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NUTRITIONAL ASSESSMENT AND NUTRITIONAL ASSESSMENT AND COUNSELING FOR DENTAL COUNSELING FOR DENTAL
HYGIENE PATIENTSHYGIENE PATIENTS
CHAPTER 20CHAPTER 20
Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
22Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Evaluation of the Patient: Health Evaluation of the Patient: Health HistoryHistory
Ask open-ended questions about Ask open-ended questions about diseases/conditionsdiseases/conditionsDoes this disease or condition require a Does this disease or condition require a
change in diet?change in diet? Gastric bypassGastric bypass End-stage renal or liver diseaseEnd-stage renal or liver disease
What kind of changes have been What kind of changes have been made?made? Are changes supervised by an MD/RD?Are changes supervised by an MD/RD?
Frequency of alcohol or tobacco Frequency of alcohol or tobacco useuse
Changes in taste or ability to chewChanges in taste or ability to chew
33Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Evaluation of the Patient: Evaluation of the Patient: Health HistoryHealth History
Specifically ask about herbal and Specifically ask about herbal and supplement usesupplement useWhat herbal medications or supplements are you taking?What herbal medications or supplements are you taking?What is the dose and frequency of these What is the dose and frequency of these
herbs/supplements?herbs/supplements?Have patients bring in their herbal medications and Have patients bring in their herbal medications and
dietary supplements and all prescription medicationsdietary supplements and all prescription medications1 in 5 patients unable to properly identify herbs and 1 in 5 patients unable to properly identify herbs and
supplements they are takingsupplements they are takingDuring routine preoperative assessment, 70% of patients During routine preoperative assessment, 70% of patients
failed to disclose dietary supplementsfailed to disclose dietary supplements
44Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Evaluation of the Patient: Nutrition Evaluation of the Patient: Nutrition ScreeningScreening
Purpose in dentistryPurpose in dentistryIdentify patients at nutritional risk or suspected to Identify patients at nutritional risk or suspected to
be at risk due to eating habits, disease, or medical be at risk due to eating habits, disease, or medical treatmenttreatment
Identify those with cariogenic eating habits that are Identify those with cariogenic eating habits that are at high caries riskat high caries risk
ProcedureProcedurePatient can fill out the screening form while waiting Patient can fill out the screening form while waiting
for treatmentfor treatmentDental professional should evaluate whether Dental professional should evaluate whether
patient receiving nutrition care from another sourcepatient receiving nutrition care from another source
55Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Evaluation of the Patient: Evaluation of the Patient: Psychosocial/Social HistoryPsychosocial/Social History
Socioeconomic status of patientSocioeconomic status of patientIs there access to adequate food?Is there access to adequate food?
May need to direct to social service agencies for May need to direct to social service agencies for assistanceassistance
Does the patient live alone?Does the patient live alone?Often a significant risk factor for poor nutrition in Often a significant risk factor for poor nutrition in
the elderlythe elderly Does the patient like to cook for him- or herself?Does the patient like to cook for him- or herself? Is patient able to get to the grocery store or to congregate Is patient able to get to the grocery store or to congregate
meal sites?meal sites?
66Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Evaluation of the Patient: Evaluation of the Patient: Dental HistoryDental History
Does oral condition affect what patient eats?Does oral condition affect what patient eats?People with dentures eat less meat, fruit, vegetablesPeople with dentures eat less meat, fruit, vegetablesAphthous ulcers interfere with eating and drinkingAphthous ulcers interfere with eating and drinking
Are there significant changes in oralAre there significant changes in oralhealth (caries rate)?health (caries rate)?
Does dry mouth or xerostomia affectDoes dry mouth or xerostomia affectwhat patient eats and drinks?what patient eats and drinks?
History of fluoride exposureHistory of fluoride exposure
77Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Clinical Observation: Clinical Observation: Physical Appearance AssessmentPhysical Appearance Assessment
WeightWeightDoes patient appear to be under- or overweight?Does patient appear to be under- or overweight?
