i n d i a n j o u r n a l o f d e n t i s t r y 5 ( 2 0 1 4 ) 5 2 e5 5

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Review Article

Nutritional considerations for patients undergoing

maxillofacial surgery e A literature review

Shilpa Jain a, Arpit Jain b,*, Umesh Palekar c, Kamal Shigli d, Ajay Pillai e,
Ashutosh Dutt Pathak f
a
PG Student, Department of Prosthodontics, Crown and Bridge and Implantology, Modern Dental College and
Research Centre, Indore, M.P., India
b
PG Student, Department of Oral Medicine and Radiology, People’s College of Dental Science and Research Centre,
Bhopal, M.P., India
c
Professor and Head, Department of Prosthodontics, Crown and Bridge and Implantology, Modern Dental College and
Research Centre, Indore, M.P., India
d
Professor, Department of Prosthodontics, Crown and Bridge and Implantology, BVP Dental College and Hospital,
Sangli, M.H., India
e
Associate Professor, Department of Oral and Maxillofacial Surgery, People’s Dental Academy, Bhopal, M.P., India
f
PG Student, Department of Oral and Maxillofacial Surgery, People’s College of Dental Science and Research Centre,
Bhopal, M.P., India

article info abstract

Article history: Malnutrition is one of the most common causes of morbidity in patients undergoing
Received 27 February 2013 maxillofacial surgery. In these patients, normal food intake is impaired because of the
Accepted 9 July 2013 disease state and is complicated further by the surgical procedures. Surgery imparts
Available online 31 July 2013 controlled injury and delays wound healing capacity. Consideration should be given to the
nutritional status of these patients in both preoperative and postoperative period so as to
Keywords: reduce postoperative complications. It should be imperative upon the part of dental pro-
Diet fessional to identify patients at nutritional risk, perform nutritional screening tests and
Nutrition provide dietary guidelines. In this paper we have focused on nutritional risk, nutritional
Nutritional assessment assessment, and recommendations for such kind of patients.
Nutritional risk ª 2013 Indian Journal of Dentistry. All rights reserved.

1. Introduction
Nutrition is defined as the science of how the body utilizes
food to meet requirements for development, growth, repair,
and maintenance.1 There are six classes of nutrients found in
food: carbohydrates, fats, proteins, vitamins, minerals, and
water.2 First three categories are energy producing nutrients;
that is, they provide calories and enable the body to generate
energy for carrying on its many functions.2 Although the latter
three do not provide energy, they facilitate a variety of activ-
ities in the body. In the patient having dental surgery, there
are several considerations that impact and rely on nutritional
status.2 Malnutrition accounts for one of the major factors
contributing to the postsurgical morbidity.3 Firstly, surgery

* Corresponding author. Tel.: þ91 9425474806.

