Transcript The Dental Hygienist`s Guide to Nutritional Care

Module 9
Nutrition, HIV/AIDS and
Oral Health
Nutrition, HIV/AIDS and Oral
Health
Deborah E. Fleming, RDH, MS
Marion Manski, RDH, BS
University of Maryland, Baltimore
Baltimore College of Dental Surgery
Objective
To develop a protocol for healthcare providers
to become proactive in managing nutrition as it
relates to oral health, specifically in the client
with HIV/AIDS.
Goal
As healthcare providers we need to assist
our clients in every venue possible, this
includes a thorough approach to good
nutrition.
Nutritional considerations for
dental clients with HIV/AIDS
Clients with
HIV/AIDS have
nutritional concerns
that can profoundly
influence the
progression of their
disease.
Thuita FM and Mirie W. East African Medical Journal 1999: 76:507-509
Roles of the Oral Healthcare Provider
• Educate clients about the
interrelationship between the
oral cavity and overall health.
• Educate clients regarding the
influence nutrition has on oral
and systemic manifestations
associated with the disease.
Sumpter J. Nursing Times 1997: 93:67-71
Educate clients about
relationship of nutrition
and the body’s ability to
absorb medications.
Sumpter J. Nursing Times 1997: 93:67-71
• Recognize when the client’s needs are too
great and make an appropriate referral to
a dietician.
• Continue to provide motivation and
support to the client.
Sumpter J. Nursing Times 1997: 93:67-71
Thuita FM and Mirie W. East African Medical Journal 1999:
76:507-509
Nutrition Screening
Information can be collected
from a client about nutritional
status.
Screening can determine the
client’s understanding of
nutrition and the role it can play
in overall health.
Nutrition
Defined as the process by which living
organisms utilize food to obtain nutrients
for energy, growth, development and
maintenance.
Nutrients are biochemical substances
from an outside source. They are known
to produce physiological and biochemical
reactions within the body for digestion,
absorption and elimination.
Davis J.R and Stegeman C.A. The Dental Hygienist’s Guide to
Nutritional Care 1998 W.B. Saunders, Philadelphia
Malnutrition
Defined as the inadequate intake or excess of
nutrients required for development and
maintenance body functions.
Unfortunately, malnutrition is common in clients
with HIV.
It can occur at any time during the disease
process, therefore, healthcare providers of all
disciplines have a responsibility to identify
nutritional problems and treat or refer
accordingly.
Lands L. Positively Well: Living with HIV as a chronic, manageable
survival disease 1995 Irvington Publishers. New York
Malnutrition
Research has shown that malnutrition can
result in the inability to absorb
medications necessary to control or arrest
disease.
One way to increase or improve
absorption is to increase the nutrients
that the client receives.
Thuita FM and Mirie W. East African Medical Journal 1999 76:507-509
Malabsorption
Defined as a condition that occurs
when the tissue and cells lining the
intestinal tract have lost their ability
to properly transfer nutrients.
Lands L. Positively Well: Living with HIV as a chronic, manageable
survival disease 1995 Irvington Publishers. New York
Eating Well
Eating a balanced diet as recommended
by the Dietary Guidelines for Americans
and the Food Guide Pyramid can be an
enormous task for the client living with
HIV/AIDS.
The first step is to understand the
functions of nutrients.
Heslin KC. Aids Alert 2001:16:69, 72-73
Davis J.R and Stegeman C.A. The Dental
Hygienist’s Guide to Nutritional Care 1998 W.B.
Saunders, Philadelphia
Functions of Nutrients
• Provide energy
• Build and maintain tissue
• Regulate metabolic processes
Davis J.R and Stegeman C.A. The Dental Hygienist’s Guide to
Nutritional Care 1998 W.B. Saunders, Philadelphia
Classes of Nutrients
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Protein
Lipids/Fats
Carbohydrates
Minerals
Vitamins
Water
Davis J.R and Stegeman C.A. The DentalHygienist’sGuide to
Nutritional Care 1998 W.B. Saunders, Philadelphia
Nutrients that provide energy to
fuel our bodies
• Protein
• Carbohydrates
• Fats
Davis J.R and Stegeman C.A. The Dental Hygienist’s Guide to
Nutritional Care 1998 W.B. Saunders, Philadelphia
Nutrients that build and maintain
tissue and also regulate metabolic
processes
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•
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Protein
Vitamins
Minerals
Water
Davis J.R and Stegeman C.A. The Dental Hygienist’s Guide to
Nutritional Care 1998 W.B. Saunders, Philadelphia
To increase the quality of life and to
possibly extend the life of a client with
HIV/AIDS, these nutrients need to be
obtained through food sources or
supplements.
