), treatments for medical conditions (eg, radiation
or conditions that may impact oral intake. Based on oral therapy to the head and neck), and medications (eg,
conditions or compromised oral integrity, RDNs may antihypertensive, antidepressant, antipsychotic) that cause
need to modify dietary plans and food texture. General significant reductions in salivary flow.15 Reductions in saliva
inspection of the head, neck, oral cavity, and cranial nerve production (hyposalivation or xerostomia) can lead to an
function allows RDNs to further identify risk factors when increased risk for dental caries.16 Rapidly progressive and
developing a nutrition diagnosis to tailor dietary counseling. widespread formation of dental caries, often called rampant
caries, is a potential problem in individuals with reduced
salivary flow. Early preventive measures are essential in
Oral Health Care Professionals (OHCPs) helping to reduce these individuals risk for dental caries (see
OHCPs are charged with providing education and Figure 2).
maintenance for the health of the mouth, teeth, and
surrounding hard and soft tissues. Identification of dietary Dietary Factors. All carbohydrates can be cariogenic. A
habits that increase risk for oral disease and contribute strong relationship exists between sucrose consumption and
negatively to systemic health should be addressed as caries prevalence and incidence.1719 Type of carbohydrate,
a component of comprehensive care. Accreditation food combinations, the carbohydrates physical form,
standards for both dental and dental hygiene programs and frequency and timing of consumption of foods
require graduates to develop competence about the containing sucrose are important factors in dental caries
interrelationships of body systems to provide prevention, development.18,19 Fructose and lactose are less cariogenic
intervention, and educational strategies in the context of than sucrose.19 Processed, cooked starches alone or in
overall health.911 Competencies for OHCPs encourage the combination with sucrose are cariogenic because of a process
participation of dental team members with other health called gelatinization that allows salivary amylase to begin
care professionals.1214 breaking down starches in the oral cavity.20 The resulting
carbohydrate is metabolized by plaque bacteria to produce
acid and begin demineralization of the tooth surface.20,21
DYNAMIC DENTAL CARIES PROCESS
Dental caries (tooth decay) is a multifactorial disease and Certain food combinations may reduce the cariogenic
one of the most common diseases. There are both pathologic potential of fermentable carbohydrates. For example, a
and protective factors that need to be in balance to reduce meal with a combination of foods containing protein,
the risk for dental caries. fat, and fermentable carbohydrate is less carogenic than
a meal of foods containing only sugars or starches.22 The
presence of protein, fat, and other nutrients like calcium
Pathologic Factors and phosphorus appear to increase the plaque pH. In
Pathologic factors involved in the disease process include the presence of calcium, phosphorus, and fluoride in
presence of acid producing bacteria in plaque biofilm, foods, the remineralization potential is enhanced.23,24 The
reductions in salivary flow, and cariogenic dietary factors.
All of these factors must be present for the demineralization Buffering capacity
of the tooth surface (loss of mineral content from the tooth) Provides an antibacterial action
to occur; however, the process is reversible until the tooth
structure is compromised. All the pathologic factors can be Aids in remineralization of enamel
managed to reduce risk for dental caries. Lubricates oral tissues

Assists in chewing, swallowing, digestion, and speaking


Plaque Biofilm. Thorough daily oral hygiene is an integral
component of reducing the bacterial load. OHCPs are best Removes debris from teeth
equipped to provide individuals with education on oral Affects the rate of dental plaque biofilm formation
hygiene. However, RDNs and DTRs can assist individuals
Influences taste
in reducing risk for dental caries by recognizing changes
in salivary flow, cariogenic food and beverage choices, and Figure 1. Benefits of saliva. Adapted from references 15, 58, and 75.
eating behaviors.
2
erupts, fluoride has a significant impact. Fluoride can
Rinse with water
be received systemically (eg, fluoridated water, fluoride
Chew sugarless gum to stimulate saliva flow
supplements) and topically (eg, fluoridated toothpastes,
Consume fluids with meals mouthrinses, fluoride applied in the dental office). The
Consume fluids throughout the day role of RDNs and DTRs is to encourage individuals in
Suck on ice chips throughout the day communities with fluoridated water to consume tap water
Use products to relieve xerostomia
and receive regular preventive care from an OHCP. All
health care professionals should support community water
Use lip balm to keep lips moist
fluoridation based on strong evidence for caries reduction
Choose moist, nutrient-dense foods and lack of evidence of harm (see the Position of the
Avoid dry, coarse, or hard foods Academy of Nutrition and Dietetics: The Impact of Fluoride
Avoid sticky, sugary foods and choose foods/beverages with on Health27).
sugar alcohols and nonnutritive sweeteners
o Caution with excessive use of sugar alcohols Other trace minerals like zinc, iron, copper, nickel,
selenium, and molybdenum may be significantly higher in
Choose tart, sour, sweet, bitter, and citrus food/beverages to
stimulate saliva flow healthy teeth. Developing research also indicates a possible
reduction caries-causing bacteria in Streptococci mutans
o Caution with excessive use of acidic foods/beverages
(S. mutans) and Streptococci sobrinus (S. sobrinus) with the
Avoid alcohol and alcohol-containing products
incorporation of probiotics.2830
Avoid products with caffeine
Cariostatic Food Factors. These factors work to decrease
Figure 2. Best practices for xerostomia. Adapted from references 58 caries risk by increasing salivary flow, increasing buffering
and 76.
capacity, or decreasing the growth of caries causing bacteria.

