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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