Hyman and Kaufman S. 1989. Journal of the American
Dietary Association 89:520-527.
Body composition changes in
clients with HIV/AIDS
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Wasting Syndrome
Fat redistribution syndrome
Elevated Cholesterol levels
Elevated Triglycerides levels
Elevated blood sugars levels
http://www.hivdent.org/nutrNandH012002.htm
Wasting Syndrome
• A condition characterized by weight loss
associated with chronic fever and diarrhea.
• Over a period of one month, the client may lose
10% of baseline body weight.
• Malnutrition coupled with with HIV/AIDS
exacerbates the condition.
Karlsson A and Nordstrom G. Journal of Clinical Nursing 2001 10:609-617
Wasting Syndrome
• Opportunistic infections usually have
significant impact on the client’s
gastrointestinal tract as do the medications
given for the treatment of HIV/AIDS.
• It would be ideal to create the best environment
possible in the GI tract to enhance the
effectiveness of the drugs and to minimize the
secondary infection that may contribute to
wasting syndrome.
Kotler DP. Journal of Acquired Immune Deficiency Syndromes and Human
Retrovirology 1997: 16 Suppl 1:S30-S35
Nutritional recommendations
for combating body
composition changes
• High protein diet will help the client fight
wasting syndrome.
• Low saturated fat diet will help keep cholesterol
level down.
• A diet high in grains and low in sugar will help
the client maintain adequate sugar and
triglyceride levels.
Stack JA, Bell SJ, Burke PA, and Forse RA. Journal of American Dietetic Association
1996: 96:337-341
Additional Recommendations
In addition to a heart healthy diet, 1 or 2
multivitamins and minerals should be
taken to insure that micronutrient needs
are met.
http://www. hiv.org/nutrNandH012002.htm
Functions and Deficiencies
of Nutrients
• A review of the functions of various nutrients
helps focus efforts to improve dietary intake.
• Healthcare providers, specifically oral
healthcare providers, are in a position to
identify nutritional deficiencies by observing
clinical signs and symptoms associated with
specific nutritional deficiencies.
Wardlaw, G.M, Insel, P.M, Seyler, M.F Contemporary Nutrition issues and
insights 2 ed. 1994 Mosby, St. Louis, Missouri
Vitamin A Functions
• Help to maintain epithelial tissues and the
development and maintenance of salivary
glands.
• Foods rich in vitamin A may suppress
lesions in the oral cavity.
Wardlaw, G.M, Insel, P.M, Seyler, M.F Contemporary Nutrition issues and
insights 2 ed. 1994 Mosby, St. Louis, Missouri
Vitamin A Deficiency
• Without vitamin A, mucus forming cells
deteriorate and no longer synthesize mucus.
• Contributes to poor health of cells in general,
which increases risk of infection in the oral
cavity.
• Reduces activity of certain immune cells.
• Vitamin A deficient individuals are at a great risk
for infection.
Wardlaw, G.M, Insel, P.M, Seyler, M.F Contemporary Nutrition
issues and insights 2 ed. 1994 Mosby, St. Louis, Missouri
Vitamin A Food Sources
• Recommend foods such as yellow/orange
vegetables and fruits, green leafy
vegetables, and dairy.
• Additional recommendations could
include organ meats.
Wardlaw, G.M, Insel, P.M, Seyler, M.F
Contemporary Nutrition issues and insights 2
ed. 1994 Mosby, St. Louis, Missouri
Vitamin B6 Functions
• Coenzymes in metabolizing protein
• Converts tryptophan to niacin
• Involved in synthesis of hemoglobin and
fatty acids
• Production of energy from glycogen
• Helps proper function of the nervous
system
Wardlaw, G.M, Insel, P.M, Seyler, M.F Contemporary Nutrition
issues and insights 2 ed. 1994 Mosby, St. Louis, Missouri
Vitamin B6 Deficiency
Symptoms in the Oral Cavity
• Glossitis
• Pain in the tongue
 Feels as if tongue is scalded
• Edema
• Papillary changes
• Smooth, purple tongue
Wardlaw, G.M, Insel, P.M, Seyler, M.F Contemporary Nutritio
issues and insights 2 ed. 1994 Mosby, St. Louis, Missouri
Vitamin B6 Deficiency
• Deficiency results in overall risk for
opportunistic infections, due to its role in
immune function.
• HIV/AIDS clients, even with proper RDA,
tend to be deficient in B6; supplementation
may be indicated to decrease risk of
infection.
