EFFECTS OF SYSTEMIC DISEASE ON NUTRITIONAL STATUS AND ORAL HEALTH CHAPTER 17 Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc

EFFECTS OF SYSTEMIC DISEASE ON EFFECTS OF SYSTEMIC DISEASE ON NUTRITIONAL STATUS AND ORAL NUTRITIONAL STATUS AND ORAL

HEALTHHEALTH

CHAPTER 17CHAPTER 17

Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

2

Effects of Chronic Disease on Dietary Intake

Anorexia is a condition in which a person has a poor appetite for various reasons (e.g., cancer treatment)Appetite may decrease because of pain, apathy,

anorexia, drugs, inactivity, or other reasons Malnutrition or other stresses, such as infection, surgery,

or injuries resulting in anorexia, deplete body stores of kilocalories, macronutrients (e.g., protein), and micronutrients (e.g., vitamin C) needed to regenerate and repair cells and sustain immune system


3


Taste and smell disordersWith a loss of smell patients report eating

lessWith loss of taste patient may require

greater amounts of sodium and sugar


4


Xerostomia affects nutritional status in several ways: Chewing is difficult because a bolus cannot be formed

without additional moistureChewing is painful because the mouth is soreSwallowing is difficult because of loss of lubrication

from salivaFood intake may decrease because of changes in

taste perception


5

Anemias: Iron Deficiency Anemia (IDA)

EtiologyIncreased needs during

growth periods such as infancy or pregnancy

Excessive bleedingInadequate intake

Oral manifestations:Atrophic glossitisAphthous ulcersGingival and mucosal

pallorAngular cheilosisCandidiasisMay impair wound

healingFrom Cawson RA, Odell EW: Cawson’s From Cawson RA, Odell EW: Cawson’s Essentials of Oral Pathology and Oral Essentials of Oral Pathology and Oral

Medicine, ed 8. St. Edinburgh, UK: Churchill Medicine, ed 8. St. Edinburgh, UK: Churchill Livingstone, 2008.Livingstone, 2008.


6

Anemias: Iron-Deficiency Anemia (IDA)

Dental hygiene considerationsMay need to postpone invasive nonsurgical

periodontal therapy until IDA improvesEncourage iron-rich foods (e.g., meat)Encourage vitamin C to enhance

absorptionIf iron supplement is liquid, dilute with

water or juice and drink with straw to minimize tooth staining


7

Anemias: Megaloblastic Anemia—Vitamin B12

Also called pernicious anemia

EtiologyIncreased needsInadequate intake

B12 only in animal products Vegans at risk of

deficiency

Malabsorption Common in elderly

Oral symptomsAngular cheilosisRecurrent

aphthous ulcersErythematous

mucositis Pale or yellowish oral

mucosa Atrophic glossitis; beefy

red color

From Ibsen OAC, Phelan JA: From Ibsen OAC, Phelan JA: Oral Pathology for the Dental Oral Pathology for the Dental

Hygienist, ed . St. Louis: Hygienist, ed . St. Louis: Saunders, 2014.Saunders, 2014.


8

Anemias: Megaloblastic Anemia—Folate

EtiologyPoor dietMedications that

interfere with absorption (e.g., phenytoin or methotrexate)

Oral manifestationsAtrophic glossitisUlcerationsGlossodyniaAngular cheilitisFungal infections


9

Anemias: Megaloblastic AnemiaDental hygiene considerations

Encourage folate-rich food sources

and supplement to meet the RDA for folate (400 µg) Large doses of folate can negate effects of anticonvulsants, so

consultation with medical provider is necessary

Encourage intake of foods from animal sources high in vitamin B12 for pernicious anemia For vegans encourage fortified foods or supplements

Patients with permanent gastric or ileal damage need monthly intramuscular or oral vitamin B12 supplementation for life

Refer to a registered dietitian


10

Other Hematological Disorders: Neutropenia

EtiologyDrugs (e.g.,

chemotherapeutics)Autoimmune disease

(e.g., rheumatoid arthritis)

Hematologic disease (e.g., leukemia)

Nutritional deficienciesBacterial or viral infection

Oral manifestationsMucositisViral infectionsFungal infections (e.g.,

candidiasis)

From Ibsen OAC, Phelan JA: Oral From Ibsen OAC, Phelan JA: Oral Pathology for the Dental Hygienist, ed 6. St. Pathology for the Dental Hygienist, ed 6. St.

Louis: Saunders, 2014.Louis: Saunders, 2014.


