NUTRITIONAL ASSESSMENT AND COUNSELING FOR DENTAL HYGIENE PATIENTS CHAPTER 20 Copyright © 2010,...

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


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


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


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?


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


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


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


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


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


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


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


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.


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


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


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


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


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


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


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


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

NUTRITIONAL ASSESSMENT AND COUNSELING FOR DENTAL HYGIENE PATIENTS CHAPTER 20 Copyright © 2010,...

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