E-mail address: jain.23.me@gmail.com (A. Jain).
0975-962X/$ e see front matter ª 2013 Indian Journal of Dentistry. All rights reserved.
http://dx.doi.org/10.1016/j.ijd.2013.07.014
 i n d i a n j o u r n a l o f d e n t i s t r y 5 ( 2 0 1 4 ) 5 2 e5 5
imparts controlled injury and delays or lengthens the process
of healing.4 Secondly, the success of the body to heal itself is
critically dependent on the extent of the injury and the pres-
ence of sufficient and continued nutrition.4 The mouth is the
portal for entry of food into the body; thus, disease of the oral
and maxillofacial region and/or surgery of these structures
may result in impaired food intake both prior to and after
surgery.4 The severity and duration of impairment is depen-
dent on the disease state and the surgical intervention
required correcting it.4 The dentist must be cognizant of
methods to ensure the patient has appropriate nutritional
support.
2. Nutrition and wound healing
Patients undergoing surgical procedures require protein
source and energy. Carbohydrates, proteins and fatty acids are
chief source of energy.5 The body requires an adequate supply
of carbohydrates to prevent protein catabolism and fatty acid
metabolism.5 Alternatively, excess glucose or hyperglycemia
is not beneficial as it results in decreased leukocyte function,
in dehydration and in metabolic acidosis.5 Wound healing
requires energy,5 thus nutritional status of patient affects
wound healing.5 Although, protein serves as a source of en-
ergy, its primary purpose is cellular proliferation and cell
repair.5 Prognosis of the maxillofacial surgery depends upon
bone healing.5 Protein plays vital role in fracture repair. Pa-
tients who are severely malnourished, demonstrate delayed
wound healing and impaired wound contraction.5 A
malnourished patient has increased susceptibility towards
infection. All these conditions lead to prolonged rehabilitative
period.5
3. Surgical considerations
The dentist can be confronted with numerous situations that
require dietary management. Patients must be first assessed
for baseline nutritional status and then assessed for the
impact that dental treatment will have on the nutritional
status.4 Treatment of head and neck cancer may severely
affect the patient’s normal eating pattern.4 The surgical
resection of oro-facial structures can impair patient’s dietary
intake.4
Chemotherapy/radiotherapy may produce irreversible
changes in cancer patients. Oral mucositis occurring during
acute treatment phase of chemotherapy or radiotherapy may
produce severe pain and may alter the patient’s dietary
intake. Altered taste sensation and xerostomia may also be
found following the therapy for oral cancer which affects the
nutritional intake of the patient.4
4. Basic diet
The basic dietary requirement for the surgical patients in-
cludes adequate amount of proteins, vitamins and minerals.6
In addition sufficient calorie from carbohydrates and lipids are
necessary to provide energy.6 Except for the patients who
53
require artificial nutritional support, the maxillofacial surgery
patients should follow food guide that is organized into four
major food groups to achieve optimal nutrition. A food group
in the food guide includes:
- Milk Group: 2 or more cups.
- Meat Group: 1 or more servings e fish, poultry, eggs.
- VegetableeFruit Group: 4 or more servings: include citrus
fruits for vitamin C, green and deep yellow vegetables for
vitamin A, other vegetables, fruits and potatoes.
- BreadeCereal Group: 4 or more servings of whole grain
enriched or restored products.7
There are several modes of support that are commonly
used in the ambulatory patients during perioperative period4:
clear liquid diet, full liquid diet, pureed diet, mechanical soft
diet, and regular diet.4 A clear liquid diet is often used in im-
mediate postoperative period after a parenteral sedation.4 A
patient is advised for complete diet after he gains recovery
from gastrointestinal intolerance. The diet is low in
nutrients.4
A fully liquid diet is more nutritionally complete. The diet
is good for patients who cannot chew or swallow foods. A fully
liquid diet frequently consists of milk products. But, it should
be used with caution in patients with lactose intolerance.4
A pureed or mechanical soft diet is transitional diet. These
diets provide patients with increased consistency and food
texture. A pureed diet can be administered easily in patients. A
soft diet allows more freedom in selecting food items and also
is less monotonous than liquid diet. Meats and fruits can be
made quite flavored. Meats can be thinned with milk to make
broth, while fruits can be used or is added to other foods.8
4.1. Nutritional support
Nutritional support is indicated in patients who cannot have
adequate nutrition by diet alone. On the contrary, artificial
nutritional support in well-nourished or undernourished pa-
tients may either provide no benefit or may increase patient
morbidity. Nutritional support for a malnourished patient:
- Promotes growth, tissue healing and maturation of
collagen.9
- Enhances immunity.10
- Reduces muscle bulk and function.11
- Prevents septicaemia.12
4.2. Nutritional assessment
All patients should be assessed perioperatively by the dieti-
cian and this should be an integral part of multidisciplinary
team approach in managing nutritional deficient patients.
Following information should be used to assess nutritional
status of the patient:
- History: preoperative weight, recent weight loss if any, loss
of appetite, ability to swallow. Unintentional weight loss of
more than 10% body weight within 6 months is considered
hazardous. Proper nutritional support is indicated in these
patients.13
54 i n d i a n j o u r n a l o f d e n t i s t r y 5 ( 2 0 1 4 ) 5 2 e5 5
- Assessment of nutrition should include calorieenitrogen
ratio using daily dietary intake.14
- Examination e height/weight ratio, muscle wasting, triceps
skinfold thickness, arm circumference and crea-
tinineeheight index should be assessed.15
- Body mass index e calculated as body weight in kilograms
divided by height in meter squares.16
- Laboratory tests: diagnostic tests including haematological
evaluations provide insight into possible causes of oral or
other systemic diseases. Complete blood count should be
assessed to aid in determining immune response. Labora-
tory data provides value for electrolytes, serum proteins,
trace elements, glucose, lipids, and organ function.17
4.3. Nutritional requirements
Gastrointestinal (G.I) tract acts as an important immune
organ. Patients suffering from upper gastrointestinal tract
cancer suffer from severe proteinecalorie malnutrition. In
these patients, enteral nutrition is preferred over parenteral
nutrition. Immunonutrition should be considered in critically
ill patients and elective surgery patients.18,19
5. Recommendations20
Level 1
 Patients with chronic malnutrition benefit from nutritional
support.
 Enteral nutrition:
- is preferred over parenteral nutrition in patients with
functional GI tract.
- should be initiated within 18 h of injury in burn patients.
- should be initiated within 24 h of admission in critically
ill patients.
 Immunonutrition should be used in malnourished elective
GI surgical patients.
 Immunonutrition should involve an initial 5e7 day course
with subsequent re-evaluation.
Level 2
 Patients with severe head injury who did not tolerate gastric
feeding within 48 h of injury should receive post-pyloric
feeding.
 Nutritional assessments should be performed weekly and
adequate nutritional support should be provided to meet
individual’s needs.
Level 3
 Incompletely resuscitated patients should not receive direct
small bowel feedings due to gastric intolerance.
 Intragastric feeding of severe closed head injury patients
should be initiated within 12 h of admission.
 In severely injured patients, parenteral nutrition should be
started within 7 days if patient is unable to tolerate atleast
50% of caloric requirement.
5.1. Patient monitoring
An important part of nutritional support is monitoring the
patient. Whether it is enteral or parenteral, a check on pa-
tient’s weight, calorieenitrogen ratio, daily dietary intake and
fluid balance is necessary. Continuous supervision of patients
by dietician from the diagnosis of the disease is essential in
limiting weight loss.21
6. Conclusion
Poor nutrition plays an important role in development of
postoperative complications and may increase patient
morbidity. Proper nutritional assessment and appropriate
preventive measures should be undertaken in the patients
undergoing maxillofacial surgery. Nutritional support should
be considered in severely malnourished patients. But, the
indiscriminate use of nutritional support should be avoided to
reduce postoperative complications.
Conflicts of interest
All authors have none to declare.
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