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Position of The American Dietetic Association:
    Oral health and nutrition

  Just click on one of the topics below to learn more:

Position Statement

Oral Infectious Diseases:
Dental Caries
Periodontal Disease

Medically Compromised Conditions:

Oral Cancer

High-Risk Groups Throughout the Life Span:

Infant and Children
Keys Points
Nutrition In Dental Education
Oral Health In Dietetic Education
Collaborative Approach to Nutrition and Oral Health Education
Partnerships in Practice
Summary and Future Directions

As a body of knowledge, dietetics and nutrition has expanded to touch all segments of professional health care. Scientific and epidemiologic data suggest a lifelong synergy between nutrition and oral health status in health and disease. Paralleling this crossdisciplinary trend is a change in the health care system toward a coordinated team care approach that requires collaborative effort among health care providers (1-3). Thus, partnerships among dietetics, dental, and other allied health professionals need to be identified, developed, and strengthened to encourage improved levels of practice. There is also a need to clearly delineate interactions between nutrition and oral health in practice, education, and research.

Position Statement

It is the position of The American Dietetic Association (ADA) that nutrition is an integral component of oral health. The ADA supports the integration of oral health with nutrition services, education, and research. Collaboration between dietetics and dental professionals is recommended for oral health promotion and disease prevention and intervention.



The links between oral health and nutrition are many. Oral infectious diseases, as well as acute, chronic, and terminal systemic diseases with oral manifestations, affect diet and nutritional status. Likewise, nutrition and diet may affect the development and progression of diseases of the oral cavity.


Oral Infectious Disease

Dental caries Dental caries is a major cause of tooth loss in the United States. One type of caries - baby bottle tooth decay in infants and preschool children - appears to be related to feeding behaviors after longer bottle-or breast-feeding. Patterns in the introduction of foods, when eating behaviors are being established, may be influential in the prevention and treatment of this disease (4,5). Caries seen in children and young adults, and root and coronal caries in the elderly, cause unnecessary pain and expense (6). Further, children and adults with craniofacial problems, neurological abnormalities, or impaired cognitive abilities are at greater risk for infectious dental diseases that can interfere with appropriate responses to feeding protocols (7).

Diet and nutrition have a direct influence on the progression of tooth decay, a preventable oral infectious disease (8). Major components of a preventive dental regimen include nutrition counseling, fluoride therapy (8,9), use of sealants, and control of cariogenic bacteria (10-12). Nutrition education by dental professionals and nutrition counseling by dietetics professionals must address dietary risk factors associated with dental disease. The primary factors to consider in determining the cariogenic, cariostatic, and anticariogenic properties of the diet are food form (liquid, solid and sticky, long lasting), frequency of consumption of sugar and other fermentable carbohydrates, nutrient composition, sequence of food intake, and combinations of foods (13-16). A focus on the importance of improved dietary habits supports good oral health as well as good general health (10-13,17,18) and should be included with counseling. Nutrition counseling for caries prevention and control should be done by a dental professional as a component of a patient's comprehensive dental care (8). Nutrition counseling for patients with caries who have coexisting medical problems that affect diet, such as cardiovascular diseases, diabetes, end-stage renal disease, or cancer, should be performed by a registered dietitian.

Periodontal disease Although nutrition is thought to play only a minor part in either the etiology or control of periodontal disease, nutrient deficiencies can compromise associated inflammatory response and wound healing. Likewise, malnutrition can elicit adverse alterations in the volume, antibacterial, and physiochemical properties of saliva. Good nutritional status and dietary practices combined with removal of the stimuli of inflammatory periodontal lesions are important in diminishing the severity of periodontal lesions (19). Changes in structural tissue can also affect masticatory functions (12,20).


Medically Compromised Conditions

The oral cavity is the beginning of the gastrointestinal tract. Thus, risks for oral problems increase with many disease states, changes in health status, and/or adoption of practices that may also affect diet and nutritional status. Figure 2 lists numerous examples of these conditions.


Diabetes mellitus Diabetes mellitus is a chronic disease with systemic manifestations. Poorly controlled diabetes (characterized by hyperglycemia and increased salivary glucose) is associated with an increased risk of several dental diseases and conditions. Microangiopathies, altered vascular permeability, and altered host response mechanisms increase risk of periodontal disease. Xerostomia and its consequent reduced salivary flow increase risk of dental caries, altered sense of taste, and burning mouth syndrome. Success of certain dental procedures, such as surgery and denture placement, is dependent on good glycemic control, which is a result of good dietary management. Evidence suggests that periodontal disease can also affect diabetes control.

It is incumbent on dental professionals to screen high-risk patients for dental-nutrition risk. The high-risk patient population includes persons at risk for oral problems because of poor glycemic control and those with diabetes who face dental (oral) procedures that will affect their ability to eat. Qualified dietetics professionals need to incorporate questions and guidelines on dental sequelae of diabetes into medical nutrition therapy as well as refer patients for dental care (21,22).

HIV infection ADA's position statement on nutrition intervention in the treatment of human immunodeficiency virus (HIV) infection states that "nutrition intervention - medical nutrition therapy - and education should be components of the total health care provided to persons infected with human immunodeficiency virus" (23, p 1042). Because of the magnitude and impact of HIV-associated oral diseases on dietary intake and nutritional status, dental intervention in conjunction with nutrition management is an essential component of care at the earliest stage of HIV infection. Persons with HIV infection are at risk for oral disease with accompanying nutritional and systemic consequences. For example, oral-pharyngeal fungal infections may cause a burning, painful mouth and dysphagia. Oral viral diseases, such as herpes simplex and cytomegalovirus, lead to chronic, painful ulcerations. These problems, along with stomatitis and periodontitis, are associated with pain and can lead to reduced oral intake. Esophagitis and oral and esophageal candidiasis result in painful chewing, sucking, and swallowing, thus reducing an already compromised appetite and intake. Kaposi's sarcoma, an oral malignancy seen in HIV-positive patients, has the combined effect of compromising oral intake and increasing nutrient needs.

Oral and pharyngeal cancer The most consistent dietary findings on the role of diet and nutrition in the etiology of oral cancer (24) are the protective effects of high fruit consumption and the carcinogenic effect of alcohol intake. Although use of vitamins and other nutrients to reduce risk of oral cancer and oral leukoplakia have shown promise, side effects and a lack of biomarkers to measure intermediate outcomes are still a concern. Beta carotene and vitamin E may have chemopreventive effects on oral cancer risk, but well-designed control studies are needed to confirm these effects (25,26). Findings in epidemiologic studies examining nutritional factors and oral and pharyngeal cancer risk indicate nondefinitive trends because of differences in methodologies and populations studied. In the future, continued multidisciplinary research is likely to result in a better understanding of the role of diet in oral cancer prevention and treatment.

Cancer therapies often produce oral complications. Radiation treatment of the oropharyngeal area may result in loss of teeth, painful stomatitis, xerostomia, fibrosis of the muscles of mastication, and loss of sense of taste. Borderline vitamin and mineral deficiencies associated with cancer treatment may manifest themselves in the oral cavity. Likewise, surgical treatment, including reconstruction, causes alterations in masticatory functions, increases energy and nutrient needs for healing, and can permanently affect chewing and swallowing (27,28).

Polypharmacy Medications used to treat the oral and systemic manifestations of HIV infection, cancer, autoimmune diseases, and cardiovascular diseases may also have notable side effects on a person's ability to ingest, digest, and absorb an adequate diet. Common consequences of antiretroviral, antiviral, antifungal, antiparasitic, antihypertensive, antidepressant, antihistamine, narcotic, sedative, and antineoplastic agents include xerostomia, stomatitis, reduced salivary flow, altered taste, and/or oral ulcers. All of these factors have notable drug-diet consequences and can lead to reduced intake in terms of total nutritive value and types of foods consumed (23,27).


High-Risk Groups Throughout the Life Span

Infants and children Adequate nutrients are needed for normal growth and development of the oral cavity (13,29). On the basis of findings in two cross-sectional studies of 1,776 Peruvian children between the ages of 1 and 13 years and a longitudinal study of 209 children, researchers have concluded that one episode of mild to moderate malnutrition in the first year of life is associated with increased incidence of caries in both deciduous and permanent teeth later in life (29). Maxillary anterior caries (baby bottle tooth decay) is the major nutrition-related dental disease found in young children. Other conditions that may affect dental health include developmental anomalies that alter eating ability and require specialized feeding strategies (7) and craniofacial surgery, which causes increased energy, protein, and nutrient needs for wound healing and may require multiple feeding modes, including oral supplements and tube feedings.

The elderly The elderly are the fastest growing population segment in the United States. National trends indicate that older patients frequently have one or more chronic diseases and/or other problems that can affect their dental treatment (30). Among the frail elderly, poor oral health is thought to be an important contributing factor in the development of substantial involuntary weight loss associated with protein-energy malnutrition (31). Because today's elderly tend to retain more of their natural teeth, new patterns of oral diseases, including root and coronal decay, are becoming more common. Oral manifestations of chronic diseases, xerostomia, side effects of polypharmacy on the oral cavity, osteoporosis, and eating problems associated with denture placement are examples of the scope of dental nutrition problems faced by the elderly (32). The negative effect of tooth loss, edentulism, and removable prostheses on eating habits, diet adequacy, masticatory function, sense of taste, and gastrointestinal disorders has been documented (33,34). Persons who wear dentures have been termed "oral invalids" (35). Researchers have found that they have about one sixth the chewing ability of their dentate counterparts (33) and take more drugs (including laxatives and antireflux agents) for gastrointestinal disorders (34).

Despite clear evidence of the relationship between diet and nutritional status and the dental problems faced by the elderly, nutrition counseling has not been a routine component of dental practice (36-38). Conversely, when planning medical nutrition therapy, qualified dietetics professionals have not routinely considered the oral manifestations of diseases and medications or the dental problems faced by patients who wear dentures. The Nutrition Screening Initiative, introduced in 1990 as a national approach to early detection of nutrition risk and its potential causes in the elderly, is an example of a rapid strategy to detect combined nutrition and oral health problems (39). This initiative exemplifies transdisciplinary care by dental and dietetics professionals. The Determine Your Nutritional Health Checklist and the separate Oral Health Risk Factor Checklist identify oral problems contributing to nutrition risk in the elderly (39).


Key Points

Leaders in promotion of nutrition and oral health include representatives from the dietetics and dental professions. It is essential that a body of knowledge that supports practice in these specialties is delineated to ensure health promotion and comprehensive health care. Knowledge of the synergy between oral health and nutrition should also be promoted in other allied health education programs. Collaborative efforts within the oral health and nutrition specialties to promote interdisciplinary health care teams will foster successful strategies related to oral health and nutrition- presents strategies for dietetics and dental professionals to address oral health and nutrition issues in practice.


Nutrition In Dental Education

Nutrition education at the predoctoral level in the curriculum of dental schools includes competencies that focus on knowledge of basic nutrition, role of diet and nutrients in health and oral diseases, and nutrition counseling as it relates to oral health. In 1988, the American Dental Association's Commission on Dental Accreditation Standards for Dental Education Programs specified that "The graduate must be competent to provide dietary counseling and nutritional education relevant to oral health" (40, p 15). The majority of postdoctoral (advanced education) programs include competencies focusing on management of medically compromised patients, those with chronic and terminal diseases, and those who have undergone surgical interventions. Implied in these required competencies is knowledge of diet and nutrition as they relate to comprehensive dental management (2,3). Specific curriculum guidelines that identify nutrition content germane to select dental practice specialties exist.

Recommendations for improving nutrition education of dental professionals have been proposed. National surveys in 1980, 1986, 1990, and 1992 showed that curricular time devoted to nutrition is low compared with time devoted to other academic subject areas (41-44). Experts in the field of nutrition in dentistry have recommended integration of nutrition into the dental curriculum throughout the 4 years of didactic and clinical coursework (42,43,45). The need for this integration is supported by the report Healthy America: Practitioners for 2005 (46), which highlights the need for expanded access to care by health providers in coordinated teams.

According to the Accreditation Standards for Dental Hygiene Education Programs (47), the clinical education component of the curriculum must include instruction and experiences in nutrition counseling. A survey of the dental nutrition knowledge of public health dental hygienists revealed inaccuracies in their knowledge of the role of diet in the prevention of dental caries (48). The authors concluded that up-to-date material on diet/nutrition and dental caries should be included in the didactic and clinical teaching of dental hygiene students and in continuing education programs for professionals.

Cross-training on basic levels of care, including risk identification and referral for intervention, is becoming common for health professionals as clients seek comprehensive health care. An Institute of Medicine (IOM) study supports comprehensive training of dental professionals to ensure that they can "assess and treat the whole patient, not just the mouth" (3, p 154). One of its primary emphases is on the need for preventive health measures, including improved feeding practices (2). Specifically, recommendation 5 of the IOM study states: "To prepare future practitioners for more medically based modes of oral health care and more medically complicated patients, dental educators should work with their colleagues in medical schools and academic health centers" (2, p 12).


Oral Health In Dietetics Education

Oral health education is not outlined as a specific competency or criterion in dietetics education. In a survey of the dental nutrition knowledge of nutritionists with the Special Supplemental Food Program for Women, Infants, and Children, only 50% recognized that dental caries is caused by a bacterial infection, and 66% incorrectly linked severity of caries to total sugar concentration in foods (48). The need for dental professionals to form partnerships with qualified dietetics professionals to facilitate patient referrals has been identified (3,42). Yet attempts to put this into practice have not been documented. Because a healthy, functional oral cavity is a necessary part of mastication and digestion, oral health concepts should be incorporated into didactic and clinical training in baccalaureate, preprofessional, and graduate levels of dietetics education.  Dental topics and opportunities for clinical preprofessional dental training experiences should be included in dietetics education programs. Graduate and continuing education programs should include research and applications as they relate to medical and nutrition management of orally compromised patients. Cross-training in the conduct of oral assessments and identification of dental risk should be included (3,49). Likewise, models for community health promotion should include oral health messages in combination with nutrition messages.