May be concerns about protein and calorie intakeMay be concerns about protein and calorie intakeHas the patient’s weight changed significantly since the last visit?Has the patient’s weight changed significantly since the last visit?
Hair, fingernails, skin color and toneHair, fingernails, skin color and toneIron deficiency results in changes in the fingernailsIron deficiency results in changes in the fingernailsPatients with anemia are often extremely palePatients with anemia are often extremely paleVitamin A toxicity may result in alopecia, cheilosisVitamin A toxicity may result in alopecia, cheilosisBeta-carotene excess may cause yellowish palms of the handsBeta-carotene excess may cause yellowish palms of the hands
MobilityMobilityMay limit dexterity and ability to perform HC procedures May limit dexterity and ability to perform HC procedures May affect obtaining and preparing foodMay affect obtaining and preparing food
88Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Clinical Observation: Clinical Observation: Extraoral/Intraoral ExaminationExtraoral/Intraoral Examination
Look for abnormal findingsLook for abnormal findingsFindings must be interpreted with careFindings must be interpreted with care
Relatively rare to find a true nutrient deficiency in the Relatively rare to find a true nutrient deficiency in the healthy US populationhealthy US population
Patients suspected of having marginal or frank Patients suspected of having marginal or frank nutrient deficiencies should be referred to an nutrient deficiencies should be referred to an MD and RD for careMD and RD for care It is outside the scope of dentistry to prescribe doses of It is outside the scope of dentistry to prescribe doses of
nutrients in excess of the RDAsnutrients in excess of the RDAs Some nutrient deficiencies (those seen in alcohol Some nutrient deficiencies (those seen in alcohol
withdrawal) require pharmacologic doses of nutrients, withdrawal) require pharmacologic doses of nutrients, e.g., thiamin and folic acide.g., thiamin and folic acid
99Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Clinical Observation: Clinical Observation: Anthropometric EvaluationAnthropometric Evaluation
Anthropometric evaluationAnthropometric evaluationAsk patient’s height and weightAsk patient’s height and weightCalculate BMI Calculate BMI
Reduction of 10% of usual weight Reduction of 10% of usual weight over a 6-month period is significant over a 6-month period is significant
Loss of 20% of body weight or Loss of 20% of body weight or greater may indicate depletion of greater may indicate depletion of body stores affecting immune body stores affecting immune response and ability to heal following response and ability to heal following invasive dental treatmentinvasive dental treatment
1010Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Determining Diet History: Determining Diet History: 24-Hour Recall24-Hour Recall
Retrospective data about food intake/habitsRetrospective data about food intake/habitsDisadvantagesDisadvantages
Remembering accurately what eaten the day Remembering accurately what eaten the day beforebefore
May consciously or unconsciously alter intake May consciously or unconsciously alter intake reported to simplify recording or to impress the reported to simplify recording or to impress the interviewerinterviewer
May be an atypical dayMay be an atypical dayAdvantageAdvantage
Relatively quick and simple to do during a clinic Relatively quick and simple to do during a clinic visitvisit
1111Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Determining Diet History: Determining Diet History: Food Frequency QuestionnaireFood Frequency Questionnaire
Purpose of FFQ is to determine how often a Purpose of FFQ is to determine how often a patient consumes specific foodspatient consumes specific foods
DisadvantagesDisadvantagesNot specific and does not gather enough data to Not specific and does not gather enough data to
evaluate nutrient intakeevaluate nutrient intakeRelies on patient’s memoryRelies on patient’s memory
AdvantageAdvantageRequires limited explanation and little timeRequires limited explanation and little timeAllows for analysis of food group consumption and Allows for analysis of food group consumption and
carbohydrate intakecarbohydrate intake
1212Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Determining Diet History: Determining Diet History: 3- to 7-Day Food Diary3- to 7-Day Food Diary
