This course was published in the May 2012 issue and expires May 2015. The author has no commercial conflicts of interest to disclose. This 2 credit hour self-study activity is electronically mediated.
After reading this course, the participant should be able to:
- Discuss the basics of good nutrition as designated by the Dietary Guidelines for Americans.
- Detail nutritional suggestions for patients requiring liquid and soft diets.
- Identify nutritional considerations for patients undergoing oral surgery, orthodontic treatment, and denture fitting.
Nutrition plays an essential role in both oral and systemic health, including wound healing and immune response.1,2 Diet is related to socioeconomic status, as people with low income tend to consume high-fat foods and few vegetables and fruits, whereas individuals with greater disposable income consume more whole grains and fresh fruits and vegetables.3–7 Obesity is also a problem in the United States. Data from the 2009-2010 National Health and Nutrition Examination Survey show that more than 37% of Americans are obese with a body mass index (BMI) equal to or greater than 30, as compared to a normal BMI of 18.5–24.9.8 As such, the dental hygienist’s role in educating patients about the importance of a healthy diet is paramount to improving oral and systemic health.
Nutritional advice is especially needed for patients who require a modified diet, which is often recommended to control systemic diseases such as hypertension, obesity, diabetes, high cholesterol, and gastrointestinal disorders. Dental patients may also require diet modifications for those undergoing oral surgery and orthodontic treatment, as well as those who are new denture wearers.
LIQUID AND SOFT DIET
Patients who require a liquid diet should consume less acidic fruit juices without the pulp, such as apple or grape, bouillon, gelatin, milk, and liquid nutritional supplements. Dental patients going through the healing phase need to also consume enough protein to promote tissue repair.9 A liquid diet can help patients feel full and hydrated, but it may lack the necessary protein and nutrients to support repair growth and tissue maintenance, so transition to a soft diet should begin as soon as possible. Patients on a liquid diet need to eat every 2 hours during the day in order to consume enough calories to prevent weight loss.9 After a liquid diet, patients may move to a soft diet until wound healing is sufficient to support a solid diet.
A soft diet includes foods such as scrambled eggs, mashed or soft fruits, yogurt, cottage cheese, pureed soups, milkshakes (with added fat-free milk powder to boost protein intake), custards, soft porridge, and cooked, mashed vegetables. The use of a blender or food processor is helpful in creating a soft diet.9 These diets tend to be more cariogenic because of their higher carbohydrate content and the retentive qualities of soft foods. Dental hygienists should encourage patients to decrease their intake of simple carbohydrates while following the Dietary Guidelines for Americans, which promote a low-sodium, low-sugar diet composed of lean meats, low-fat milk products, fruits, vegetables, and whole grains (Table 1 and Table 2).10
Integral to wound healing, proteins promote growth and maintenance of tissues in the body.11 Proteins neutralize the pH in the mouth and should be eaten with carbohydrates to mitigate their cariogenic effects. Foods containing proteins increase salivary excretion, thus improving oral clearance of food debris and decreasing the incidence of dental caries.12
Low saturated fats enable the body to absorb fat-soluble vitamins (A, D, E, and K), which are essential to health. Fats also coat the mouth during mastication, altering the surface properties of the enamel and providing an anticariogenic effect.13 A soft diet is not typically needed after simple tooth extraction, implant fixture placement, biopsy, or other less invasive procedures. Liquid and soft diets should be considered for patients undergoing periodontal surgery, alveolar ridge reconstruction, orthognathic (jaw) surgery, temporomandibular joint surgery, facial fractures, or intermaxillary fixation.14
Patients undergoing oral surgery may have difficulty consuming a nutritious diet due to the surgical incision and post-surgery discomfort.1,14 The median recovery for oral surgery is between 5 days and 6 days.15–16 Dental hygienists should determine the patient’s diet quality using a 3-day dietary analysis to provide presurgical dietary counseling when necessary. Generally, healthy individuals have sufficient nutrient stores to last between 3 days and 5 days.17 Patients who have insufficient nutrient intake prior to surgery need to be counseled on how to improve their diet quality to ensure postoperative healing. Patients with a complex medical history or systemic diseases will need a referral to a registered dietitian.
For the first 24 hours, oral surgery patients should avoid sipping through a straw, smoking, and spitting in order to prevent dislodging or dissolving the blood clot. Patients should also be instructed to chew on the opposite side of the surgical site, and avoid irritant foods such as acidic fruit juices; dry, spicy foods; textured foods; extremely hot or cold foods; and alcoholic beverages.17 After 24 hours, patients may begin to rinse the area with lukewarm salt water (8 oz of warm water mixed with half a teaspoon of salt) and/or a dentist-prescribed antimicrobial solution by rolling the head to the left and right gently, letting the solution move over the area. Avoiding swishing the solution between the teeth will protect the blood clot and surgical wound. Instead of spitting, advise the patient to hold his or her head over a sink and allow the solution to fall out of the mouth. This prevents the creation of suction in the mouth that may dislodge the clot. If the blood clot dislodges, it can create a dry socket, whichcan be extremely painful, thereby limiting the ability to eat.