• Recommend foods such as poultry, fish,
whole grains.
Thuita FM and Mirie W. East African Medical Journal 1999: 76:507-509
Vitamin B12 Functions
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Coenzyme involved in folate metabolism
Nucleic acid synthesis
Involved in production of red blood cells
Synthesis of myelin
Catabolizes some amino and fatty acids
Wardlaw, G.M, Insel, P.M, Seyler, M.F Contemporary Nutrition issues
and insights 2 ed. 1994 Mosby, St. Louis, Missouri
Vitamin B12 Deficiency
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Burning/itching of the tongue
Red, smooth, shiny tongue
Absence of papilla on tongue
Painful lesions on buccal, pharyngeal
mucosa and ventral surface of tongue
• Pale, yellow mucosa
Wardlaw, G.M, Insel, P.M, Seyler, M.F Contemporary Nutrition
issues and insights 2 ed. 1994 Mosby, St. Louis, Missouri
Vitamin B12 Deficiency
• HIV/AIDS Clients:
 Deficiency due to malabsorption
•Poor diet
•Bacteria overgrowth along
digestive tract
•Lowered GI function
Thuita FM and Mirie W. East African Medical Journal 1999: 76:507-509
Vitamin B12 Deficiency
• If diet cannot provide, recommend
supplementing.
• Too much Vitamin C will interfere with
absorption of B12.
• HIV/AIDS clients with B12 deficiencies were
shown to progress to advanced disease twice
as quickly as those without deficiencies.
• Recommend foods such as beef liver, lean
beef, shrimp, protein fortified milk, whole
eggs, chicken breast and cheddar cheese.
Wardlaw, G.M, Insel, P.M, Seyler, M.F Contemporary Nutrition issues and insights 2 ed. 1994
Mosby, St. Louis, Missouri
Vitamin C Functions
• Significant in collagen formation
• Necessary for the use of proline and lysine
in collagen formation.
• Increases iron absorption. Vitamin C eaten
with iron can double iron absorption.
Wardlaw, G.M, Insel, P.M, Seyler, M.F Contemporary Nutrition issues and insights 2 ed.
1994 Mosby, St. Louis, Missouri
Vitamin C Deficiency
• Local irritation must be present before C
deficiency can produce worsening of
gingival infection.
• Gingival swelling and bleeding, slow
wound healing.
• Recommend foods such as tomatoes,
green/red peppers, citrus fruit.
Wardlaw, G.M, Insel, P.M, Seyler, M.F Contemporary Nutrition
issues and insights 2 ed. 1994 Mosby, St. Louis, Missouri
Iron Functions
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Major component of hemoglobin
Transfers oxygen to tissues and lungs
Catalyzes oxidative reactions
Helps to metabolize energy
RDA: 10mg/d males, 15mg/d females
Wardlaw, G.M, Insel, P.M, Seyler, M.F Contemporary Nutrition issues
and insights 2 ed. 1994 Mosby, St. Louis, Missouri
Iron Deficiency Anemia
• Extremely common in HIV/AIDS clients
• Involved in rapidly progressing cases
• Reduces functional capacity
Semba RD, Shah N, Strathdee SA, and Vlahov D. Journal of
Acquired Immune Deficiency Syndrome 2002: 29:142-144.
Iron Deficiency Anemia/Oral
Cavity
• Oral healthcare provider should evaluate
the diet to include RDA of iron.
• Foods rich in iron include meats, egg
yolk, dark green vegetables, enriched
breads and cereals.
Semba RD, Shah N, Strathdee SA, amd Vlahov D. Journal of
Acquired Immune Deficiency Syndrome 2002: 29:142-144
Iron Deficiency Anemia/Oral
Cavity
• Symptoms: Pallor, glossitis soreness, and
burning tongue.
• Supplementation in HIV patients should
be approached cautiously.
 Could interfere with body’s response to
interferon
 Could accelerate progression of disease
Semba RD, Shah N, Strathdee SA, amd Vlahov D. Journal of
Acquired Immune Deficiency Syndrome 2002: 29:142-144
Folate Functions
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Involved in RNA and DNA synthesis
Coenzyme
Helps to maintain red blood cells
RDA: 200mcg/d males, 180mcg/d females
Davis J.R and Stegeman C.A. The Dental Hygienist’s Guide to
Nutritional Care 1998 W.B. Saunders, Philadelphia
Folate Deficiency:
Oral Symptoms
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Glossitis
Chronic Periodontitis
Loosening of the teeth
Deficiency impairs immune response
 Oral cavity more prone to infections,
such as candidiasis
• Vitamin C helps with absorption of folate.
