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Medically Compromised Conditions:
High-Risk Groups Throughout the Life Span:
Infant and Children
In Dental Education
Oral Health In
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.
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
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
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
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
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
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
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).
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
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.
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,
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