Food is recorded as it is eatenFood is recorded as it is eatenNutrient intakes are calculated and averaged Nutrient intakes are calculated and averaged
over the 3- to 7-day period and compared to over the 3- to 7-day period and compared to RDA or FGP guidelinesRDA or FGP guidelines
DisadvantagesDisadvantagesComplianceComplianceFoods not written down immediately may be forgottenFoods not written down immediately may be forgottenTime-consuming to the person assessing the dietTime-consuming to the person assessing the diet
AdvantagesAdvantagesGet a better idea of the actual intakeGet a better idea of the actual intake
1313Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Clinical ExaminationClinical ExaminationSignificant increase in caries rateSignificant increase in caries rate
XerostomiaXerostomiaDietary changes Dietary changes Changes in oral self-care routinesChanges in oral self-care routines
Decay or erosion in unusual Decay or erosion in unusual locationslocationsEating disordersEating disordersGERDGERD
Periodontal disease out of Periodontal disease out of proportion to local factorsproportion to local factors
Difficulty chewing or swallowingDifficulty chewing or swallowing
From Perry DA, Beemsterboer P: Periodontology From Perry DA, Beemsterboer P: Periodontology for the Dental Hygienist, ed 3. St. Louis: for the Dental Hygienist, ed 3. St. Louis:
Saunders, 2007.Saunders, 2007.
1414Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Identification of Nutritional StatusIdentification of Nutritional StatusComparison of intake to MyPyramid and Comparison of intake to MyPyramid and
Dietary Guidelines for Americans 2005Dietary Guidelines for Americans 2005Tally the number of servings consumed from each Tally the number of servings consumed from each
food group food group Average intakes determined by dividing totals by Average intakes determined by dividing totals by
the number of days in the food diarythe number of days in the food diaryUse averages for comparison with MyPyramidUse averages for comparison with MyPyramidIdentify deficient or excessive nutrientsIdentify deficient or excessive nutrients
Cariogenicity of the dietCariogenicity of the dietCircle or highlight each carbohydrateCircle or highlight each carbohydrate
exposure and identify form, frequency, and time exposure and identify form, frequency, and time eateneaten
1515Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Formation of Nutrition Formation of Nutrition Treatment PlanTreatment Plan
How do you decide what to focus on once the How do you decide what to focus on once the nutrient analysis is complete?nutrient analysis is complete?What issues did you identify in the screening or review What issues did you identify in the screening or review
of the patient history?of the patient history? Lactose-intolerant adolescent or postmenopausal womanLactose-intolerant adolescent or postmenopausal woman Elderly man living alone who doesn’t cook and doesn’t like to Elderly man living alone who doesn’t cook and doesn’t like to
shopshop Middle-aged woman with poorly controlled diabetes and active Middle-aged woman with poorly controlled diabetes and active
moderate periodontitis that requires SRP and possible surgery moderate periodontitis that requires SRP and possible surgery Elderly woman with a dry mouth due to polypharmacyElderly woman with a dry mouth due to polypharmacy Teenager who eats fast food and energy drinks and tells you he Teenager who eats fast food and energy drinks and tells you he
has “tons” of new cavities every time he visits the dentisthas “tons” of new cavities every time he visits the dentist
1616Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Formation of Nutrition Treatment Plan: Formation of Nutrition Treatment Plan: Integration and ImplementationIntegration and Implementation
Purpose of nutritional counseling is to provide Purpose of nutritional counseling is to provide accurate information and motivate and encourage accurate information and motivate and encourage patient to initiate positive changes in behaviorpatient to initiate positive changes in behaviorSetting goalsSetting goals
Resistance to change, despite knowledge, a natural responseResistance to change, despite knowledge, a natural response Goal chosen should be difficult enough to be challenging but not so Goal chosen should be difficult enough to be challenging but not so
difficult as to seem impossibledifficult as to seem impossible Goal needs to be measurable or observable: Eat one vegetable Goal needs to be measurable or observable: Eat one vegetable