Davis J.R and Stegeman C.A. The Dental Hygienist’s Guide to Nutritional
Care 1998 W.B. Saunders, Philadelphia
Zinc Functions
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Cell growth/maturity
Immune response
Taste/appetite
Collagen synthesis
Bone formation
RDA: 15mg/d males, 12mg/d females
Davis J.R and Stegeman C.A. The Dental Hygienist’s Guide to Nutritional Care
1998 W.B. Saunders, Philadelphia
Zinc Deficiency: Oral symptoms
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Changes in tongue epithelium
Flattened filiform papillae
Loss of taste, appetite
Impaired wound healing
HIV/AIDS clients suffer from diarrhea and
malabsorption, thus zinc deficiency
• Supplementation indicated
Davis J.R and Stegeman C.A. The Dental Hygienist’s Guide to
Nutritional Care 1998 W.B. Saunders, Philadelphia
Protein Functions
• Maintenance and growth (if protein is low,
degeneration of connective tissue including
periodontium).
• Provides for enzyme and antibodies and their
respective functions.
• Supplies amino acids which are building blocks
for tissue synthesis.
• Participates in RBC production.
• When infection is present, body’s protein needs
are doubled.
Karlsson A and Nordstrom G. Journal of Clinical Nursing 2001 10:609-617
Protein Deficiencies
• Protein malnutrition and resulting loss of
energy are the most frequent condition
reported with HIV/AIDS.
• Presents as a client with a low body
weight and a general lack of energy,
protein and other nutrients, and a small
muscle mass.
Karlsson A and Nordstrom G. Journal of Clinical Nursing 2001 10:609-617
Protein and Oral Health
Amino Acids
10 Essential Amino Acids
Cannot be manufactured by the body in
adequate amounts.
Davis J.R and Stegeman C.A. The Dental Hygienist’s
Guide to Nutritional Care 1998 W.B. Saunders,
Philadelphia
Protein and Oral Health
Amino Acids
12 Nonessential Amino Acids
• “Nonessential” does not mean they
are not needed by the body.
• Can be synthesized by the body so
they are not essential in relation to
dietary intake.
Davis J.R and Stegeman C.A. The Dental Hygienist’s Guide to
Nutritional Care 1998 W.B. Saunders, Philadelphia
Sources of Protein
• Complete Proteins
 Contain all 10 of
the essential amino
acids in an amount
that will meet the
body’s needs
 Animal sources
 Egg, milk, cheese,
meat
• Incomplete Proteins
 Foods lacking at
least 1 essential
amino acid
 Plant Sources
 Legumes, nuts,
grains, vegetables,
fruit, seeds
Davis J.R and Stegeman C.A. The Dental Hygienist’s Guide to
Nutritional Care 1998 W.B. Saunders, Philadelphia
Protein Supplements
• High protein drinks are easy for clients to
take and often consumed by clients with
HIV/AIDS.
• Some brand name drinks include:
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Advera
Nutren
Resourse
Ensure
http://www.projectinform.org
Protein Supplements
• Supplements should not replace food.
• Using them in combination with solid food
and exercise is ideal.
• Fiber intake may need to be reduced if
liquid nutritional sources are abundant
and controlling diarrhea is a concern.
Karlsson A and Nordstrom G. Journal of Clinical Nursing 2001 10:609-617
Clinical Signs & Symptoms of
Protein Deficiency
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Loss of appetite
Flaking dermatitis
Temporal muscle wasting
Sparse, thin hair
Parotid enlargement
Abdominal distention
Transverse lines on nails
Karlsson A and Nordstrom G. Journal of Clinical Nursing 2001 10:609-617
Protein and Infection
Interaction
• Infection can produce malnutrition and
malnutrition can worsen an infectious process.
• Infection decreases the digestion of foods rich
in protein and other nutrients.
• Protein malnutrition can affect antibody
formation, phagocytic activity, tissue integrity
and non-specific resistance factors.
Karlsson A and Nordstrom G. Journal of Clinical Nursing 2001 10:609-617
Protein and Infection
Interaction
• Protein deficient diets impair the production of
white cells and therefore interfere with the
phagocytic capacity of macrophages.
• Decreased tissue resistance of skin, mucous
membranes, as well as tissue edema and
accumulation of debris which serves as a
substrate for bacterial growth are produced by
protein deficient diets.
• Proteins also help in resisting viral infections.