carbohydrates physical form provides another consideration Foods like cheese, milk, and yogurt without added sugar
in potential caries development. Carbohydrates that may raise the plaque pH and concentrations of calcium,
stick to the tooth surface (eg, raisins, bananas, bread, phosphorus, casein, and protein to assist in buffering the
crackers, pretzels, potato chips) may be more cariogenic acids and encourage tooth remineralization.
than carbohydrates in liquid form, like juices. Other
factors in caries risk are: 1) frequent snacking on foods Polyols have been shown to reduce dental caries. In a pooled
containing processed starch and 2) total number of analysis conducted for a systematic review, xylitol, sorbitol,
snacks consumed.1719,25,26 RDNs and DTRs can identify and xylitol-sorbitol chewing gum reduced caries by 59%,
cariogenic eating and feeding practices, encourage optimal 53%, and 20%, respectively.31
oral hygiene, and provide information about food forms
and patterns of eating that can contribute to caries risk Plant polyphenols, like those found in coffee, red wine,
and help families plan and structure meals and snacks to berries, olives, tea, and cocoa have antioxidant functions
achieve a balanced diet that promotes total body health and that have been shown in vivo and in vitro studies to
minimizes risk for oral disease. MNT for some conditions
decrease growth of S. mutans.32 A limited number of
may require frequent consumption of foods and beverages;
human studies suggest an anti-caries and anti-plaque
in these situations, a consultation with an OHCP may
effect, but reduction in dental caries has not been directly
be helpful in individualizing preventive approaches to
measured, so evidence for use of polyphenols to prevent
minimize risk for caries.
caries is minimal and more research is needed.

