Download Message to our patients: you are what you eat, and your mouth

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Message to our patients: you are what you eat,
and your mouth shows it
Larry N. Williams, DDS
T
he daily practice of dentistry includes many aspects of oral
health. Some key questions concerning your practice center
on your inclusion of nutritional counseling into your daily
practice. Do you advise your patients about the impact their
nutrition has on their mouths and the restorations you have
placed? Do you feel it is important to discuss with patients what
they eat or drink? If so, do you delegate this task to others on
your staff? Or is it not done at all? These questions focus on two
key aspects of health that are very much related—the dietary
habits of your patients and the condition of their oral health.
In May 2013, the Academy of Nutrition and Dietetics published an outstanding position paper that firmly stated “nutrition is an integral component of oral health.”1 This paper went
further to recommend that dental practitioners collaborate with
nutrition experts in developing programs for “oral health promotion and disease prevention.”1 The Academy also made an important point that “nutrition and diet can affect the development
and integrity of the oral cavity.”1
Before proceeding further in this article, one vital point must
be made. There is always the small but financially important fact
that practitioners are concerned about reimbursement for their
valuable time spent in nutritional counseling in addition to their
other oral health duties. Without monetary incentive, some will
think nutritional counseling has no place in the carefully managed time schedule of a busy practice. The fact is that nutritional
counseling must be done to discuss the links between diet and
oral health, and that poor nutrition can adversely impact the
longevity of current or planned restorations.
Patients must understand that their mouths are linked to
what they eat, and it is our job to make this understanding
a part of their oral health care. Everything eaten, imbibed,
chewed, and dissolved in the oral cavity can impact oral health.
Given the many factors linking our diet to our oral health, it
is important that we fully understand some of the key connections. This column will look at some important links between
oral health and nutrition.
Dental caries and nutrition
Dental caries and periodontitis are both common diseases, and
both are connected to dietary factors. When discussing caries,
we know they are linked to the presence of fermentable carbohydrates which are incorporated, along with salivary constituents,
into the biofilm present on teeth. There are specific dietary factors associated with an increased risk of caries, including sugarsweetened components of liquids and foods (such as corn syrup),
sugar-coated food products, starchy snacks, low pH drinks,
and simple sugars. There are also specific dietary habits that
are linked to increased caries, including frequent snacking and
prolonged exposure of teeth to acids or sugars—for example, dissolving hard candies in the mouth or sipping sugar/acidic drinks.
Of course we know that the risk of dental caries can be
prevented and/or controlled by addressing the risks previously
discussed, along with good oral hygiene behavior and healthy
nutritional intake. Some dietary habits can lessen the impact of
caries such as chewing sugar-free gum between meals, eating
fresh fruits and vegetables, eating hard cheeses, and eating lowsugar content breads. In addition to the impact on caries, it is
also important to note that studies show that those who eat fresh
fruits and vegetables high in vitamin C, folate, and carotenoids
as part of their daily diet also have a lower incidence of oropharyngeal cancer (OPC).2 There are certain eating patterns that
also impact caries risk. According to the Academy of Nutrition
and Dietetics’ position paper, waiting at least 2 hours between
meals, eating whole/unprocessed foods, and using sugarless gum
immediately after a meal or a snack when unable to brush can all
help decrease the risk of caries.1
Systemic diseases, oral health, and nutrition
There are some very specific links between the nutritional habits
of our patients and certain deficiencies and diseases, and their
respective treatments that may have a negative impact on the
oral cavity. As mentioned earlier, there is a decreased incidence
of OPC in patients who eat fresh vegetables and fruits that
contain vitamin C, folate, and carotenoids. Pavia et al looked at
a meta-analysis of several studies that showed an inverse relationship between citrus fruits and vegetable consumption and the
risk of OPC.2 In the treatment of a patient with OPC—or any
form of cancer for that matter—the resulting chemo- and/or
radiation therapy can have an adverse impact on the oral cavity
and the patient’s nutritional intake. Chemotherapy by itself can
cause mucositis, altered taste, xerostomia, and dysphagia. In
order to ensure that nutrition and oral health care are optimum
for the patient, the dental team and nutritional experts must
work together to help these cancer patients.