The length of orthodontic treatment depends on the patient’s malocclusion, crossbite, over bite, and other parafunctional oral habits. On average, orthodontic treatment can range from a few months to 2 years. Patients with orthodontic appliances will need diet modification and nutritional guidance to maintain the quality of appliances and gingival health. Adolescents presenting with orthodontia generally have considerably higher caries risk due to their food choices that are typically high in simple carbohydrates and fat, and low in nutrients. Young people with orthodontic appliances need nutrient-dense foods to support their developmental needs and tooth movement goals.2 Poor diet can negatively affect the forces exerted by orthodontic appliances that cause tooth movement.2,23,24 In some cases, the diet requirements for adolescents with orthodontic appliances may be higher than the recommended daily allowance due to their growth needs.2 Clinicians should be mindful of patients’ current food intake and their nutritional needs to provide effective education on nutrition.
After initial placement of the orthodontic appliances, the patients’ mouth will be sore due to the projection of the brackets and circumferential molar bands on the oral mucosa and the pressure of the elastomers on the arch wire. Patients may require a soft diet after each adjustment to the orthodontic appliance.
Orthodontic patients need to avoid hard, crunchy, sticky foods, such as popcorn, ice, candy, jelly beans, hard bagels, whole fruits, pretzels, and chips, that can affect the integrity of orthodontic appliances. 17 Patients should be instructed to eliminate foods high in simple carbohydrates due to their cariogenic effects and the plaque-retentive ability of orthodontic appliances.25 Caries risk assessments should be completed to evaluate the need for fluoride and other caries prevention regimens.26 Patient-centered, one-on-one oral hygiene instructions should be provided prior to the placement of the orthodontic appliances to reduce the incidence of demineralization and oral infections.27
Tooth loss remains a problem among older adults.29 Oral prostheses can restore vertical dimension and improve function for denture wearers, who loose up to 75% of their biting force.28,29 Successful denture fabrication depends on clinician skill, effective communication between the patient and dentist, and the precision of the lab.28,30 The new denture wearer needs to be educated on denture use, limitations, and functions. The patient needs to gradually work toward wearing the denture all day. The more the patient wears the denture, the shorter the adjustment period. The patient may initially develop sore areas on the oral mucosa where the denture rests, which should be reported to the dentist so adjustments can be made to improve comfort.
Research reports that an impaired ability to chew has a negative effect on food selection and diet.31 The new denture wearer should start with a soft diet, and gradually consume firmer foods. Patients may report an increase in salivary flow as their mouths adjust to dentures. Salivary flow will return to its normal quantity within 4 weeks to 6 weeks as the oral cavity gets accustomed to having the denture in place. Patients with low salivary flow may struggle to maintain stability and retention of either maxillary or mandibular dentures and should seek their dentist’s recommendation for products to improve this condition.
Occasionally, patients may complain of an altered taste of foods due to the materials used to construct the denture. Patients experiencing altered taste may wish to add extra seasoning to foods, however sodium should be limited. Patients should be instructed to cut foods into smaller-sized portions and chew more slowly on both sides of the back teeth to prevent tipping of the denture. Patience is important as these skills take time to learn. The temperature of food is important because although dentures often protect the hard palate, tissues of the soft palate and throat are susceptible to burns.17
Denture wearers should slowly modify the selection of foods as some will be more difficult to chew than others. Learning to eat with a new denture can take several weeks for the facial muscles, oral mucosa, and tongue to adapt. Success with dentures is based on the consistent wearing of the prosthesis and acknowledging its limitations. During this learning phase, keeping variety in the diet is important to achieve nutrient balance and overall systemic health.
The dental hygienist plays a critical role in nutritional counseling for patients with modified diets. Thus, it is important for dental hygienists to keep up-to-date in the provision of current, evidence-based nutrition counseling to meet the ongoing demands of patients of all ages. Tailoring a patient’s diet to meet individual nutritional needs is as important as the oral hygiene education provided.
- 1. Touger-Decker R, Mobley CC, American Dietetic Association. Position of the American Dietetic Association: Oral health and nutrition.J Am Diet Assoc. 2007;107:1418–1428.
- Riordan DJ. Effects of orthodontic treatment on nutrient intake. Am J Orthod Dentofacial Orthop. 1997;111:554–561.
- Drewnowski, A. Concept of a nutritious food: toward a nutrient density score. Am J Clin Nutr. 2005;82:721–732.
- Galobardes B, Morabia A, Bernstein MS. Diet and socioeconomic position: does the use of different indicators matter? Int J Epidemiol. 2001;30:334–340.
- Mishra G, Ball K, Arbuckle J, Crawford D. Dietary patterns of Australian adults and their association with socioeconomic status: results from the 1995 National Nutrition Survey. Eur J Clin Nutr. 2002; 56:687–693.
- Drewnowski A. The cost of US foods as related to their nutritive value. Am J Clin Nutr. 2010;92:1181–1188.
- Giskes K, Turrell G, Patterson C, Newman B. Socio-economic differences in fruit and vegetable consumption among Australian adolescents and adults. Public Health Nutr. 2002;5:663–669.
- Ogden CL, Carroll MD, Kitt BK, Flegal KM, Prevalence of obesity in the united states, 2009-2010. National Center for Health Statistics Data Brief. 2012;82:1–8.
- Robinson RC, Holm RL. Orthognathic surgery for patients with maxillofacial deformities.AORN J. 2010;92:28–52.
- Dietary Guidelines. United States Department of Agriculture 2012. Available at:www.choosemyplate.gov/dietaryguidelines.html. Accessed April 17, 2012.
- Protein. British Nutrition Foundation 2004.Available at: www.britishnutrition.org.uk/upload/Protein%20pdf.pdf. Accessed April 17,2012.
- Johansson I, Lenander-Lumikari M, Saellstrom AK. Saliva composition in Indian children with chronic protein-energy malnutrition. J Dent Res. 1994;73:11–19.
- Ahola AJ, Yli-Knuuttila H, Suomalainen T, Poussa T, Ahlström A, Meurman JH, Korpela R. Short-term consumption of probiotic containing cheese and its effect on dental caries risk factors. Arch Oral Biol. 2002;47:799–804.
- American Association of Oral and Maxillofacial Surgeons. Nutrition. Available at: www.aaoms.org/nutrition.php. Accessed April 17, 2012.
- Lago-Méndez L, Diniz-Freitas M, Senra-Rivera C, Seoane-Pesqueira G, Gándara-Rey JM, García-García A. Postoperative recovery after removal of a lower third molar: role of trait and dental anxiety. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;6:855–860.
- Phillips C, White RP Jr, Shugars DA, Zhou X. Risk factors associated with prolonged recovery and delayed healing after third molar surgery. J Oral Maxillofac Surg. 2003;61:1436–1448.
- Sroda, R. Nutrition for a Healthy Mouth. Philadelphia: Lippincott Williams and Wilkins; 2009.
- Darmon N, Briend A, Drewnowski A. Energy-dense diets are associated with lower diet costs: a community study of French adults. Public Health Nutr. 2004;7:21–27.
- Drewnowski A. Obesity and the food environment: dietary energy density and diet costs. Am J Prev Med. 2004;27(Suppl):154–162.
- Drewnowski A. Concept of a nutritious food: toward a nutrient density score. Am J Clin Nutr. 2005;82:721–32.
- Drewnowski A. Fat and sugar: an economic analysis. J Nutr. 2003;133:838S–840S.
- Hansen RG, Wyse BW, Sorenson AW. Nutritional Quality Index of Foods. Westport, Conn: AVI Publishing Co; 1979.
- Bakdash MB, Zaki HA. The impact of diet and nutrition on periodontal health. Northwest Dent. 1978;57:5–14.
- Navia JM, Menaker L. Nutritional implications in wound healing. Dent Clin North Am. 1976;20:549–568.
- Bernie KM. Clinical considerations for the dental hygienist in orthodontic therapy. Calif Dent Hyg Assoc J. 2011;23:7–18.
- Azevedo S, Francisco EM, Young DA. Integrating CAMBRA into dental practice. Dimensions of Dental Hygiene.2009;7(3):28-–31.
- Hempton, T, Ovadia R, McManama JC, Bonacci FJ. Addressing cervical class V lesions. Dimensions of Dental Hygiene. 2010;8(3):48–51.
- Berg E. Acceptance of full dentures. Int Dent J. 1993;43(Suppl):299–306.
- Muller F, Schimmel M. Tooth loss and dental prostheses in the oldest old. Eur Geriatr Med. 2010;1:239–243.
- Celebic A, Knezovic-Zlatatic D, Papic, M, Carek V, Baucic I, Stipetic J. Factors related to patient satisfaction with complete denture therapy. J Gerontol A Biol Sci Med Sci.2003;58:M948–953.
- Wostmann B, Michel K, Brinkert B, Melchheier-Weskott A, Rehmann P, Balkenhol M. Influence of denture improvement on the nutritional status and quality of life of geriatric patients. J Dent. 2008;36:816–821.
From Dimensions of Dental Hygiene. May 2012; 10(5): 56-59.