Protective Factors
In addition, it is necessary to understand the protective DENTAL EROSION
factors to reduce an individuals risk for caries. Protective Another dental issue in which diet or dietary behavior
factors are related to saliva (see Figure 1), good oral has an impact is dental erosiona loss of tooth structure
hygiene, exposure to fluoride (eg, fluoride varnish, fluoride due to exposure to acid in the absence of plaque bacteria.
toothpaste), consumption of foods containing fluoride and Dental erosion can be localized to one tooth or generalized
other nutrients, and consumption of cariostatic food. to multiple or all teeth. The individual may complain of
sensitivity to temperature or touch. Prevalence of dental
Fluoride and Other Nutrients. The value of fluoride in erosion seems to be increasing and is estimated to be 30% to
preventing dental caries is well established. Once a tooth 70% worldwide.33
3
Etiology Classification System for Periodontal Diseases and Conditions
Erosion may occur from extrinsic (eg, diet, some occupations is gingival disease modified by malnutrition.38 Studies suggest
with exposure to acid fumes), and/or intrinsic (eg, disease, that vitamin C, vitamin D, and calcium, may reduce gingival
habits) sources. The primary extrinsic sources include inflammation, but further research is needed.3941
consumption of soft drinks, sports drinks, energy drinks,
fruit juices, pickled foods, sour candies, citrus fruit, and Periodontitis. Nutrition, which can impact immunity and
wine. A neutral and safe pH is 7.0 in the oral cavity, while a wound healing, is the mechanism most likely to influence
critical pH is considered to be 5.5 or less, capable of causing the severity of periodontal disease. Epidemiologic studies
demineralization. The pH of soft drinks ranges from 2.38 to suggest that inadequate intakes of calcium, vitamin C,
2.92 and of fruit juices from 2.77 to 3.30.34 The pH of energy vitamin D, folic acid, protein, n-3 fatty acids, and probiotics
and sports drinks ranges from 2.76 to 2.84.35 These drinks are associated with the severity of periodontal disease.3945 In
create an acidic oral environment. Intrinsic factors commonly addition, evidence suggests the use of probiotics to inhibit
leading to erosion include gastroesophageal reflux disease growth of dental plaque biofilm and pathogens associated
(GERD), eating disorders, and other issues involving frequent with periodontal disease. To impact periodontal disease
vomiting and rumination.16,33 selection of the correct strain and strength, mode, and time
of administration, health of the individual, and retention
and exposure times in the oral cavity are considerations.4648
Risk Factors
Risk factors for dental erosion and resulting caries include Pre- and Postoperative Periodontal Surgery
poor eating habits and hyposalivation. Frequency and Considerations. Individuals at nutritional risk
duration of exposure to acidic beverages or foods along need guidance in attaining optimal nutritional status
with the method of consumption (eg, sipping, using a to enhance healing following periodontal surgery.
straw), impact the amount of time the acid remains in the Nutritional status pre-surgery, severity and duration of
mouth and in contact with tooth surfaces.16.33 Suggestions periodontal infection, and postperative dietary intake are
for individuals who vomit frequently or who experience all important aspects of nutrition that can affect optimal
sensitivity when consuming acidic foods and beverages outcomes of periodontal surgery.49, 50
can be found in Figure 3.
DIET AND DENTAL CONNECTIONS FOR SPECIFIC
Populations at High Risk for Dental Erosion POPULATIONS
Individuals who vomit frequently are at risk for dental
erosion. The pH of gastric contents is approximately Pregnant Women
3.8, well below the critical pH of 5.5, where tooth Nutrition during pregnancy is key to the oral health of the
demineralization occurs. A neutral pH is 7.0. Frequent woman and future child. To achieve optimal pregnancy
vomiting with decreased salivary flow sets the stage for a outcomes, adequate oral hygiene (eg, daily homecare
low pH environment favoring erosion. regimen) and regular dental appointments are encouraged.
Community-based programs like the Special Supplemental
GERD is a common gastrointestinal disorder that may result Nutrition Programs for Women, Infants, and Children
in exposure of the teeth to gastric acid.36 Gastric acid has a (WIC) and Early Head Start that provide care for pregnant
pH of 1.2, but the pH is modified by partially digested food women with low incomes present an ideal opportunity
and bile acids.37 Case-control studies suggest that 20% to for OHCPs and RDNs and DTRs to work collaboratively
30% of individuals with GERD have tooth erosion.37 to help ensure that pregnant women achieve optimal oral
health. Being a minority and having a low income are
common deterrents to dental services utilization.51 Women
PERIODONTAL DISEASE with low income are more likely than those with higher
Periodontal disease is multifactorial, making it difficult to incomes to give birth prematurely to have an infant with
determine the effect of suboptimal nutrition on initiation and/ low birth weight. RDNs can provide pregnant women
or progression of disease. The impact of nutritional status on with education about preventive oral care throughout the
immune response may be an important modifying factor in the pregnancy and can also refer pregnant women to OHCPs.52
progression of the disease and healing of periodontal tissues.
Nausea, Vomiting, and Oral Implications. Over 80% of
pregnant women suffer from nausea and vomiting during
Implications of Nutrition the first trimester of pregnancy.53,54 These symptoms may
Gingivitis. One of the dental plaque-induced gingival be eased by consuming cariogenic foods like crackers, dry
diseases in the American Academy of Periodontology toast, or cereal. Muffins, cake, and cookies and carbonated
4
Prevention of dental caries:
o a high-calorie, high-protein, mechanically-altered diet may
o minimize snacks containing sugars or processed starches be used post-surgery to enhance healing in medically
o optimal oral hygiene after cariogenic foods compromised individuals and those at nutritional risk
o chew xylitol or sorbitol gum after meals or snacks when
o for individuals with ulcerated lesions and those unable
thorough oral hygiene is not possible to eat a normal diet for extended periods, a liquid or
o consume dairy products to neutralize the acidic pH mechanically-altered diet may be indicated until they have
and provide sources of calcium and phosphorus for had adequate healing
remineralization
o optimal oral hygiene
o fluoridated water, mouthrinses, and toothpaste at home
Dental prosthesis:
Establish a dental home with an oral health care o start chewing on your molars and progress forward
professional for regular dental care o avoid biting on one side of mouth; distribute food evenly
o incorporate best practices for xerostomia
For those who experience frequent vomiting: o liquid and mechanically-altered foods may be indicated if
o avoid toothbrushing immediately after the episode chewing is difficult initially
o rinse with sodium bicarbonate after an acidic event to o increased consumption of protein foods may be
neutralize pH recommended for optimum healing
o follow prevention of dental caries guidelines
Pregnant women:
Rinse the mouth with water when unable to brush o optimal oral hygiene
o schedule dental visits at regular intervals throughout the
Acidic foods/beverages: pregnancy to monitor peridontal health and overall oral
o limit consumption health status.53
o consume with meals to minimize the acidic changes in pH. o prevent periodontal disease
o do not brush immediately after exposure33the enamel o Enforce best practices for prevention of early childhood
is softened from the acidic environment and prone to caries
damage from brushing, even with a soft-bristled brush. o optimal dietary intake for healthy growth and development
of the fetus, infant, and young childs oral cavity
Prevention of periodontal disease: o When working with pregnant patients at WICa clinics, RDNs
o consume dairy products including yogurt with active can educate about optimal oral hygiene and the potential
cultures, citrus fruit, and proteins in addition to usual impact for the developing fetus
healthy eating recommendations for individuals
undergoing periodontal treatment.

