Nutrition for Oral and Dental
Health
Oral Health
 Diet and nutrition play a key role in
—Tooth development
—Gingival and oral tissue integrity
—Bone strength
—Prevention and management of
diseases of the oral cavity
Effects of Nutrient Deficiencies on
Tooth Development
Dental and Oral Health
 Teeth are made from protein matrix that is
mineralized with collagen (requiring vitamin
C), calcium, and phosphorus (requiring
vitamins D and A)
Anatomy of a Tooth
Dental Caries
 Infectious disease of teeth in which organic
acid metabolites lead to gradual
demineralization of enamel; proteolytic
destruction of tooth structure
 Any tooth surface can be affected.
The Decay Process
 Plaque formation: sticky mix of microorganisms,
protein, polysaccharides
 Bacteria metabolizing fermentable carbohydrate
produce acid
 Acid production: oral pH<5.5 allows tooth
demineralization
 Saliva function: rinses away food; neutralizes
acid; promotes remineralization
 Caries patterns:pattern depends on cause
Early Childhood Caries
 Also called “baby bottle tooth decay”
 Nursing bottle caries—putting baby to bed
with a bottle of sweetened liquid (juice,
Kool-Aid, etc.)
 Front teeth rapidly develop caries
 Common among Native Americans
 Wean children before age 2 from bottle
Early Childhood Caries
(From Swartz MH. Textbook of Physical Diagnosis, History, and Examination, 3rd ed. Philadelphia: W.B. Saunders, 1998.)
Dental Caries—cont’d
 Streptococcus mutans—most common
bacteria involved
 Fermentable Carbohydrate
 Time
 Drop in salivary pH to below 5.5
Dental Caries—cont’d
 Cariogenicity of foods
 Frequency of consumption of fermentable
Carbohydrate
 Food form—slowly dissolving
 Food combinations
 Nutrient composition of food/beverages
 Timing (end of meal)
Medical Sequelae of Dental Caries
 Bacteria from tooth decay can enter
bloodstream and inoculate heart valves,
cause bacterial endocarditis
 Oral-pharyngeal secretions inoculated with
bacteria can cause aspiration pneumonia
Fluoride
 Primary anticaries agent
 Water fluoridation
 Fluoridated toothpastes
 Oral rinses
 Dentrifices
 Beverages made with fluoridated water
Recommendations for
Fluoride Supplementation
(Data from American Dietetic Association: Position of ADA: The impact of fluoride on dental health. J. Am Diet Assoc. 94:1428,
1994.) * Milligrams of supplemental fluoride recommended according to fluoride concentration in drinking water.
Cariogenic vs. Cariostatic
 Cariogenic: containing fermentable
carbohydrates that can cause a decrease in
salivary pH to <5.5 and demineralization when
in contact with microorganisms in the mouth;
promoting caries development
 Cariostatic: not metabolized by
microorganisms in plaque to cause a drop in
salivary pH to <5.5
Cariogenic Foods
 Promote formation of caries
 Fermentable carbohydrates, those that
can be broken down by salivary amylase
 Result in lower mouth pH
 Include crackers, chips, pretzels, cereals,
breads, fruits, sugars, sweets, desserts
Cariostatic Foods
 Foods that do not contribute to decay
 Do not cause a drop in salivary pH
 Includes protein foods, eggs, fish, meat and
poultry; most vegetables, fats, sugarless
gums
Anticariogenic Foods
 Prevent plaque from recognizing an
acidogenic food when it is eaten first
 May increase salivation or have
antimicrobial activity
 Includes xylitol (sweetener in sugarless
gum) and cheeses
Other Factors that Affect Diet
Carogenicity
 Consistency: Liquids are cleared quickly while
sticky foods remain on the teeth
 Meal frequency: frequent meals and snacks
increase duration of exposure
 Food composition
 Food form: liquid, solid, slowly dissolving
 Sequence of eating: cheese or milk at the end of
the meal decrease the cariogenicity of the meal
Caries Prevention Guidelines
Periodontal Disease
 Inflammation of the gingiva with destruction
of the tooth attachment apparatus
 Gingivitis—early form
 Nutritional care involves increasing vitamin C,
folate, and zinc
Tooth Loss and Dentures
 Tooth loss—denture placement
 Food selections change
 Saliva production decreases
 Reduced chewing ability
 Lower calorie and nutrient intake occurs for
many
 Simple nutrition counseling; Food Guide
Pyramid, etc.
Oral Manifestations of Disease
 Stomatitis:
inflammation of oral
mucosa
 Candidiasis and herpes
simplex: fungal and
viral infections which
can affect mouth and
esophagus causing
pain and dysphagia
Photo: http://webpages.marshall.edu/~gain/bactnote/Image9.gif
Oral Manifestations of Disease
 Xerostomia: Dry mouth
 Periodontal disease
 Kaposi’s sarcoma—lesions in mouth and
esophagus; associated with AIDS
Kaposi’s Sarcoma
in AIDS
MNT for Mouth Pain/
Oral Infections
 Avoid acidic and spicy foods
 Offer soft, cold, nutrient dense foods such
as canned fruit, ice cream, yogurt, cottage
cheese
 Try oral supplements
 Use PEG or NG feeding if oral
supplementation is unsuccessful
 For xerostomia, try artificial salivas, citrus
beverages, sugar free candies or gums
Medications That May Cause
Xerostomia
Dental Health Affects Nutrition
 Tooth loss may affect ability to chew
(relationship between loss of teeth and
reduced intake of fruits and vegetables
 Dentures are often ill-fitting (especially
common after weight loss); problem foods
include fresh fruits and vegetables, chewy
and crusty breads and chewy meat like
steak
Interventions
 Obtain a dental consult: if dentures are
missing, find them. If they are loose,
replace or reline them
 Modify diet consistency: mechanical soft,
ground, pureed
 Use least restrictive diet possible;
individualize; mix consistencies if
appropriate
MNT for Wired or Broken Jaw
 Provide pureed, strained, or blenderized foods
as appropriate
 Encourage nutrient-dense foods such as
blenderized casseroles
 Recommend small, frequent meals with oral
supplements such as milkshakes, Instant
Breakfast, medical nutritionals
 Use liquid vitamin supplement if necessary
 Recommend patient weigh self to monitor
weight status
Dysphagia = difficulty
swallowing
 Mechanical causes
– Trauma to esophagus with scar tissue
– Inelasticity due to repeated inflammation
– Tumor of esophagus
– Aneurism of aorta
Dysphagia = difficulty
swallowing
Neuromuscular causes
 CVA, brain tumors
 Head injury
 Parkinson’s disease, MS, ALS
 Achalasia (cardiospasm)
 Spinal cord injury
Dysphagia
 Oral phase problems
Pocketing food
Drinking from cup or straw
Drooling
 Pharyngeal phase
Gagging
Choking
Nasal regurgitation
 Esophageal phase
Obstruction
Symptoms of Dysphagia
 Drooling, choking, coughing during or
after meals
 Inability to suck from a straw
 Holding pockets of food in cheeks (pt
may be unaware)
 Absent gag reflex
 Chronic upper respiratory infections
 Gargly voice quality or moist cough
after eating
Diagnosis of Dysphagia
 Nerve assessment
 X-rays
 Fluoroscopic swallow study: barium
swallow/cookie swallow
 Measurement of esophageal sphincter
pressure and peristalsis
Aspiration
 Inhalation of food, liquid into lungs
 Can cause aspiration pneumonia
 Appears to be dose-dependent
 A major cause of aspiration pneumonia
is thought to be aspiration of
oropharyngeal secretions, particularly if
contaminated by bacteria
MNT for Dysphagia
(National Dysphagia Diet)
Intervention depends on severity of deficit
 Mealtime supervision, cueing
 Thickened liquids: thin » nectarlike »
honeylike » spoon thick
 Altered consistency:
– Level 1: pureed
– Level 2: mechanically altered
– Level 3: advanced
Thickened Liquids
MNT for Dysphagia
 In severe cases, patient may
be made NPO and enteral
feedings initiated
National Dysphagia Diet
 NDD diets are more restrictive than
dental consistency diets; may wish to
use more liberal diet for edentulous
patients
 Developed by consensus committee; no
evidence as yet that it is effective in
preventing aspiration
 Provides much-needed standardization
NDD: Level 1 -- Pureed
 Foods are totally pureed; no coarse textures or
lumps of any kind
 Breads must be pureed or pregelled, slurried
through entire product thickness
 Cereals should be homogeneous or “puddinglike;” such as cream of wheat, cream of rice,
farina; avoid oatmeal
 Fruits pureed without pulp, seeds, skins; juice
should be thickened to desired consistency
 Soups should be pureed, strained, and thickened to
desired consistency
 Mashed potatoes and pureed pasta are main
starches
NDD Level 2 – Mechanically
Altered
 Foods are soft-textured and moist so they easily form a






bolus
Breads must be slurried, pre-gelled through entire
thickness, but well-moistened pancakes are allowed
Cooked cereals may have some textures and some try,
well-moistened cereals allowed
Soft canned or cooked fruits, no seeds or skins
Ground or minced tender meats with no larger than ¼ inch
pieces, well-cooked casseroles, cottage cheese; avoid
peanut butter, sandwiches, pizza
Most soups
Soft, well-cooked vegetables with less than ½ inch pieces;
no corn, peas, fibrous varieties
NDD Level 3 -- Advanced
 Nearly normal textures, but exclude crunchy,
sticky, hard foods
 Foods should be bite-sized and moist
 Moist, tender meats and casseroles with small
pieces
 Most vegetables except corn
 Potatoes, rice, stuffing allowed
 All beverages if they meet ordered consistency
 Moist breads allowed; no tough, crusty bread
 Most desserts allowed, no nuts, seeds, pineapple,
coconut, dried fruit
Strategies for Improving
Acceptance
 Thickened liquids: commercial products
can improve quality and consistency of
thickened liquids
 Seasoning: persons with dysphagia often
have dulled sense of taste. Serve
seasoned foods such as spaghetti, chili,
apple pie
 Piping and molding: pureed foods can
be thickened and molded for more
attractive appearance
Piped and Molded Pureed Foods
Dysphagia Diet Issues
 Patients on altered
consistencies tend to
eat less and often lose
weight
 Patients on thickened
liquids are at risk for
dehydration
 Re-evaluate patients
and advance diet as
quickly as possible