nutritional assessment and counseling for the dental
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Transcript nutritional assessment and counseling for the dental
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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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