each day each day Successful achievement of smaller steps motivates one toward Successful achievement of smaller steps motivates one toward
larger changeslarger changes
1717Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Formation of Nutrition Treatment Formation of Nutrition Treatment Plan: Integration and ImplementationPlan: Integration and Implementation
Menu creationMenu creation Dental hygienist helps patient establish a Dental hygienist helps patient establish a
menu that follows principles in the Menu menu that follows principles in the Menu Planning Record, including nutritionally Planning Record, including nutritionally adequate and noncariogenic situationsadequate and noncariogenic situations
Follow-upFollow-up Monitor progress, provide Monitor progress, provide
encouragement, adjust goals as encouragement, adjust goals as necessarynecessary
ReviewReview Summarize the pertinent pointsSummarize the pertinent points
1818Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Formation of Nutrition Treatment Formation of Nutrition Treatment Plan: Integration and ImplementationPlan: Integration and ImplementationEvaluationEvaluation
Ongoing process that occurs in all stages of Ongoing process that occurs in all stages of assessment and counseling; need to continually revise assessment and counseling; need to continually revise goalsgoals
DocumentationDocumentationTreatment record serves as tool for communication Treatment record serves as tool for communication
with other members of the dental team as well as other with other members of the dental team as well as other health care professionalshealth care professionals
1919Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Facilitative Communication SkillsFacilitative Communication SkillsCreate atmosphere of sincerity, trust, and Create atmosphere of sincerity, trust, and
empathyempathyUse nonjudgmental and noncritical responsesUse nonjudgmental and noncritical responses
Active listeningActive listening Involves more than hearing; it includes interpreting what is Involves more than hearing; it includes interpreting what is
said, how it is said, and nonverbal actions observedsaid, how it is said, and nonverbal actions observed
Nonverbal actionsNonverbal actions Facial expressions, eye contact, body movements, personal Facial expressions, eye contact, body movements, personal
distance, head-nodding, and vocal cuesdistance, head-nodding, and vocal cues
QuestioningQuestioning Ask open-ended questions to encourage sharingAsk open-ended questions to encourage sharing
2020Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Appropriate ReferralAppropriate Referral
Know when the case is outside the scope Know when the case is outside the scope of dental practice! Know when and how to of dental practice! Know when and how to refer!refer!If complex conditions require special diet If complex conditions require special diet
instructions, consult with the physician to see if instructions, consult with the physician to see if a referral can be made to a registered dietitian a referral can be made to a registered dietitian Referral by the MD is more likely to result in coverage Referral by the MD is more likely to result in coverage
by insuranceby insurance Find a nutrition professional online at Find a nutrition professional online at
www.eatright.org Most medical insurance and Medicaid cover medical Most medical insurance and Medicaid cover medical
nutrition therapy for specific disease conditionsnutrition therapy for specific disease conditions
2121Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Nutrition and Oral Health BasicsNutrition and Oral Health BasicsLimit between-meal snacksLimit between-meal snacksEat cariogenic foods during mealsEat cariogenic foods during mealsInclude whole grains, vegetables, fruits, low-fat dairy Include whole grains, vegetables, fruits, low-fat dairy
as snacksas snacks Limit simple and retentive CHOs like crackers, soft drinks, Limit simple and retentive CHOs like crackers, soft drinks,
sports drinks, fruit juice between mealssports drinks, fruit juice between meals
Rinse with water, chew xylitol gum, or brush teeth Rinse with water, chew xylitol gum, or brush teeth after snacks with fermentable carbohydratesafter snacks with fermentable carbohydrates
Calcium-rich foods such as low-fat cheese, yogurt, or Calcium-rich foods such as low-fat cheese, yogurt, or milk for snacksmilk for snacks
Appropriate use of fluorides, meticulous dailyAppropriate use of fluorides, meticulous daily
plaque removalplaque removal