Nutritional Counseling in the Dental Setting

The oral cavity is the first point in the digestive process and has a bidirectional relationship with diet. The patient’s diet and nutrition directly impact the health of the oral tissues and vice versa; the health of the teeth and oral structures directly affects how food and nutrients are consumed.¹ The 2020-2025 United States Department of Agriculture Dietary Guidelines (USDADG) report that Americans are grossly undernourished. Approximately 80% to 90% of Americans do not eat the recommended five servings of fruit and vegetables a day and 98% do not eat enough whole grains.²

Dentists and dental hygienists typically do not receive extensive training in nutrition and therefore may be reluctant to offer nutritional counseling to patients. Yet, the opportunity for nutritional counseling in dental practice is broad and can address all ages.^3,4 The current dental terminology (CDT) code D1310 is for “nutritional counseling for control of dental disease.” The dental team can obtain dietary, caries, and periodontal risk assessment in new patient intake by using a nutritional analysis form that addresses food choices, allergies, or intolerances.³

Poor oral health due to caries and periodontal diseases may correlate with poor whole-body health. Nutritional counseling in the dental office can be an important interprofessional approach to address a patient’s diet along with oral health goals and treatment.⁴ Effective nutritional counselling can also complement the oral cancer screening. Micronutrients and nutrient dense diets have been found to intervene in apoptosis and positively affect tumor-suppressor genes in oral cancers.⁵ A referral to and from the primary care provider, nurse practitioner, or dietitian to the oral health professional is a multidisciplinary best practice.

Origins of Food Supply

After World War II, food production in the United States moved from farm to factory in order to feed a growing nation.⁶ These changes in how food was grown and produced had unforeseen consequences by contributing to the chronic inflammatory diseases plaguing society today. Three major food felons are charged with causing these diseases: sugar and high fructose corn syrup (SHFCS), hydroge­nated oils and saturated trans-fats (HOSTF), and bleached or refined flour.⁷

During the COVID-19 pandemic, SHFCS production surpassed 36 million net tons.⁸ The recommended maximum daily sugar intake is 6 teaspoons for women and 9 teaspoons for men. Daily limits are easily met and highly exceeded since a cup of bottled apple juice has 7 teaspoons of sugar and an 8-ounce mocha coffee has 18 teaspoons.⁹

When SHFCS are consumed in excessive quantities, dopamine is reduced in the brain, leading to mood changes, euphoria, and compulsive eating with sugar addiction.¹⁰ The results may be metabolic dysregulation and increased risk for obesity.¹¹ The US Centers for Disease Control and Prevention (CDC) reports that about 65% of American youth and 50% of adults consume at least one sugary beverage, such as sodas, energy drinks, and sweetened coffees or teas, per day.¹² Middle-aged women who drink more than two sodas per day may have depleted calcium absorption with resultant lower bone density and bone fractures¹³ and a higher risk for liver cancers and chronic liver diseases.¹⁴

HOSTF are in processed foods such as breakfast cereals, margarine, fried foods, potato chips, crackers, and non-dairy coffee creamers. The World Health Organization (WHO) statistics show that HOSTF not only cause coronary artery diseases but lead to 500,000 premature deaths annually worldwide. WHO is encouraging the removal of these oils and fats from processed foods.¹⁵

Consuming enough whole grains appears to be a challenge in modern diets, with only 2% of Americans meeting the recommended standards of 3 to 6 ounces of whole grains per day.² One ounce of grains is equivalent to one slice of bread. Whole grains are found in brown rice, oats, quinoa, barley, and whole-grain bread.