Another systemic issue that directly impacts the relationship
between the oral cavity and nutrition relates to patients with
eating disorders and gastric dysfunction. Bulimia and gastric
esophageal reflux disease (GERD) produce excess acids in the
oral cavity. The purging of gastric contents during bulimic
episodes can directly impact the integrity of the lingual enamel
on anterior teeth and the occlusal surfaces of maxillary posterior
teeth. This loss of enamel integrity can also lead to an increased
risk of caries and damage to restorations. Patients who suffer
from GERD may also have acid damage in their mouths as a
result of the reflux from the digestive tract. The acid impact
of GERD is mainly on the occlusal surfaces of mandibular
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General Dentistry
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posterior teeth due to the pooling of the gastric acid. Those
patients suffering from anorexia can have xerostomia (dry
mouth) and nutritional deficiencies secondary to poor nutritional habits and antidepressant medications.3-5
Another area of concern in the relationship between nutrition
and oral health involves certain vitamin deficiencies. Due to the
quick turnover of mucosal cells in the mouth, various nutritional
deficiencies are first identified in the oral cavity. In the turnover
cycle of the oral mucosa (3 to 7 days), the impact of decreased
water-soluble C and B vitamins, proteins, and iron can be seen.
Patients who suffer eating disorders, alcohol abuse, fad diets,
and those who have problems with nutrient absorption are the
most commonly affected by vitamin deficiency issues. Some
specific vitamin-related deficiency issues involving the oral cavity
include vitamin B1 (thiamin) and beriberi, which can present
with increased emesis; vitamin B2 (riboflavin) and the presence
of glossitis, angular cheilitis, and swelling of the oral mucosa;
vitamin B3 (niacin) and pellagra, which can present with glossitis and stomatitis; vitamin C (ascorbic acid) and scurvy, which
can lead to oral infection and bone loss; vitamin D (considered a
hormone) which is linked to rickets in children and osteomalacia
in adults—both of which affect bone development; and iron
deficiency anemia, which can lead to angular cheilitis and oral
mucosal atrophy.6
A very important systemic disease that significantly impacts
both the oral cavity and nutritional health is diabetes. The oral
manifestations of diabetes are generally limited to Type I diabetes
mellitus, and include increased caries, periodontal disease, and
tooth loss. Salivary gland dysfunction, xerostomia, candidiasis,
and glossitis may also be involved.7
impact of caries, tooth loss, and other oral diseases. To complicate
matters, baby boomers have a greater tendency to suffer from
xerostomia, due to either the medications they take or physical
conditions associated with aging that alter salivary flow. Dental
providers must carefully evaluate older patients to look for signs
of nutritional difficulty, and conduct follow-up consultations with
nutritional specialists as needed.
Two other groups with special nutritional needs include pregnant women and children. Hormonal changes during pregnancy
can impact the gingival tissues and may cause discomfort and
bleeding. Women who are pregnant can also suffer from morning
sickness, which may result in the presence of gastric acids which
can lead to acid erosion and increased caries risk. “Morning” sickness, which can occur at any time of day, can alter proper nutrition
by limiting the intake of nutritionally adequate meals. Another
key issue is that mothers can also pass oral bacteria to their unborn
infants, thus increasing the risk of caries.10 A lack of education for
mothers regarding proper feeding of infants can also lead to early
childhood caries, which is also known as baby bottle tooth decay.
Children have been targeted unfairly by various groups focused
on selling less than adequate “nutritional” items. These items
include high fructose drinks, sports drinks, sugar-coated breakfast
foods, and various candies, all of which directly impact the oral
health of children. While it is very encouraging to see such great
oral health campaigns as Give Kids A Smile and 2Min2x, these
campaigns are no match for television commercials advertising
sugar-coated this and chocolate-covered that. It is also unfortunate that caries and poor oral health are in greater evidence in
lower-income communities, along with an increased risk of obesity and other health problems.
Oral stability and nutrition
Nutritional and oral health guidance
The ability of a person to chew his or her food can greatly affect
foods selected to be eaten and the patient’s ability to properly digest
those foods. Persons with edentulous arches, ill-fitting dentures,
partial dentures, and patients suffering from dental pain and/or soft
tissue discomfort all suffer some degree of difficulty in maintaining
proper nutrition. This is especially true with patients wearing an illfitting removable prosthesis such as a complete or partial denture.