Karlsson A and Nordstrom G. Journal of Clinical Nursing 2001
10:609-617
Protein Deficiency in Relation
to Oral Health
• Protein malnutrition even of the
subclinical type can and very likely
will exacerbate oral infections and
parotid enlargement.
Karlsson A and Nordstrom G. Journal of Clinical Nursing 2001 10:609-617
Fat
• Fat : an essential nutrient
 Involved in energy production.
 HIV/AIDS clients should NOT be
restricted regarding fat consumption.
 Vitamin A deficiency is related to fat
malabsorption in HIV/AIDS clients.
Thuita FM and Mirie W. East African Medical Journal 1999 76:507-509
Meal Alternatives
• The client with HIV/AIDS will need to eat
small frequent meals and focus on
increasing calorie levels.
 Some foods that may benefit them include:
High protein shakes and ice cream
Yogurt
Milk, fruits, peanut butter, wheat germ and
fruit nectars.
Liss M. Nutrition and HIV. ABCNews.com/Healthology Press . 1-4-2002
http://www.hivdent.org
Stack JA, Bell SJ, Burke PA, and Forse RA. Journal of American Dietetic
Association 1996 96:337-341.
Oral Lesions and Eating
• Oral infections and lesions of the oral
cavity can impair the ability to eat.
• Severe lesions can reduce pleasure
associated with eating, resulting in poor
nutrition, which can then exacerbate the
disease.
http://www.hivdent.org/oralm/oralmolah0698.htm
Anti-retroviral Therapy
Anti-retroviral therapy (HAART) and the
commitment to HIV/AIDS research continue to
improve the number of clients living with HIV
and the quality of life that these individuals
maintain.
HAART’s provide an additional benefit by
reducing the likelihood of fungal infections that
previously caused clients difficulty when eating.
Schmidt-Westhausen AM, Priepke F, Bergmann FJ, and Reichart PA. Journal of Oral
Pathology and Medicine 2000: 29:336-341
Reichart PA. International Dental Journal 1999: 49:251-259.
Chapple, ILC; Hamburger, J. Sexually Transmitted Infections 2000: 76 (4):236-243
Oral Lesions
Clients infected with the HIV/AIDS virus
often develop oral lesions that have a
unique clinical appearance. If these
lesions go undiagnosed or untreated and
are worsened by inadequate nutrition the
client’s needs are not being met.
Reichart PA. International Dental Journal 1999 49:251-259.
Hyman C and Kaufman S. J Am Diet Assoc 1989 89:520-527
Oral signs and symptoms of
nutritional deficiencies
Xerostomia: vit A, B12
Bleeding gingiva: vit C, vit K
Angular Cheilosis: iron, B vitamins
Nutritional deficiencies weaken the
resistance of oral tissues to plaque
bacteria, causing an increase in
inflammation.
Sifri R et al. The Journal of the American Board of Family Practice
1998:11:434-444
Angular Cheilosis
•
http://www.hivdent.org
Treating Oral Lesions
• Providing palliative treatment for oral
lesions is essential, as is addressing
nutritional deficiencies that contribute to
the lesions.
• Optimal nutrition is necessary to minimize
the likely discomfort as the progression of
the disease continues.
.
Heslin KC. Aids Alert 200116:69, 72-73
Oral Lesions and Eating
• Some suggestions that can be made to clients
so that they can continue to eat with mouth
sores include:
• Drink Apple juice, fruit nectar, milk.
• Avoid carbonated beverages, and salty or
acidic foods.
• Choose soft, moist foods, such as mashed
potatoes, macaroni and cheese.
• Use melted butter or gravy to soften foods.
• Drink water with meals.
.
Heslin KC. Aids Alert 200116:69, 72-73
Summary
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Assess nutritional status.
Determine chief complaints.
Examine for oral signs of malnutrition.
Evaluate current food intake and eating habits.
Advise clients to ingest adequate amounts of
calories, protein and vitamins which will help
decrease oral opportunistic infections.
• Personalized dietary guidance for clients with
HIV/AIDS infection shows supportive care and
concern for the client’s comfort as he/she is
living with HIV/AIDS.
Conclusion
• Although actual practice of good nutrition
is the client’s responsibility, oral
healthcare providers with a good
understanding of nutrition can recognize
oral manifestations of nutritional
problems in clients with HIV/AIDS.
• The nutritional component should be
considered as much a part of oral health
assessment as oral hygiene instruction.
Conclusion
Research is still needed to fully
understand and document the impact
vitamin and nutritional deficiencies have
on the client with HIV/AIDS. The degree to
which supplements can be beneficial also
needs continued research.