Collaborative Approach to Nutrition and Oral Health Education

The changing social and economic realities of today's health care system have had a dramatic effect on the preparation and training of health professionals, including dietetics professionals, dentists, and allied dental personnel. The ADA position on nutrition education of health professionals advocates "the need for nutrition instruction in the education of health professionals. These professionals should collaborate with nutrition professionals in the care of clients" (50, p 611).

Oral health and nutrition experts should assume leadership in promoting this dual content area in the curriculums of other allied health professions. Dental and dietetics professionals need to form networks with other members of the health care team (e.g., physicians, nurses) to advance health promotion and preventive/community health initiatives that promote oral health and nutrition as they relate to general health. Dental teams should integrate dental disease education with general health education (51). In the long-term-care setting, dietetics professionals are responsible for incorporating questions and guidelines on oral sequelae of acute and chronic diseases into medical nutrition therapy and for referring patients for dental care when they have untreated oral problems. Under the Omnibus Budget Reconciliation Act regulations and guidelines, dental and dietetics professionals in long-term-care settings are encouraged to use a combined oral/nutritional status screening approach in development of care plans (52).


Partnerships in Practice

The objectives of the US Public Health Service's Healthy People 2000 report (53) specifically address not only the need to reduce occurrence and severity of oral disease but also the need to alleviate barriers (physical, cultural, racial, ethnic, social, educational, health care delivery, environmental) that prevent people from achieving healthy oral functioning. Health promotion and disease prevention initiatives launched by national dental organizations, federal and state agencies, and private foundations to meet these objectives will contribute to good nutritional status. Issues related to fluoride and to oral cancer prevention are examples of topics being addressed. Opportunities to carry nutrition into the oral health arena are open to dietetics professionals who are knowledgeable about oral health and related public health initiatives.

In certain dental and medical settings, nutrition counseling aimed at improving oral health may be submitted for third-party reimbursement. The integration of oral and nutrition health therapy as part of the treatment provided by both dietetics and dental professionals is an excellent example of comprehensive and cost-effective care.


Summary and Future Directions

Medical nutrition therapy can reduce the risk of oral infectious diseases and improve the outcome of treatment of patients with oral manifestations of acute, chronic, and terminal diseases. Clinical trials to identify interactions between oral health and nutrition/diet may support findings of animal and laboratory research and provide a foundation for more effective health promotion and disease prevention and for successful treatment modalities. Given the current climate of health care delivery, which stresses collaborative efforts of health care providers, qualified dietetics and dental professionals are challenged to pursue opportunities to create a health care paradigm that will mesh optimum oral and nutritional health status-identifies activities for future action.

To prepare practitioners with the skills and knowledge that will lead to a successful practice that exemplifies this paradigm, dietetics and dental educators must assume responsibility for embedding oral health topics and clinical/community experiences in education. Figure 4 provides a foundation for future initiatives in this area. Changes in the epidemiology of oral disease, along with population shifts and new technology, have major implications for the future of dentistry and dietetics. More research examining the links between nutrition and oral health and disease is needed (54). Collaborative endeavors between dietetics and dentistry in research, education, and delineation of health provider practice roles are needed to ensure comprehensive health care to persons with oral infectious disease and/or oral manifestations of systemic diseases.

For health professionals, the burden of responsibility to provide comprehensive health care is rapidly increasing (2,3,55). Dental practitioners of the future will be called on to expand their role not just to treat oral disease, but to share with other health professionals the responsibility for attaining and maintaining a patient's total health. Similarly, dietitians of the future will not only need to treat a specific diagnosis with medical nutrition therapy but will need to incorporate a pa-patient's total health needs into the treatment approaches. Although members of each profession must maintain their respective roles, they must also be able to function as partners in providing baseline comprehensive health services.



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 ADA Position adopted by the House of Delegates on October 29, 1995. This position is in effect until December 31, 2001. The American Dietetic Association authorizes republication of the position statement/support paper, in its entirety, provided full and proper credit is given. Requests to use portions of the position must be directed to ADA Headquarters at 800/877-1600, ext 4896.

Recognition is given to the following for their contributions:



Riva Touger-Decker, PhD, RD, and Connie Mobley, PhD, RD



American Association of Dental Schools (Kenneth R. Etzel, PhD; James L. McDonald, Jr, PhD; Byron L. Olson, PhD); American Dental Association; American Dental Hygienists' Association; Dominick P. DePaola, DDS, PhD; Ruth Gitchell, MS, RD; Carole Palmer, EdD, RD.

American Dietetic Association position paper on: Oral Health and Nutrition

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