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NUTRITIONAL ASSESSMENT AND NUTRITIONAL ASSESSMENT AND EDUCATION FOR DENTAL PATIENTSEDUCATION FOR DENTAL PATIENTS
CHAPTER 21CHAPTER 21
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
2
Evaluation of the Patient: Health HistoryAsk open-ended questions about
diseases/conditionsDoes 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 chewCopyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
3
Evaluation of the Patient: Health History
Specifically ask about herbal and supplement useWhat 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 medications1 in 5 patients unable to properly identify herbs and
supplements they are takingDuring routine preoperative assessment, 70% of patients
failed to disclose dietary supplements
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
4
Evaluation of the Patient: Nutrition Screening
Purpose in dentistryIdentify 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
ProcedurePatient can fill out the screening form while waiting
for treatmentDental professional should evaluate whether
patient receiving nutrition care from another source
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
5
Evaluation of the Patient: Psychosocial/Social History
Socioeconomic status of patientIs 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.
6
Evaluation of the Patient: Dental History
Does oral condition affect what patient eats?People with dentures eat less meat, fruit, vegetablesAphthous ulcers interfere with eating and drinking
Are there significant changes in oralhealth (caries rate)?
Does dry mouth or xerostomia affectwhat patient eats and drinks?
History of fluoride exposure
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
7
Clinical Observation: Physical Appearance Assessment
WeightDoes patient appear to be under- or overweight?
May be concerns about protein and calorie intakeHas the patient’s weight changed significantly since the last visit?
Hair, fingernails, skin color and toneIron deficiency results in changes in the fingernailsPatients with anemia are often extremely paleVitamin A toxicity may result in alopecia, cheilosisBeta-carotene excess may cause yellowish palms of the hands
MobilityMay 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.
8
Clinical Observation: Extraoral/Intraoral Examination
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
9
Clinical Observation: Anthropometric Evaluation
Anthropometric evaluationAsk patient’s height and weightCalculate 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.
10
Determining Diet History: 24-Hour Recall
Retrospective data about food intake/habitsDisadvantages
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 dayAdvantage
Relatively quick and simple to do during a clinic visit
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
11
Determining Diet History: Food Frequency Questionnaire
Purpose of FFQ is to determine how often a patient consumes specific foods
DisadvantagesNot specific and does not gather enough data to
evaluate nutrient intakeRelies on patient’s memory
AdvantageRequires limited explanation and little timeAllows for analysis of food group consumption and
carbohydrate intakeCopyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Determining Diet History: 3- to 7-Day Food Diary
Food is recorded as it is eatenNutrient intakes are calculated and averaged
over the 3- to 7-day period and compared to RDA or FGP guidelines
DisadvantagesComplianceFoods not written down immediately may be forgottenTime-consuming to the person assessing the diet
AdvantagesGet a better idea of the actual intake
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
13
Clinical ExaminationSignificant increase in caries rate
XerostomiaDietary changes Changes in oral self-care routines
Decay or erosion in unusual locationsEating disordersGERD
Periodontal disease out of proportion to local factors
Difficulty 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.
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
14
Identification of Nutritional StatusComparison of intake to MyPlate and Dietary
Guidelines for Americans 2020Tally the number of servings consumed from each food
group Average intakes determined by dividing totals by the
number of days in the food diaryUse averages for comparison with MyPlateIdentify deficient or excessive nutrients
Cariogenicity of the dietCircle or highlight each carbohydrate
exposure and identify form, frequency, and time eaten
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
15
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.
16
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 behaviorSetting 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.
17
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.
18
Formation of Nutritional Treatment Plan: Integration and ImplementationEvaluation
Ongoing process that occurs in all stages of assessment and counseling; need to continually revise goals
DocumentationTreatment 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.
19
Facilitative Communication SkillsCreate atmosphere of sincerity, trust, and
empathyUse 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.
20
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.
21
Nutrition and Oral Health BasicsLimit between-meal snacksEat cariogenic foods during mealsInclude whole grains, vegetables, fruits, low-fat dairy
as snacksLimit 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.