Bread is one of the most basic and oldest forms of food. The processes of refining, bleaching, and fermenting still in use today, make bread more appealing in texture and appearance, but results in the depletion of nutrients. The “enrichment” of bread with iron, vitamins, and calcium began in the 1940s due to concerns for diseases of malnutrition of pellagra and beriberi.¹⁶ Recent research looks for natural ways to enrich bread with antioxidants by the addition of pomegranate and grape seed to the dough.¹⁷

Motivation Behind Food Choices

This paper does not have the scope to discuss the many nutritional and non-nutritional motivators in human food choices. Suffice it to say, extensive research on the myriad of psychological, cultural, and social reasons for these behaviors has been done.¹⁸ Research has found that genetic differences in taste receptors on the tongue allow for “supertasters” who can recognize 6-n-propylthiouracil found in cruciferous vegetables. Supertasters experience a very bitter, unappealing flavor in kale, broccoli, cauliflower, and cabbage.¹⁹

Cultures and populations in hot climates may select spicy foods. Capsaicin, found in chili peppers, and other spices offer positive health outcomes, anti-inflammatory effects, and may even have antibacterial properties by removing pathogens from fresh foods.²⁰

Fasting, defined as the choice to abstain from eating, may also have psychological and cultural motivators. Intermittent fasting diets have become increasingly popular but require a physician’s guidance. Lowering caloric intake on nonfasting days and not eating on fasting days releases ketones into the blood stream. Research has found that this may slow disease processes in the brain, therefore protecting memory and learning functions. On the downside, overeating on nonfasting days or detoxifying liquid fasts have shown to be detrimental to health.²¹

The USDADG dietary statistics anticipate that by year 2025 obesity rates will rise to 75% of American adults and 40% of children and adolescents.² With this portent of declining population health, more studies are focused on understanding obesity. The CDC reports obesity as a multifactorial result of genes and environmental factors interacting in complex mechanisms. Nine rare gene variants are associated with monogenic obesity. The outcome in children with this genetic abnormality is hyperphagia or extreme sensations of hunger leading to childhood ­obesity.²² In 2023, the American Association of Clinical Endocrinology ­presented a consensus statement that newly defines obesity as adiposity-based chronic disease. Abnormal body fat accumulation may lead to chronic inflammatory illnesses of high blood pressure, diabetes, obstructive sleep apnea, cancers,²³ and periodontitis.²⁴

Obesity and Diabetes

Obesity and diabetes are national healthcare concerns, and the dental profession can be an important component in diagnosis, treatment, and education. A proposed update to CDT code D0121 encourages dentists to perform screening procedures that may then require multidisciplinary consultations and interprofessional collaboration. These screenings may include taking blood pressure before each dental appointment,²⁵ periodontal screening, caries and nutritional assessments,⁴ and point-of-care HbA1C testing to screen for diabetes.²⁶

Depending on individual state practice acts, a dentist may be able to order an HbA1C testing in an interprofessional approach when diabetes is suspected. More than 95% of those with diabetes have periodontal diseases. Diabetes and nutritional screening can diagnose patients who are unaware of their oral or systemic disease status.²⁷

Nutritional Trends

Of the many diet trends and fads that have come and gone, two lifestyle diets persist. The Mediterranean and plant-based diets continue to retain their popularity due to resultant health benefits. Both diets reduce the risk of inflammatory diseases such as diabetes, heart disease, arthritis, Alzheimer disease, gingivitis, and periodontitis.²⁸ Both diets stress low processed food, limit or eliminate meat, encourage whole grains, and stress five or more servings of fruits and vegetables per day. The Mediterranean diet is considered environmentally sustainable and high in omega 3 polyunsaturated fatty acids from nuts and seafood.⁹ Research continues to show that plant-based diets significantly reduce cholesterol levels, body weight, and glucose levels.²⁹ Vegetarian or vegan diets have been successful in the management of type 2 diabetes and are supported by the American Diabetes Association.³⁰