11

Other Hematological Disorders: Neutropenia

Dental hygiene considerationsInvasive dental treatment contraindicated until white

blood cell counts risePalliative care such as nonalcohol chlorhexidine rinse

may help reduce bacterial load until patient can perform more thorough oral self-care

Stress importance of frequent oralprophylaxis and meticulous oral hygienecare once muscositis pain subsides

Refer to a registered dietitian


12

Gastrointestinal Problems: Gastroesophageal Reflux Disease (GERD)

Lower esophageal sphincter (LES) allows gastric contents to enter the esophagus

EtiologyHiatal herniaObesityPregnancy

RecommendationsAvoid foods causing

GERD (e.g., fatty foods)Eat small mealsKeep patient in semisupine

positionAssist with tobacco

cessationWeight loss as needed


13

Gastrointestinal Problems: Malabsorptive Conditions

EtiologyCrohn’s diseaseUlcerative colitisCystic fibrosisGluten-sensitive

enteropathy (sprue or celiac disease)

AIDS

Oral manifestationsSwollen, bleeding,

erythematous gingivaDiffuse pustular eruptions

on buccal gingivaOral ulcerationsSwelling of the lipsCobblestone-like, raised

hypertrophic lesionsMetallic dysgeusia


14

Gastrointestinal Problems: Malabsorptive Conditions

Dental hygiene considerationsConsult with healthcare provider about patient’s need

for supplemental steroids and prophylactic antibiotics before the dental appointment

Encourage patient to eat a nutrient-rich, well-balanced diet to enhance healing

Healthcare provider or registered dietitian may recommend vitamin and mineral supplementation


15

Cardiovascular Conditions: Cerebrovascular Accident (CVA)

CVA or stroke results if occlusion or ischemia occurs in an artery supplying the brain or if hemorrhaging in the brain occurs

Oral manifestationsDysphagiaFacial muscle

weaknessSlurred speech


16

Cardiovascular Conditions: Cerebrovascular Accident (CVA)

Dental hygiene considerationsMonitor blood pressureUsing water for rinsing or ultrasonic instrumentation

may be contraindicated during dental care if dysphagia is present

Neurological deficits may cause some to be unaware of the presence of food in the mouth, so the mouth should be checked for any pocketed foods after meals

Excellent oral self-care is needed to prevent caries; patient may have a softer, more cariogenic diet


17

Cardiovascular Conditions: Hypertension

Dental hygiene considerationsMinimize stress for the appointmentMonitor blood pressureManage medication-induced xerostomiaRecommend fruits and vegetables, low-fat/nonfat dairy

products; to limit sodium, alcohol, caffeine; tobacco cessation; exercise; lose weight; reduce stress Direct to information about the DASH diet on the NHLBI

website


18

Cardiovascular Conditions: Hyperlipidemia

Dental hygiene considerationsRecommend reducing total fat, saturated fat, dietary

cholesterolEncourage noncariogenic, low-fat snacksLong-term use of bile acid sequestrants

(cholestyramine and colestipol) to lower serum lipids may cause malabsorption of fat-soluble vitamins and folic acid Encourage food sources rich in these nutrients


19

Skeletal SystemEtiology

Osteoporosis Bisphosphonates used to treat

osteoporosis and multiple myeloma increases risk for osteonecrosis (bone death of the jaw)

HyperparathyroidismPaget’s disease or fibrous

dysplasia




20

Skeletal SystemOral manifestations

Increase in size or alteration in contour of maxilla or mandible

Alteration in radiographic patternMobility of individual teeth without significant

periodontal diseasePain or discomfort in jaw without obvious dental

pathologyIncreased sensitivity of teeth without obvious dental or

periodontal diseaseChanges in the occlusion of the teethAbnormal sequence of deciduous tooth loss or eruption

of permanent molars in youngCopyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

21

Skeletal SystemDental hygiene considerations

Provide guidance to ensure that the patient obtains adequate calcium and vitamin D

Avoid alcohol consumption


22

Metabolic Problems: Diabetes Mellitus

SymptomsFruity-smelling breath

(more prevalent in type 1 diabetes)

