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EFFECTS OF SYSTEMIC DISEASE ON
NUTRITIONAL STATUS AND ORAL
HEALTH
CHAPTER 17
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Effects of Chronic Disease on
Dietary Intake
 Anorexia is a condition in which a person has a
poor appetite for various reasons (e.g., cancer
treatment)
 Appetite may decrease because of pain, apathy, anorexia,
drugs, inactivity, or other reasons
 Malnutrition or other stresses, such as infection, surgery,
or injuries resulting in anorexia, deplete body stores of
kilocalories, macronutrients (e.g., protein), and
micronutrients (e.g., vitamin C) needed to regenerate and
repair cells and sustain immune system
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
2
Effects of Chronic Disease on Dietary
Intake
 Taste and smell disorders
 With a loss of smell patients report eating
less
 With loss of taste patient may require
greater amounts of sodium and sugar
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
3
Effects of Chronic Disease on
Dietary Intake
 Xerostomia affects nutritional status in several
ways:
 Chewing is difficult because a bolus cannot be formed
without additional moisture
 Chewing is painful because the mouth is sore
 Swallowing is difficult because of loss of lubrication
from saliva
 Food intake may decrease because of changes in
taste perception
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
4
Anemias:
Iron Deficiency Anemia (IDA)
 Etiology
 Oral manifestations:
 Increased needs during
 Atrophic glossitis
growth periods such as
infancy or pregnancy
 Excessive bleeding
 Inadequate intake
 Aphthous ulcers
From Cawson RA, Odell EW: Cawson’s
Essentials of Oral Pathology and Oral
Medicine, ed 8. St. Edinburgh, UK: Churchill
Livingstone, 2008.
 Gingival and mucosal
pallor
 Angular cheilosis
 Candidiasis
 May impair wound
healing
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
5
Anemias:
Iron-Deficiency Anemia (IDA)
 Dental hygiene considerations
 May need to postpone invasive nonsurgical
periodontal therapy until IDA improves
 Encourage iron-rich foods (e.g., meat)
 Encourage vitamin C to enhance
absorption
 If iron supplement is liquid, dilute with
water or juice and drink with straw to minimize
tooth staining
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
6
Anemias: Megaloblastic Anemia—Vitamin B12
 Also called pernicious  Oral symptoms
anemia
 Etiology
 Angular cheilosis
 Recurrent
aphthous ulcers
From Ibsen OAC, Phelan JA:
 Erythematous
 Inadequate intake
Oral Pathology for the Dental
Hygienist, ed . St. Louis:
mucositis
 B12 only in animal products
Saunders, 2014.
 Vegans at risk of deficiency  Pale or yellowish oral
mucosa
 Malabsorption
 Common in elderly
 Atrophic glossitis; beefy
red color
 Increased needs
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
7
Anemias: Megaloblastic Anemia—Folate
 Etiology
 Oral manifestations
 Poor diet
 Atrophic glossitis
 Medications that
 Ulcerations
interfere with absorption
(e.g., phenytoin or
methotrexate)
 Glossodynia
 Angular cheilitis
 Fungal infections
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
8
Anemias: Megaloblastic Anemia
 Dental hygiene considerations
 Encourage folate-rich food sources
and supplement to meet the RDA for folate (400 µg)

Large doses of folate can negate effects of anticonvulsants, so
consultation with medical provider is necessary
 Encourage intake of foods from animal sources high in
vitamin B12 for pernicious anemia

For vegans encourage fortified foods or supplements
 Patients with permanent gastric or ileal damage need
monthly intramuscular or oral vitamin B12
supplementation for life
 Refer to a registered dietitian
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
9
Other Hematological Disorders:
Neutropenia
 Etiology
 Oral manifestations
 Drugs (e.g.,




 Mucositis
chemotherapeutics)
 Viral infections
Autoimmune disease
 Fungal infections (e.g.,
(e.g., rheumatoid
candidiasis)
arthritis)
Hematologic disease
From Ibsen OAC, Phelan JA: Oral
(e.g., leukemia) Pathology
for the Dental Hygienist, ed 6. St.
Louis: Saunders, 2014.
Nutritional deficiencies
Bacterial or viral infection
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
10
Other Hematological Disorders:
Neutropenia
 Dental hygiene considerations
 Invasive dental treatment contraindicated until white
blood cell counts rise
 Palliative care such as nonalcohol chlorhexidine rinse
may help reduce bacterial load until patient can
perform more thorough oral self-care
 Stress importance of frequent oral
prophylaxis and meticulous oral hygiene
care once muscositis pain subsides
 Refer to a registered dietitian
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
11
Gastrointestinal Problems: Gastroesophageal
Reflux Disease (GERD)
 Lower esophageal
 Recommendations
sphincter (LES) allows
 Avoid foods causing
GERD (e.g., fatty foods)
gastric contents to
 Eat small meals
enter the esophagus
 Keep patient in
 Etiology
 Hiatal hernia
 Obesity
 Pregnancy
semisupine position
 Assist with tobacco
cessation
 Weight loss as needed
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
12
Gastrointestinal Problems:
Malabsorptive Conditions
 Etiology
 Oral manifestations
 Crohn’s disease
 Swollen, bleeding,
 Ulcerative colitis
 Cystic fibrosis

 Gluten-sensitive
enteropathy (sprue or
celiac disease)
 AIDS




erythematous gingiva
Diffuse pustular eruptions
on buccal gingiva
Oral ulcerations
Swelling of the lips
Cobblestone-like, raised
hypertrophic lesions
Metallic dysgeusia
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
13
Gastrointestinal Problems:
Malabsorptive Conditions
 Dental hygiene considerations
 Consult with healthcare provider about patient’s need
for supplemental steroids and prophylactic antibiotics
before the dental appointment
 Encourage patient to eat a nutrient-rich, well-balanced
diet to enhance healing
 Healthcare provider or registered dietitian may
recommend vitamin and mineral supplementation
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
14
Cardiovascular Conditions:
Cerebrovascular Accident (CVA)
 CVA or stroke results
if occlusion or
ischemia occurs in an
artery supplying the
brain or if
hemorrhaging in the
 Oral manifestations
 Dysphagia
 Facial muscle
weakness
 Slurred speech
brain occurs
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
15
Cardiovascular Conditions:
Cerebrovascular Accident (CVA)
 Dental hygiene considerations
 Monitor blood pressure
 Using water for rinsing or ultrasonic instrumentation
may be contraindicated during dental care if dysphagia
is present
 Neurological deficits may cause some to be unaware
of the presence of food in the mouth, so the mouth
should be checked for any pocketed foods after meals
 Excellent oral self-care is needed to prevent caries;
patient may have a softer, more cariogenic diet
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
16
Cardiovascular Conditions:
Hypertension
 Dental hygiene considerations
 Minimize stress for the appointment
 Monitor blood pressure
 Manage medication-induced xerostomia
 Recommend fruits and vegetables, low-fat/nonfat dairy
products; to limit sodium, alcohol, caffeine; tobacco
cessation; exercise; lose weight; reduce stress

Direct to information about the DASH diet on the NHLBI
website
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
17
Cardiovascular Conditions:
Hyperlipidemia
 Dental hygiene considerations
 Recommend reducing total fat, saturated fat, dietary
cholesterol
 Encourage noncariogenic, low-fat snacks
 Long-term use of bile acid sequestrants
(cholestyramine and colestipol) to lower serum lipids
may cause malabsorption of fat-soluble vitamins and
folic acid

Encourage food sources rich in these nutrients
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
18
Skeletal System
 Etiology
 Osteoporosis
 Bisphosphonates used to treat
osteoporosis and multiple myeloma
increases risk for osteonecrosis (bone
death of the jaw)
 Hyperparathyroidism
 Paget’s disease or fibrous
From Ibsen OAC, Phelan JA: Oral
Pathology for the Dental Hygienist, ed 6. St.
Louis: Saunders, 2014.
dysplasia
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
19
Skeletal System
 Oral manifestations
 Increase in size or alteration in contour of maxilla or






mandible
Alteration in radiographic pattern
Mobility of individual teeth without significant
periodontal disease
Pain or discomfort in jaw without obvious dental
pathology
Increased sensitivity of teeth without obvious dental or
periodontal disease
Changes in the occlusion of the teeth
Abnormal sequence of deciduous tooth loss or eruption
of permanent molars in young
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
20
Skeletal System
 Dental hygiene considerations
 Provide guidance to ensure that
the patient obtains adequate
calcium and vitamin D
 Avoid alcohol consumption
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
21
Metabolic Problems:
Diabetes Mellitus
 Symptoms
 Fruity-smelling breath
(more prevalent in type
1 diabetes)
 3 P’s



Polydipsia: increased thirst
Polyphagia: hunger
Polyuria: frequent urination
 Unexplained weight loss
 Oral manifestations in
poorly controlled DM
 Poor healing
 More severe
periodontal disease
 Tissue necrosis from
minor trauma
 Xerostomia
 Candidiasis
From Ibsen OAC, Phelan JA: Oral
Pathology for the Dental Hygienist, ed 6. St.
Louis: Saunders, 2014.
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
22
Metabolic Problems:
Diabetes Mellitus
 Dental hygiene considerations
 Encourage frequent periodontal
maintenance/meticulous oral self-care
 Prevent hypoglycemia by treating patient in
the morning, ensuring patient ate at usual
time and took medications
 Have access to a glucometer and glucose
source
 Recognize and treat hypoglycemia quickly
with the rule of 15’s
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
23
Metabolic Problems:
Hypopituitarism
 Etiology
 Oral manifestations
 Congenital
 Decreased skeletal
 Tumor
growth results in
disproportionate
retardation of
mandibular growth
 Delayed eruption
 Malocclusion
 Head trauma
 Stroke
 Radiation
 Brain infection
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
24
Metabolic Problems:
Cushing’s Syndrome
 Symptoms
 High blood pressure
 Pre-diabetes or diabetes
 Obesity
 Muscle weakness
 Bruise easily
 Oral manifestations
 Diabetes and
osteoporosis may affect
management of
periodontal disease
and associated bone
loss
 Acne
 Hirsutism
 Osteoporosis
 Depression
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
25
Metabolic Problems:
Hypothyroidism
 Etiology
 Oral manifestations
 Inadequate consumption of





iodine
Inborn error of metabolism
High intake of goitrogen
Treatment of
hyperthyroidism
Thyroid gland disorder
Deficient secretion of TSH
 In children
 Short stature
 Intellectual disabilities
 Delayed eruption
 Severe malocclusion
 Risk for caries
 Macroglossia
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
26
Metabolic Problems:
Hyperparathyroidism
 Hypersecretion of the
parathyroid hormone
(PTH), leading to
alterations in calcium,
phosphorus, and bone
metabolism
 Oral manifestations
 Increased osteoclastic
bone resorption
 Brown tumors occur in
the head and neck,
especially the mandible

May affect ability to
consume an adequate
diet
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
27
Metabolic Problems:
Renal Disease
From Ibsen OAC, Phelan JA: Oral Pathology for the
Dental Hygienist, ed 6. St. Louis: Saunders, 2014.
 Etiology
 Oral manifestations
 Primary glomerular
disease
 Secondary glomerular
disease (hypertension,
diabetes, lupus)
 Vascular disease
 Tubulointerstitial disease
(e.g., polycystic kidneys)
 Platelet abnormalities






may cause gingival
bleeding
Gingival pallor
Slow wound healing
Bad taste (from urea)
Malodor
Stomatitis
Hairy leukoplakia
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
28
Metabolic Problems:
Renal Disease
 Dental hygiene considerations
 Medical consult needed because of bleeding tendency
and to determine need for antibiotic prophylaxis to
prevent endocarditis and/or infection of vascular
access site for dialysis
 Minimize water due to fluid restrictions
 Schedule dental appointment day after dialysis
treatment
 Meticulous oral self-care and frequent care
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
29
Neuromuscular Problems: Parkinson’s
Disease
 Symptoms
 Oral manifestations
 Involuntary muscle tremors
 Abnormal chewing
and swallowing
 Bradykinesia (slowness of
pattern
movement)
 Holding food in
 Muscular weakness
mouth for extended
 Rigidity
periods
 Stooped posture
 Frequent drooling
 Decreased fine motor
 Tremor of mandible,
coordination
lips, tongue
 Orthostatic hypotension
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
30
Neuromuscular Problems: Parkinson’s
Disease
 Dental hygiene considerations
 Educate patient and/or caregiver on use of electric
toothbrush if difficulty holding conventional toothbrush
 After supine positioning, sit patient upright for >2
minutes before standing to avoid orthostatic
hypotension
 Minimize use of water due to swallowing problems
 Encourage adequate protein intake and overall healthy
diet to maintain weight and bone health
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
31
Neuromuscular Problems:
Developmental Disabilities
 Cerebral palsy, muscular dystrophy, Down
syndrome may be associated with abnormal
oral-motor development
 Oral-motor impairment is associated with:
 Tongue retraction
 Tongue thrust
 Tonic bite reflex
 Oral hypersensitivity
 Hyperactive gag reflex
 All make feeding difficult, as well as performing
dental and self-care
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
32
Neuromuscular Problems: Epilepsy
 Epilepsy does not usually result in any specific
oral or feeding problems, but the phenytoin used
to treat it can affect oral health as well as
nutritional status
 Gingival hyperplasia makes oral self-care challenging
 Phenytoin increases the need for vitamins D, K, and
folate and can affect bone mass long term

Refer to healthcare provider for nutrition counseling because
supplements can affect effectiveness of phenytoin
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
33
Neoplasia
 Nutritional requirements for persons with
neoplasms generally increased to maintain lean
body mass and immune responses
 Oral symptoms or signs may be secondary to
malnutrition or nutrient deficiencies (e.g., changes in
taste perception)
 Intake reduced in those with cancer of the oral cavity,
pharynx, or esophagus because of odynophagia (pain
on swallowing) or dysphagia
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
34
Neoplasia: Kaposi’s Sarcoma
 Highly malignant tumor of blood
vessel origin that occurs on the
skin and oral mucosa
 Red-purple macular lesions in the
mouth may progress to raised,
indurated lesions with central areas
of necrosis and ulceration
 Appear in many HIV-positive
patients
From Ibsen OAC, Phelan JA: Oral
Pathology for the Dental Hygienist, ed 6. St.
Louis: Saunders, 2014.
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
35
Neoplasia: Acute Leukemia
 Generalized malignant
disease characterized
by distorted
proliferation and
development of white
blood cells (WBCs)
 Oral manifestations
 Gingiva may become
severely inflamed with
tissue hyperplasia,
areas of ulcerations,
necrosis, and
spontaneous bleeding
 Delayed wound healing
 Increased susceptibility
to infection
From Ibsen OAC, Phelan JA: Oral
Pathology for the Dental Hygienist, ed 6. St.
Louis: Saunders, 2014.
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
36
Neoplasia: Cancer Treatments
 Radiation therapy to
 Chemotherapy effects
head and neck affects: include:
 General appetite loss
 Stomatitis or mucositis
 Nausea, vomiting,
 Oral ulcerations




diarrhea
Loss of taste sensation
Xerostomia
Difficulty in swallowing
Burning sensation in
the mouth
 Decreased absorptive
capacity
 Changes in taste
sensation
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
37
Neoplasia: Cancer Treatments
 Dental hygiene considerations
 Using antimicrobial mouth rinse (nonalcohol
chlorhexidine), meticulous oral self-care, frequent care
 Soft and/or bland diet may be necessary; encourage
protein intake
 Avoid alcohol and hot, spicy, and acidic foods when
oral lesions are present
 Caution against eating hard candy or drinking
beverages containing fermentable carbohydrates to
relieve the xerostomia
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
38
AIDS
 Symptoms
 Oral manifestations
 With HAART, classic
 Oral candidiasis
wasting is less
evident, although
wasting and anorexia
may be present
 Opportunistic infection
 Multiple nutrient
deficiencies
 Protein-energy
malnutrition
 Oral hairy leukoplakia
 Herpetic ulcerations
 Kaposi’s sarcoma
 May have more
severe periodontitis
 Xerostomia
From Ibsen OAC, Phelan JA:
Oral Pathology for the Dental
Hygienist, ed 6. St. Louis:
Saunders, 2014.
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
39
AIDS
 Dental hygiene considerations
 Encourage to maintain the highest possible level of




oral self-care and regular preventive dental care
To promote healing, encourage attention to adequate
nutrient intake (e.g., kilocalories, protein)
Use nutritional supplements or instant breakfast drinks
as snacks for those needing added nutrition
Limit caffeine- and alcohol-containing beverages if
xerostomia exists
Refer to RD and/or medical provider as needed
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
40
Mental Health Problems:
Anorexia Nervosa
 Primarily affecting
adolescent and young
adult females who
have an exaggerated,
intense fear of
becoming fat
 Zealous, self-imposed
restriction leads to
extreme weight loss
 Criteria for diagnosis
 Weight loss equal to or
exceeding 15% below
expected or original
body weight
 Amenorrhea
 Excessive desire for
slimness with distorted
body image
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
41
Mental Health Problems:
Bulimia
From Ibsen OAC, Phelan JA: Oral
Pathology for the Dental Hygienist, ed 6. St.
Louis: Saunders, 2014.
 Eating disorder not
necessarily associated with
significant weight loss, may
be slightly overweight
 Bingeing and purging
 Binges may occur several
times/day in late afternoon or
evening
 Most common method of purging
is self-induced vomiting
 Oral manifestations
 Erosion of enamel




(lingual maxillary
anterior teeth)
Palatal bruises
Enlarged parotid
glands
Dentin
hypersensitivity
Perimolysis
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
42
Mental Health Problems:
Mental Illness
 Many types of mental illnesses: schizophrenia,
depression, bipolar disorder or mania
 Drugs frequently prescribed to treat the
conditions may have side effects that affect oral
status
 Antipsychotics (haloperidol, thioridazine) and
anticholinergics (tricyclics, MAO inhibitors, trazodone)
frequently cause xerostomia
 Trazodone can cause unpleasant taste
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
43
Mental Health Problems
 Dental hygiene considerations
 Increased caries rate indicative of high-carbohydrate




bingeing and low pH of saliva from vomiting
Must recognize signs and symptoms of suspected
eating disorder and refer patients to health care
provider or eating disorder facility for care
Caution the patient against brushing immediately after
vomiting
Rinse with sodium bicarbonate to neutralize the oral
environment after vomiting
Encourage daily fluoride and hypersensitivity products
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
44
HEALTH APPLICATION
HUMAN PAPILLOMA VIRUS (HPV)
 Discuss why HPV is on the rise
 Discuss what HPV is a risk factor for
 Discuss possible treatments
 Discuss ways to prevent HPV
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
45