nutritional assessment and counseling for the dental

Report
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.
6
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.
7
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.
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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.
10
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.
14
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.
18
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.
19
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.
20
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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