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NUTRITIONAL ASSESSMENT AND EDUCATION FOR DENTAL PATIENTS CHAPTER 21 Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Evaluation of the Patient: Health History Ask open-ended questions about diseases/conditions Does this disease or condition require a change in diet? Gastric bypass End-stage renal or liver disease What kind of changes have been made? Are changes supervised by an MD/RD? Frequency of alcohol or tobacco use Changes in taste or ability to chew Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 2 Evaluation of the Patient: Health History Specifically ask about herbal and supplement use What herbal medications or supplements are you taking? What is the dose and frequency of these herbs/supplements? Have patients bring in their herbal medications and dietary supplements and all prescription medications 1 in 5 patients unable to properly identify herbs and supplements they are taking During routine preoperative assessment, 70% of patients failed to disclose dietary supplements Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 3 Evaluation of the Patient: Nutrition Screening Purpose in dentistry Identify patients at nutritional risk or suspected to be at risk due to eating habits, disease, or medical treatment Identify those with cariogenic eating habits that are at high caries risk Procedure Patient can fill out the screening form while waiting for treatment Dental professional should evaluate whether patient receiving nutrition care from another source Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 4 Evaluation of the Patient: Psychosocial/Social History Socioeconomic status of patient Is there access to adequate food? May need to direct to social service agencies for assistance Does the patient live alone? Often a significant risk factor for poor nutrition in the elderly Does the patient like to cook for himself or herself? Is patient able to get to the grocery store or to congregate meal sites? Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 5 Evaluation of the Patient: Dental History Does oral condition affect what patient eats? People with dentures eat less meat, fruit, vegetables Aphthous ulcers interfere with eating and drinking Are there significant changes in oral health (caries rate)? Does dry mouth or xerostomia affect what patient eats and drinks? History of fluoride exposure Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 6 Clinical Observation: Physical Appearance Assessment Weight Does patient appear to be under- or overweight? May be concerns about protein and calorie intake Has the patient’s weight changed significantly since the last visit? Hair, fingernails, skin color and tone Iron deficiency results in changes in the fingernails Patients with anemia are often extremely pale Vitamin A toxicity may result in alopecia, cheilosis Beta-carotene excess may cause yellowish palms of the hands Mobility May limit dexterity and ability to perform HC procedures May affect obtaining and preparing food Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 7 Clinical Observation: Extraoral/Intraoral Examination Look for abnormal findings Findings must be interpreted with care Relatively rare to find a true nutrient deficiency in the healthy US population Patients suspected of having marginal or frank nutrient deficiencies should be referred to an MD and RD for care It is outside the scope of dentistry to prescribe doses of nutrients in excess of the RDAs Some nutrient deficiencies (those seen in alcohol withdrawal) require pharmacologic doses of nutrients, (e.g., thiamin and folic acid) Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 8 Clinical Observation: Anthropometric Evaluation Anthropometric evaluation Ask patient’s height and weight Calculate BMI Reduction of 10% of usual weight over a 6-month period is significant Loss of 20% of body weight or greater may indicate depletion of body stores affecting immune response and ability to heal following invasive dental treatment Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 9 Determining Diet History: 24-Hour Recall Retrospective data about food intake/habits Disadvantages Remembering accurately what was eaten the day before May consciously or unconsciously alter intake reported to simplify recording or to impress the interviewer May be an atypical day Advantage Relatively quick and simple to do during a clinic visit Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 10 Determining Diet History: Food Frequency Questionnaire Purpose of FFQ is to determine how often a patient consumes specific foods Disadvantages Not specific and does not gather enough data to evaluate nutrient intake Relies on patient’s memory Advantage Requires limited explanation and little time Allows for analysis of food group consumption and carbohydrate intake Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 11 Determining Diet History: 3- to 7-Day Food Diary Food is recorded as it is eaten Nutrient intakes are calculated and averaged over the 3- to 7-day period and compared to RDA or FGP guidelines Disadvantages Compliance Foods not written down immediately may be forgotten Time-consuming to the person assessing the diet Advantages Get a better idea of the actual intake Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 12 Clinical Examination Significant increase in caries rate Xerostomia Dietary changes Changes in oral self-care routines Decay or erosion in unusual locations Eating disorders GERD From Perry DA, Beemsterboer P: Periodontology for the Dental Hygienist, ed 3. St. Louis: Saunders, 2007. Periodontal disease out of proportion to local factors Difficulty chewing or swallowing Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 13 Identification of Nutritional Status Comparison of intake to MyPlate and Dietary Guidelines for Americans 2020 Tally the number of servings consumed from each food group Average intakes determined by dividing totals by the number of days in the food diary Use averages for comparison with MyPlate Identify deficient or excessive nutrients Cariogenicity of the diet Circle or highlight each carbohydrate exposure and identify form, frequency, and time eaten Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 14 Formation of Nutritional Treatment Plan How do you decide what to focus on once the nutrient analysis is complete? What issues did you identify in the screening or review of the patient history? Lactose-intolerant adolescent or postmenopausal woman Elderly man living alone who doesn’t cook and doesn’t like to shop Middle-aged woman with poorly controlled diabetes and active moderate periodontitis that requires SRP and possible surgery Elderly woman with a dry mouth due to polypharmacy Teenager who eats fast food and energy drinks and tells you he has “tons” of new cavities every time he visits the dentist Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 15 Formation of Nutritional Treatment Plan: Integration and Implementation Purpose of nutritional counseling is to provide accurate information and motivate and encourage patient to initiate positive changes in behavior Setting goals Resistance to change, despite knowledge, a natural response Goal chosen should be difficult enough to be challenging but not so difficult as to seem impossible Goal needs to be measurable or observable: Eat one vegetable each day Successful achievement of smaller steps motivates one toward larger changes Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 16 Formation of Nutritional Treatment Plan: Integration and Implementation Menu creation Dental hygienist helps patient establish a menu that follows principles in the Menu Planning Record, including nutritionally adequate and noncariogenic situations Follow-up Monitor progress, provide encouragement, adjust goals as necessary Review Summarize the pertinent points Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 17 Formation of Nutritional Treatment Plan: Integration and Implementation Evaluation Ongoing process that occurs in all stages of assessment and counseling; need to continually revise goals Documentation Treatment record serves as tool for communication with other members of the dental team as well as other healthcare professionals Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 18 Facilitative Communication Skills Create atmosphere of sincerity, trust, and empathy Use nonjudgmental and noncritical responses Active listening Involves more than hearing; it includes interpreting what is said, how it is said, and nonverbal actions observed Nonverbal actions Facial expressions, eye contact, body movements, personal distance, head-nodding, and vocal cues Questioning Ask open-ended questions to encourage sharing Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 19 Appropriate Referral Know when the case is outside the scope of dental practice! Know when and how to refer! If complex conditions require special diet instructions, consult with the physician to see if a referral can be made to a registered dietitian Referral by the MD is more likely to result in coverage by insurance Find a nutrition professional online at www.eatright.org Most medical insurance and Medicaid cover medical nutrition therapy for specific disease conditions Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 20 Nutrition and Oral Health Basics Limit between-meal snacks Eat cariogenic foods during meals Include whole grains, vegetables, fruits, low-fat dairy as snacks Limit simple and retentive CHOs like crackers, soft drinks, sports drinks, fruit juice between meals Rinse with water, chew xylitol gum, or brush teeth after snacks with fermentable carbohydrates Calcium-rich foods such as low-fat cheese, yogurt, or milk for snacks Appropriate use of fluorides, meticulous daily plaque removal Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 21