Allergies

Almost 20% of the population has food intolerances triggered by preservatives, artificial sweeteners, flavor enhancers, and sulfites added to processed foods. Immunological food allergies are exhibited in 2% to 5% of adults and 5% to 10% of children. These individuals may be allergic to milk, soy, eggs, fruit, and wheat.³¹ Oral allergy syndrome (OAS) is a type of immunological response localized to the lips, mouth, and throat. Swelling or itching appears within minutes of eating certain fruits and nuts. OAS allergies have cross sensitivity to pollen and tree allergies. Raw mangoes may cause an oral irritation called “mango mouth,” which has cross sensitivity with poison ivy, sumac, and oak because they contain the cutaneous irritant urushiol oil. OAS reactions may be exacerbated during the spring and fall pollen seasons.³²

Natural rubber latex (NRL) is derived from the rubber tree and may have cross sensitivity to bananas, avocado, kiwi, chestnut, and papaya allergies.³² NRL allergy can be life-threatening. Recent research indicates that a patient can become sensitized after five or more general surgeries where NRL-derived products were used.³³ NRL may be found in dental products such as toothbrushes with rubber grips, irrigation tips, dental dams, and orthodontic rubber bands and elastics.³⁴ Dental professionals may want to include specific food and latex allergy questions along with seasonal allergies and surgical updates in medical history reviews.

Patients with irritable bowel syndrome (IBS) may be on a low fermentable oligosaccharides, disaccharides, and FODMAP diet. Concentrated fructose is found in fruit, corn syrup, honey, milk products, and artificial sweeteners with sugar alcohols. Artificial sweeteners are used in dental products for decay prevention such as sugar-free gum with xylitol, sorbitol, or mannitol. When eaten in excess, even patients who do not have IBS may show intolerances with gas, bloating, and diarrhea from these ingredients.⁷

Celiac disease is the world’s most common genetically inherited autoimmune disease, occurring when ingestion of gluten damages the small intestine. Gluten is found in wheat, barley, and rye grains. Almost one in 100 people have celiac disease, but may not be diagnosed until later life.⁷ Dental professionals may be the first to recognize celiac disease in childhood due to dental enamel defects, delayed dental eruption, and recurrent aphthous stomatitis.³⁵

Gluten intolerance or nonceliac gluten sensitivity has been suggested to be as high as 6% of Americans. Nonceliac gluten sensitivity is an intestinal and neurological sensitivity to gluten that causes intestinal pain, headache, brain fog, chronic fatigue, anxiety, and depression.^36,37 Manufacturers are not required to label a product with or without gluten and gluten may be found in health and personal care products. In the dental office, gluten-sensitive patients may have issues with acrylic resins with methyl methacrylate in temporary crowns and orthodontic or removable prostheses.³⁷ A thorough history of food intolerances is essential to avoid triggering celiac disease and nonceliac gluten sensitivity symptoms.^7,37 Dental offices may wish to have gluten-free items such as prophy pastes, fluorides, whitening agents, and patient samples on hand, or use gluten-free labeled products exclusively.³⁷

Calcium, magnesium, potassium, zinc, and phosphorous are essential to the health of alveolar tissues and are usually provided by dairy in the diet. Aged cheese and low-fat yogurt show positive oral health results by reducing cariogenic biofilm.⁷ But it is estimated that 65% of humans are unable to digest milk protein after infancy. Almost 50 million Americans are lactose intolerant and lack the enzyme lactase that breaks down milk sugar. Symptoms of intolerance include abdominal cramping, nausea, gas, and diarrhea.⁷ There are also life-threatening dairy allergies with a mediated immune response to cow’s milk protein. These individuals may have calcium and vitamin D deficiencies with weak bones, high caries rate, and poor gingival health.³⁸ Surprisingly, some dental toothpastes, fluoride varnishes, over-the-counter gels for xerostomia, chewing gum, and glass ionomer sealants may contain milk protein.⁷ Dental professionals should review the labels of all samples and products before making recommendations to patients who exhibit food allergies and intolerances.

Conclusion

Oral health professionals should be aware of the important role diet plays in whole-body health. The dentist and dental hygienist can make a positive impact dentally and systemically for their patients by providing nutritional counseling and healthcare screenings.

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References

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From Decisions in Dentistry. March 2024; 10(2):28-31