Studies have shown that even well-fitted removable prostheses have
20%-25% of their chewing capability compared to natural teeth.8
Patients with ill-fitting prostheses (and occasionally even those
with well-fitting prostheses), or who suffer from dental pain,
often select foods that are easier to eat. Many of these soft foods,
such as breads and mashed potatoes, often have poor nutritional
value. Patients with dentures tend to eat larger bites of food,
which are more difficult to digest. These same patients will often
avoid eating fresh fruits and vegetables due to the difficulty of
biting into these foods. It is imperative that the dental team
recognize the difficulties in eating or chewing certain foods, and
emphasize to patients how to negotiate their difficulties with mastication while striving to achieve adequate nutrition.9
Special groups, special nutrition
The fastest growing group in the United States are baby boomers who are ≥65 years. Due to the fact that this generation is
living longer, their natural teeth have a longer exposure to the
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General Dentistry
Based on the relationship between oral health and nutrition,
the following guidance is suggested for oral health providers
when nutritional issues are discussed: carefully evaluate the
patient’s oral function and any noted impact on eating ability;
work with nutritional experts in developing plans for patients
suffering from oral health-related nutritional issues; and include
diet screenings of patients who may be at risk, especially seniors,
pregnant women, and children.
The goal of this column is to get oral health experts, including
dentists and their office teams, involved in nutrition counseling.
We cannot assume that patients are getting adequate nutritional
information. For those wishing to gain greater insight into the
most current nutritional guidance, the following sources provide
more detailed information:
• For all ages, www.choosemyplate.gov
• For infants, www.nutrition.gov/life-stages/infants
• For pregnant and breastfeeding mothers,
www.choosemyplate.gov/pregnancy-breastfeeding.html
• For baby boomers, www.nutrition.gov/life-stages/seniors
• For questions about supplements, http://ods.od.nih.gov/
factsheets
Author information
Dr. Williams is an assistant professor, Midwestern University
College of Dental Medicine, Downers Grove, Illinois.
www.agd.org
Published with permission by the Academy of General Dentistry. © Copyright 2014
by the Academy of General Dentistry. All rights reserved. For printed and electronic
reprints of this article for distribution, please contact [email protected].
References
1. Touger-Decker R, Mobley C, Academy of Nutrition and Dietetics. Position of the Academy of Nutrition and Dietetics: oral health and nutrition. J Acad Nutr Diet. 2013;113(5):
693-701.
2. Pavia M, Pileggi C, Nobile CG, Angelillo IF. Association between fruit and vegetable
consumption and oral cancer: a meta-analysis of observational studies. Am J Clin Nutr.
2006;83(5):1126-1134.
3. Lifante-Olivia C, Lopez-Journet P, Camacho-Alonzo F, Esteve-Salinas J. Study of oral
changes in patients with eating disorders. Int J Dent Hygiene. 2008;6(2):119-122.
4. Aranha AC, Eduardo Cde P, Cordas TA. Eating disorders. Part 1: psychiatric diagnosis
and dental implications. J Contemp Dent Pract. 2008;9(6)73-81.
5. Russo LL, Campisi G, Di Fede O, Di Liberto C, Panzarella V, Lo Muzio L. Oral manifestations of eating disorders: a critical review. Oral Dis. 2008;14(6)479-484.
6. Neville BW, et al. Oral and Maxillofacial Pathology. 3rd ed. St Louis: Saunders Elsevier;
2009:825-827.
7. Ibid.: 843-845.
8. Pereira LJ, Duarte Gaviao MB, Van Der Bilt A. Influence of oral characteristics and food
products on masticatory function. Acta Odontol Scand. 2006;64(4):193-201.
9. Witter J, Tekamp FA, Slagter AP, Kreulen CM, Cregers N. Swallowing threshold parameters of subjects with complete dentures and overdentures. Open J Stomatol. 2011;1(3)
69-74.
10. Reisine S, Douglass J, Aseltine R, Shanley E, Thompson C, Thibodeau E. Prenatal nutrition intervention to reduce mutan streptococci among low income women. J Public
Health Dent. 2012;72(1):75-81.
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