3 P’s Polydipsia: increased thirst Polyphagia: hunger Polyuria: frequent urination

Unexplained weight loss

Oral manifestations in poorly controlled DMPoor healing More severe

periodontal diseaseTissue necrosis from

minor traumaXerostomiaCandidiasis




23

Metabolic Problems: Diabetes Mellitus

Dental hygiene considerationsEncourage frequent periodontal

maintenance/meticulous oral self-carePrevent hypoglycemia by treating patient in

the morning, ensuring patient ate at usual time and took medications

Have access to a glucometer and glucose source

Recognize and treat hypoglycemia quickly with the rule of 15’s


24

Metabolic Problems: Hypopituitarism

EtiologyCongenitalTumorHead traumaStrokeRadiationBrain infection

Oral manifestationsDecreased skeletal

growth results in disproportionate retardation of mandibular growth

Delayed eruptionMalocclusion


25

Metabolic Problems: Cushing’s Syndrome

SymptomsHigh blood pressurePre-diabetes or diabetesObesityMuscle weaknessBruise easilyAcneHirsutismOsteoporosisDepression

Oral manifestationsDiabetes and

osteoporosis may affect management of periodontal disease and associated bone loss


26

Metabolic Problems: Hypothyroidism

EtiologyInadequate consumption of

iodineInborn error of metabolismHigh intake of goitrogenTreatment of

hyperthyroidismThyroid gland disorderDeficient secretion of TSH

Oral manifestationsIn children

Short stature Intellectual disabilities Delayed eruption Severe malocclusion Risk for caries

Macroglossia


27

Metabolic Problems: Hyperparathyroidism

Hypersecretion of the parathyroid hormone (PTH), leading to alterations in calcium, phosphorus, and bone metabolism

Oral manifestationsIncreased osteoclastic

bone resorptionBrown tumors occur in

the head and neck, especially the mandible May affect ability to

consume an adequate diet


28

Metabolic Problems: Renal Disease

EtiologyPrimary glomerular

diseaseSecondary glomerular

disease (hypertension, diabetes, lupus)

Vascular diseaseTubulointerstitial disease

(e.g., polycystic kidneys)

Oral manifestationsPlatelet abnormalities

may cause gingival bleeding

Gingival pallorSlow wound healingBad taste (from urea)MalodorStomatitisHairy leukoplakia

From Ibsen OAC, Phelan JA: Oral Pathology for the From Ibsen OAC, Phelan JA: Oral Pathology for the Dental Hygienist, ed 6. St. Louis: Saunders, 2014.Dental Hygienist, ed 6. St. Louis: Saunders, 2014.


29

Metabolic Problems: Renal Disease

Dental hygiene considerationsMedical consult needed because of bleeding tendency

and to determine need for antibiotic prophylaxis to prevent endocarditis and/or infection of vascular access site for dialysis

Minimize water due to fluid restrictionsSchedule dental appointment day after dialysis

treatmentMeticulous oral self-care and frequent care


30

Neuromuscular Problems: Parkinson’s Disease

SymptomsInvoluntary muscle tremorsBradykinesia (slowness of

movement)Muscular weaknessRigidityStooped postureDecreased fine motor

coordinationOrthostatic hypotension

Oral manifestationsAbnormal chewing

and swallowing pattern

Holding food in mouth for extended periods

Frequent droolingTremor of mandible,

lips, tongue


31

Neuromuscular Problems: Parkinson’s Disease

Dental hygiene considerationsEducate patient and/or caregiver on use of electric

toothbrush if difficulty holding conventional toothbrushAfter supine positioning, sit patient upright for >2

minutes before standing to avoid orthostatic hypotension

Minimize use of water due to swallowing problemsEncourage adequate protein intake and overall healthy

diet to maintain weight and bone health


32

Neuromuscular Problems: Developmental Disabilities

Cerebral palsy, muscular dystrophy, Down syndrome may be associated with abnormal oral-motor developmentOral-motor impairment is associated with:

Tongue retraction Tongue thrust Tonic bite reflex Oral hypersensitivity Hyperactive gag reflex

All make feeding difficult, as well as performing dental and self-care


33

Neuromuscular Problems: Epilepsy

Epilepsy does not usually result in any specific oral or feeding problems, but the phenytoin used to treat it can affect oral health as well as nutritional statusGingival hyperplasia makes oral self-care challengingPhenytoin increases the need for vitamins D, K, and

folate and can affect bone mass long term Refer to healthcare provider for nutrition counseling because

supplements can affect effectiveness of phenytoin


34

NeoplasiaNutritional requirements for persons with

neoplasms generally increased to maintain lean body mass and immune responsesOral symptoms or signs may be secondary to

malnutrition or nutrient deficiencies (e.g., changes in taste perception)

Intake reduced in those with cancer of the oral cavity, pharynx, or esophagus because of odynophagia (pain on swallowing) or dysphagia


35

Neoplasia: Kaposi’s Sarcoma

Highly malignant tumor of blood vessel origin that occurs on the skin and oral mucosaRed-purple macular lesions in the

mouth may progress to raised, indurated lesions with central areas of necrosis and ulceration