Figure 3. Recommendations to prevent and manage oral disease. Adapted from reference 58.
a
WIC=Supplemental Nutrition Program for Women, Infants, and Children.

beverages are other cariogenic foods and beverages that Periodontal DiseaseLow Birthweight Infants/
may also provide relief. Frequency of vomiting can increase Premature Births/Miscarriage. Hormones and blood
the risk for dental erosion and subsequent risk for dental supply increase during pregnancy, resulting in a higher
caries. Frequent consumption of cariogenic foods and and occurrence of gingival inflammation.56 This commonly
carbonated beverages to abate nausea can increase risk for presents as pregnancy gingivitis. Evidence suggests there
caries.53 Recommendations that RDNs can provide to all may be a relationship between periodontal disease and low
pregnant women and others experiencing frequent vomiting birth weight, premature births, and miscarriage. All health
can be found in Figure 3. care professionals working with pregnant women must
understand the relationship of meal and snack patterns,
Folate Consumption. Inadequate folate consumption in overall nutrient intake, oral health status in relation to health
the months before conception and during the first 2128 of the infant, and potential oral health concerns.55
days of the pregnancy can lead to oral cavity defects. Cleft
lip or palate, which result from incomplete formation of Nutrient Needs for Growth and Development of
the cranial bones, are common oral cavity defects associated Fetus Oral Cavity. Maternal nutrient intake is
with insufficient folate deficiency.55 During pregnancy, 600 essential to the developing organs and the oral cavity
micrograms/day of folate are recommended. RDNs and of the fetus. For example, vitamin C is important for
DTRs should provide pregnant women with education collagen formation and magnesium and phosphourus are
about foods rich in folate and should encourage daily important for tooth mineralization of teeth. Inadequate
supplementation, not to exceed the Recommended Daily maternal consumption of calcium and vitamin D can
Allowance to ensure adequate intake. result in poor calcification of the developing teeth
5
of the fetus and in pitting once the teeth have fully Common Nutrition Concerns Related to Oral Health
erupted. And inadequate protein consumption can 1. Inadequate fruits and vegetables consumption: A diet
result in delayed tooth eruption and impaired salivary high in fruits and vegetables is associated with decreased
function. Increased caries susceptibility can occur if risk for chronic disease as well as having anticarcinogenic
there is inadequate consumption of vitamin A, fluoride, properties. The Centers for Disease Control and
iron, zinc, and protein. It is also important to note Prevention has reported 28.5% of high school students
that consuming too much vitamin A can impair oral consume fruit less than once/day, and approximately
mucosal epithelium development. As discussed in the 33% consume vegetables less than once/day.61
Position of the Academy of Nurition and Dietetics:
2. Inadequate dairy consumption; Dairy intake is
The Impact of Fluoride on Health,27 consumption of
important for strong bones and teeth. Inadequate dairy
excessive amounts of fluroide may contribute to dental
consumption puts children, adolescents, and adults
fluorisis. Inadequate iodine consumption can result in
at long-term risk for osteopenia, osteoporosis, and
macroglossia (large protruding tongue), malocclusion,
periodontal disease.
and delayed tooth eruption.57
3. Consumption of sugar-sweetened beverages (SSBs):
Dental caries, obesity, risk for cardiovascular disease,
Infants and Young Children
and future risk for osteoporosis or fractures have been
Nutrient Needs for Growth and Development of the Oral identified as concerns associated with excessive SSB
Cavity. Adequate consumption of nutrient-rich foods is consumption. Although a decreased consumption
necessary for growth and development of oral soft and hard and decreased frequency of SSBs has been reported,
tissues. Development of the oral musculature may be delayed SSBs still account for an average of 150 calories or 9
if food textures are not appropriatedly introduced, which can teaspoons of added sugar per person each day.62
also impact the childs ability to speak.58 RDNs and DTRs
can incorporate information about feeding practices into Orthodontics. Bones and tissue must be healthy to
anticipatory guidance given to new mothers. allow periodontal ligament and bone to respond positively
to orthodontic tooth movement.63 Dietary guidance for
Early Childhood Caries. Early childhood caries, formerly individuals with orthodontia should focus on consumption
referred to as baby bottle tooth decay or nursing bottle of nutrient-dense foods to promote oral health. Adequate
caries is defined by the American Academy of Pediatric quantities of food sources of protein, calcium, vitamin C,
Dentistry as the presence of one or more decayed (non- and vitamin D are recommended. Sticky and hard foods
cavitated or cavitated lesions), missing (due to caries), or should be avoided. Food retention can occur around
filled tooth surface in any primary tooth in children between orthodontic brackets and bands, which increases risk of
birth and 5 to 6 years of age.59 Figure 3 provides best demineralization. When orthodontic appliances are placed
practices for RDNs and DTRs when counseling pregnant or adjusted, the mouth may be sore and tender, which can
women and new mothers. affect ability to chew. A mechanically altered diet may be
recommended until a regular diet can be consumed. In
such cases, fresh fruits should be cut up, corn cut off the
Children, Adolescents, and Young Adults cob, and meat cut off the bone to reduce biting force.
Dental caries risk. Adequate consumption of nutrient-
rich foods is necessary for growth and development and for
repair of oral soft and hard tissues. According to the Centers Older Adults
By 2030, Americans 65 years of age and older will make
for Disease Control and Prevention, prevalence of untreated
up 20% of the population. Complex medical histories and
dental caries in the permanent teeth of children 6 to 19 years
polypharmacy reinforce the need for an interprofessional
of age has decreased.60 Although strides are being made in
approach to care for this population. RDNs and DTRs
prevention of tooth decay, dental caries remains a problem
should incorporate nutrition screening into assessments of
for some racial and ethnic and lower socioeconomic groups all older adults, regardless of oral health status. Individuals
who have more treated and untreated tooth decay compared with oral health problems that may negatively affect ability
with other groups. For example, only 27% of children from to consume a balance of nutrients from all food groups
families with incomes at less than 200% of the poverty level should be referred to an OHCP.
have had a dental visit in the past year. Refer to Prevention
of Dental Caries in Figure 3 for suggestions that RDNs and Tooth Loss. Tooth loss, which is preventable, impacts
DTRs can provide to help parents prevent dental caries in individuals ability to consume a balance of nutrients from
their children and adolescents. all food groups.64 Socioeconomic disparities may also play
6
a role in tooth loss. Key findings from the National Health
Babies should not be put to bed or nap with a bottle containing
and Nutrition Examination Survey 20092010 found 34% anything other than water.
of adults living below the poverty level were edentulous,
Infants should consume only 4-6 oz of fruit juice per day.
compared with only 13% of adults living above the poverty
level were edentulous.65 With each loss of a tooth comes a Fruit juices or other beverages sweetened with sugar (eg, fruit
greater risk for malnutrition. drinks, fruit punch) should not be given in bottles or sippy cups
that a child can sip on throughout the day.
Osteoporosis and Alveolar Bone Loss. Osteoporosis Children should see a dentist shortly after the first tooth erupts
and periodontal disease share several common risk factors, and no later than 12 months of age.
including older age and smoking. Inadequate intake of Encourage infants to drink from a cup by 12 months; infants
calcium and vitamin D may also be a common denominator. should be weaned from a bottle at 12 to 14 months of age.
Osteoporosis independently influences alveolar bone Toothbrushing should be performed by a parent twice daily with
height.66 RDNs and DTRs should encourage older adults an age appropriate soft bristle or soft cloth. Children do not have
to consume food sources of calcium and vitamin D and/or the fine motor skills to clean their teeth well until about age 7 to 8
possibly supplementation of calcium plus vitamin D. RDNs years. Toothbrushing should be supervised by an adult.
can also provide education about the connection of dietary For children under age 2 at moderate or high risk of caries, a
intake to oral health status. smear of fluoridated toothpaste is recommended.
Children age 2 to 5 years may use a pea-sized amount of
Dental Prostheses (Dentures and Implants). fluoridated toothpaste; parental guidance is still suggested.
Overdentures, complete dentures, implant supported
dentures, and partial dentures are examples of removable Figure 4. Best practices for the prevention of early childhood caries.
prostheses. Use of prostheses can result in taste and Adapted from reference 58, 77, and 78.
temperature alteration, increased risk for choking, and an
overall adjustment to dietary consumption. A randomized
control trial demonstrated that implant supported Sipping on supplements throughout the day can increase
overdentures increased the ability to chew and maintain caries risk. RDNs and DTRs that serve older populations
normal food habits.67 RDNs and DTRs can follow the should perform a thorough nutrition-focused physical
suggestions for individuals with dental prostheses found in assessment that includes an observation of the oral cavity.
Figure 4. Asking questions about senstivity of teeth to hot, cold, or
sweets allow RDNs or DTRs to better tailor an individuals
Recession. Gingival recession occurs when the margin of dietary intake to meet nutrient needs.
the gingiva pulls away from the tooth, leaving exposed roots.
Gingival recession increases risk for dental caries, referred to Institutionalized Long-Term Care PopulationDiet and
as root caries. Causes of recession include abnormal tooth Oral Implications. Research suggests an association between
position, aggressive toothbrushing, gingival trauma, and poor oral hygiene, respiratory problems, pathogens, and risk
peridontal disease. Exposed roots lack enamel and can easily for aspiration pneumonia in institutionalized long-term care
be abraded by brushing. The prevalence of root caries is populations.68, 69 Working in conjunction with nursing assistants
much higher in older adults than in younger adults, since and nurse advisors, RDNs and DTRs who oversee dietary
they are maintaining their natural dentition (permanent programs at long-term care institutions can help reinforce the
teeth). Issues with dexterity as well as changes in the importance of daily oral hygiene for residents to reduce the
periodontium such as gingival or gum recession can create presence of pathogenic bacteria that contribute to oral disease
challenges for adequate maintenance of oral hygiene and risk and potential of systemic complications. A nutrition-
contribute to inceased risk of root caries. focused physical assessment with emphasis on identifying
alterations in the oral cavity and making appropriate referrals to
Along with root caries, dentinal hypersensity is a result of OHCPs is warranted in this population.
recession. Xerostomia, acidic foods and beverages, and acid
influx contribute to dentinal hypersensitivity. Extreme hot Other systemic conditions connected to oral health can be
or cold food temperatures can be very painful to individuals found in Figure 5. which also discusses the role of the RDN
with dentinal hypersensitivity.58 and DTR.

When RDNs or DTRs need to recommend liquid


supplementation to individuals with recession, it is Individuals with Special Needs
important to note the carbohydrate content of supplements. Individuals with special needs commonly have difficulties
Encouraging optimal oral hygiene following consumption with sucking, swallowing, chewing, and independent
of these supplements will decrease the risk for root caries. feeding.58 A collaborative effort between OHCPs, RDNs
7
Systemic condition Oral concerns Recommendations for RDNs and DTRs
Heart disease Loss of dentition due to advance periodontal Nutrition focused physical exam that includes assessment of the
disease oral cavity
Limited ability to consume fresh fruits, Consider number of teeth present and chewing ability when
vegetables, and lean meat providing dietary prescription
Consumption of softer diet high in fat and Determine nutritional adequacy of the diet; modify diet as
refined grains needed to encourage optimal nutrient intake
Increased caries risk may occur as a result Educate on alternative methods of preparation and solutions
of healthier lifestyle modifications such as to include more fruits and vegetables: cook to increase softness,
juicing and consumption of diet beverages encourage frozen varieties, or incorporation of canned fruits and
vegetables as indicated

Osteoporosis Alveolar bone loss evidenced clinically or Educate patients about the need to rinse with water or chew
radiographically xylitol gum after consuming acidic foods and beverages
Smoking, excessive use of alcohol or caffeine Hypoparathyroidism may result in alveolar bone loss
Educate gastric bypass patients about impaired calcium absorption
and implications for oral health and whole body health
Provide lactose intolerant clients with alternative list of calcium
containing foods
Recommend sugar free calcium supplements

Diabetes Progressive periodontal disease may impact Poor glycemic control may enhance progression of periodontal
glycemic control in clients with diabetes disease
Encourage regular preventive dental care and daily regimen of
brushing twice and flossing at least once
More frequent recall intervals (every 3 to 4 months) may be
indicated dependent on a clients periodontal status.

Oral cancer/head and neck cancer Risk of oral cancer increases with age; Perform nutrition focused physical assessment of oral cavity to
head and neck cancer is more prevalent in include examination of the oropharynx area, lateral borders of
individuals over age 50 dorsal surface of the tongue, face, lips, and palpation of lymph
nodes.
Men have two times the risk of oral cancer
than women Encourage tobacco cessation programs for smokers
Ability to chew, swallow, or talk may be Recommend mouth rinses to minimize mucositis such as
impaired by treatment modality for head and chorhexidine, baking soda, or salt water
neck cancer Modify diet as necessary based on oral conditions assessed
Mucositis, glossitis, dry mouth, thickened during and after therapeutic treatments :
saliva, changes in taste, and nausea may o incorporate high-protein, nutrient-dense soothing foods for
occur clients experiencing mucositis
Stiffness of the jaw may occur and make it o limit spicy or citrus foods
difficult to open mouth wide o do not consume coarse textured foods
Encourage frequent intake of water or salivary substitutes as
needed

Obesity Increased body mass Index is an associated Educate bariatric surgery clients about the importance of
risk factor for periodontal disease effective plaque removal
Post bariatric surgery: Encourage discussion with oral health care provider about the
o dietary alterations required after bariatric use of topical fluorides
surgery may contribute to increased caries Xylitol products may be recommended for caries prevention
risk
o dentin hypersensitivity
o enamel erosion

Figure 5. Selected chronic conditions and recommendations for registered dietitian nutritionists (RDNs) and dietetic technicians, registered (DTRs) to
support oral health.

8
and DTRs, physicians, and other health care professionals is the knowledge of dental and dietetic students and
recommended to provide individualized care for those with found that OHCPs need further training in general
special needs. Special diet and nutrient considerations and health, while nutrition and dietetics students need more
oral health considerations is indicated in those with chewing training in oral health.74
and swallowing difficulties; increased/decreased metabolic
needs; or other health problems like diabetes, heart disease, Research. Many studies demonstrate an association
or digestive disorders, or those taking certain medications.70 between dietary intake, oral health, and systemic
health. However, more studies demonstrating how
Populations with Low Incomes. Limited income or oral conditions are impacted by diet and nutrients and
other barriers (eg, decreased access to food) may negatively conversely how alterations in the peridontium and
impact adequate intake of fresh fruits and vegetables, lean surrounding oral cavity can impact dietary quality are
meats, whole grains, and dairy products.71 Low income needed. Areas of research include:
can also impact access to oral health care. A prospective
cohort study using cross-sectional data demonstrating a identifying potential benefits of prebiotics and
positive association between low income and reduced levels probiotics in the prevention and control of periodontal
of oral health literacy in a WIC population.72 Oral health disease and dental caries;
literacy is defined as the degree to which individuals have identifying the role of macro and micronutrients
the capacity to obtain, process, and understand basic oral in periodontal issues, like adequacy of vitamin D,
health information and services needed to make appropriate calcium, and protein in periodontal issues;
health decisions.73 Poor dietary choices coupled with
determining if periodontal treatment impacts birth
lack of knowledge and understanding about how to keep
outcomes and sytemic disease;
teeth and mouth health may increase risk for oral disease.
Collaborative opportunities exist for OHCPs, RDNs, and determining the cost effectiveness, cost benefit, or
DTRs who work with WIC and Head Start participants and economic savings of utilizing the services of RDNs or
other programs that serve populations with low incomes DTRs in dental practices; and
to identify alternative methods of message delivery and determining effective dietary protocols for individuals
methods of education to ensure adequate understanding of who have undergone reconstructive surgeries or
how oral health relates to overall health. Regular dental visits who have prosthetics like partial dentures, complete
and daily homecare should also be reinforced. dentures, or dental implants.

Eating Disorders. A mutlidiscliplinary approach is


recommended for the effective treatment of individuals SUMMARY
eating disorders. When vomiting is used as a means of RDNs and DTRs can be instrumental in identifying
purging, the disorder is often detected orally. Thinning cariogenic eating and feeding practices, encouraging
enamel on the edges of the anterior teeth and lingual optimal oral hygiene, providing information about
surfaces of maxillary molars, raised amalgams, swollen food forms and patterns of eating that can contribute
parotid glands, damage to the oropharyngeal area, and to caries risk, and helping families plan and structure
petechiae are common oral signs of frequent vomitting. meals and snacks to plan a balanced diet to promote
Individuals should be encouraged not to brush immediately total body health and minimizes oral disease risk. There
after purging but instead to rinse with 1 tsp of sodium are many opportunities for RDNs, DTRs, and OHCPs
bicarbonate mixed in 8 oz of water. RDNs and DTRs need to work collaboratively. It is essential to integrate oral
to be aware of oral manifestations of eating disorders and to health education and interprofessional opportunities into
collaborate with OHCPs as needed. The role of OHCPs is didactic programs and internships for dietetics students.
to provide palliative care until the disorder is under control. Conversely, nutrition education and interprofessional
Figure 3 provides best practices for RDNs and DTRs to use opportunities should be components of classroom
in counseling individuals concerning prevention of dental education and clinical requirements for oral health
caries and excessive vomiting. students. Recommended professional partnerships
for RDNs and OHCPs include establishing a referral
relationship with general dentists or specialty dental
Interprofessional Teams practices like pediatric dentists, periodontists, and oral
Education. The interrelationship of diet, oral health, maxillofacial surgeons. Individuals facing periodontal
and general health is a fundamental concept that should or oral maxillofacial surgery, especially those with MNT
be introduced in dietetic, dental, and dental hygiene needs, would benefit greatly from referral to an RDN
professional programs. Shah and colleagues assessed prior to surgery. Other collaborative avenues include
9
providing joint presentations at local, state, and national 12. American Dental Education Association. ADEA core
professional meetings or developing joint educational competencies for graduate dental hygiene education. J Dent
materials. Bridged efforts among RDNs and DTRs and Educ. 2011;75(5):949953.
OHCPs can significantly impact the publics health. 13. American Dental Education Association. ADEA competencies
for entry into allied dental professions. J Dent Educ.
2011;75(5):941948.
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65. Dye BA, Li X, Thorton-Evans G. Oral health disparities The Academy of Nutrition and Dietetics authorizes
as determined by selected Healthy People 2020 oral health republication of the practice paper, in its entirety, provided
objectives for the United States, 20092010. NCHS Data full and proper credit is given. Commercial distribution is
Brief. 2012;(104)(104):18. not permitted without the permission of the Academy and
66. Iwasaki M, Nakamura K, Yoshihara A, Miyazaki H. any distribution should not be used to indicate endorsement
Change in bone mineral density and tooth loss in japanese of product or service. Requests to use portions of the paper
community-dwelling postmenopausal women: A 5-year
must be directed to the Academy headquarters at 800/877-
cohort study. J Bone Miner Metab. 2012;30(4):447453.
1600, ext. 4835, or ppapers@eatright.org. This paper will be
67. Awad MA, Morais JA, Wollin S, Khalil A, Gray-Donald K,
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oral microorgansims and aspiration pneumonia in the (Texas A&M University, Baylor College of Dentistry, Dallas,
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Dysphagia. 2010;25(4):307322. Forsyth School of Dental Hygiene, Boston, MA); Cynthia
69. El-Solh AA. Association between pneumonia and oral care in Stegeman, EdD, RDH, RD, LD, CDE (University of
nursing home residents. Lung. 2011;189(3):173180. Cincinnati Blue Ash, Cincinnati, OH).
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71. Drewnowski A. The cost of US foods as related to their Denny, MS, RD (Academy Knowledge Center, Chicago,
nutritive value. Am J Clin Nutr. 2010;92(5):11811188. IL); Pediatric Nutrition dietetic practice group (Beth
72. Lee JY, Divaris K, Baker AD, Rozier RG, Lee SY, Vann
Ogata, MS, RD, CSP, University of Washington, Seattle,
WF,Jr. Oral health literacy levels among a low-income WIC
WA); Jane McGinley, MBA, RDH (American Dental
population. J Public Health Dent. 2011;71(2):152160.
73. National Institute of Dental and Craniofacial Research,
Association, Chicago, IL); Alison Steiber, PhD, RD
National Institute of Health, US Public Health Service, (Academy Research & Strategic Business Development,
Department of Health and Human Services. The invisible Chicago, IL); Lori A. Stockert, MS, RDH (Silverdale, PA);
barrier: literacy and its relationship with oral health. J Public Pamella Vodicka, MS, RD (Maternal and Child Health
Health Dent. 2005;65(3):174182. Bureau, Health Resources and Services Administration,
74. Shah K, Hunter ML, Fairchild RM, Morgan MZ. A Rockville, MD); Public Healthy/Community Nutrition
comparison of the nutritional knowledge of dental, dietetic dietetic practice group (Victoria Warren-Mears, PhD, RD,
and nutrition students. Br Dent J. 2011;210(1):3338.
Northwest Portland Area Indian Health Board, Portland,
75. Humphrey SP, Williamson RT. A review of saliva:
OR); Academy Quality Management Committee (Paulina
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Williams, PhD, MPA, RDN, CD, Brigham Young
76. American Society of Clinical Oncology. Dry mouth or University, Provo, UT).
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Academy Positions Committee Workgroup: Katrina Holt,
effects/dry-mouth-or-xerostomia Published 2012. Accessed
March 12, 2015. MPH, MS, RD (chair); Karen R. Greathouse, PhD, RD;
77. American Academy of Pediatric Dentistry. Guideline on Cynthia Stegeman, EdD, RD, RDH, LD, CDE (content
periodicity of examination, preventive dental services, advisor).
anticipatory guidance/counseling, and oral treatment for
infants, children, and adolescents. http://www.aapd.org/ We thank the reviewers for their many constructive
media/Policies_Guidelines/G_Periodicity.pdf. Published comments and suggestions. The reviewers were not asked to
2013. Accessed March 12, 2014. endorse this practice paper.
12