Appear in many HIV-positive patients




36

Neoplasia: Acute Leukemia

Generalized malignant disease characterized by distorted proliferation and development of white blood cells (WBCs)

Oral manifestationsGingiva may become

severely inflamed with tissue hyperplasia, areas of ulcerations, necrosis, and spontaneous bleeding

Delayed wound healingIncreased susceptibility

to infectionFrom Ibsen OAC, Phelan JA: Oral From Ibsen OAC, Phelan JA: Oral

Pathology for the Dental Hygienist, ed 6. St. Pathology for the Dental Hygienist, ed 6. St. Louis: Saunders, 2014.Louis: Saunders, 2014.


37

Neoplasia: Cancer TreatmentsChemotherapy effects

include:Stomatitis or mucositisOral ulcerationsDecreased absorptive

capacityChanges in taste

sensation

Radiation therapy to head and neck affects:General appetite lossNausea, vomiting,

diarrhea Loss of taste sensationXerostomiaDifficulty in swallowingBurning sensation in the

mouth


38

Neoplasia: Cancer Treatments

Dental hygiene considerationsUsing antimicrobial mouth rinse (nonalcohol

chlorhexidine), meticulous oral self-care, frequent careSoft and/or bland diet may be necessary; encourage

protein intakeAvoid alcohol and hot, spicy, and acidic foods when

oral lesions are presentCaution against eating hard candy or drinking

beverages containing fermentable carbohydrates to relieve the xerostomia


39

AIDS

SymptomsWith HAART, classic

wasting is less evident, although wasting and anorexia may be present

Opportunistic infectionMultiple nutrient

deficienciesProtein-energy

malnutrition

Oral manifestationsOral candidiasisOral hairy leukoplakiaHerpetic ulcerationsKaposi’s sarcomaMay have more

severe periodontitisXerostomia

From Ibsen OAC, Phelan JA: From Ibsen OAC, Phelan JA: Oral Pathology for the Dental Oral Pathology for the Dental

Hygienist, ed 6. St. Louis: Hygienist, ed 6. St. Louis: Saunders, 2014.Saunders, 2014.


40

AIDSAIDSDental hygiene considerations

Encourage to maintain the highest possible level of oral self-care and regular preventive dental care

To promote healing, encourage attention to adequate nutrient intake (e.g., kilocalories, protein)

Use nutritional supplements or instant breakfast drinks as snacks for those needing added nutrition

Limit caffeine- and alcohol-containing beverages if xerostomia exists

Refer to RD and/or medical provider as needed


41

Mental Health Problems: Anorexia Nervosa

Primarily affecting adolescent and young adult females who have an exaggerated, intense fear of becoming fatZealous, self-imposed

restriction leads to extreme weight loss

Criteria for diagnosisWeight loss equal to or

exceeding 15% below expected or original body weight

Amenorrhea Excessive desire for

slimness with distorted body image


42

Mental Health Problems: Bulimia

Eating disorder not necessarily associated with significant weight loss, may be slightly overweightBingeing and purging

Binges may occur several times/day in late afternoon or evening

Most common method of purging is self-induced vomiting

Oral manifestationsErosion of enamel

(lingual maxillary anterior teeth)

Palatal bruisesEnlarged parotid

glandsDentin

hypersensitivityPerimolysis




43

Mental Health Problems: Mental Illness

Many types of mental illnesses: schizophrenia, depression, bipolar disorder or mania

Drugs frequently prescribed to treat the conditions may have side effects that affect oral statusAntipsychotics (haloperidol, thioridazine) and

anticholinergics (tricyclics, MAO inhibitors, trazodone) frequently cause xerostomia

Trazodone can cause unpleasant taste


44

Mental Health ProblemsDental hygiene considerations

Increased caries rate indicative of high-carbohydrate bingeing and low pH of saliva from vomiting

Must recognize signs and symptoms of suspected eating disorder and refer patients to health care provider or eating disorder facility for care

Caution the patient against brushing immediately after vomiting

Rinse with sodium bicarbonate to neutralize the oral environment after vomiting

Encourage daily fluoride and hypersensitivity products


HEALTH APPLICATIONHUMAN PAPILLOMA VIRUS (HPV)Discuss why HPV is on the riseDiscuss what HPV is a risk factor forDiscuss possible treatmentsDiscuss ways to prevent HPV

45Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

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EFFECTS OF SYSTEMIC DISEASE ON NUTRITIONAL STATUS AND ORAL HEALTH CHAPTER 17 Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc