Chapter 9 Consequences of Poor Oral Health

Presence of removable partial or full dentures and whether the older adult removes them for eating should be documented (1,28,39). Occlusion refers to the pattern of teeth and how they come together. For example, an individual may have four maxillary anterior teeth (teeth on the top jaw in the front) and two mandibular (lower jaw) molars; this individual has no teeth in occlusion. Consequently, biting (which is typically done with ante- rior teeth) and chewing (typically done with posterior teeth) are both compromised. The older adult should be asked questions, as noted in Box 9.1 (see pages 135– 136), about ability to bite, chew, and swallow. Adequacy of saliva can be determined with simple subjective questions, also noted in Box 9.1. Changes in salivary production should be investigated to determine any coincidences with changes in medications or onset of new disease(s). Any indication of salivary difficul- ties should be referred to the dentist for further evaluation.

Cranial nerve function may be noted in the older

adult’s records. If not, it is within the scope of dietetics practice to perform a cranial nerve screen. Cranial nerve function will provide important information rela- tive to sensory and motor functions of biting, chewing, swallowing, and taste. A comprehensive nutrition- focused oral screen should include at a minimum the following nerves (Table 9.2) (see page 146 [45]): tri- geminal, facial, vagus, glossopharyngeal, and hypo- glossal. The trigeminal nerve affects jaw strength and movement, and the facial nerve affects taste and

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muscles of facial expression that can both impact biting and chewing function. The glossopharyngeal nerve affects taste, gag reflex, and swallowing func- tion, contributing to the assessment of dysphagia, as does the vagus nerve (gag reflex and swallow) and the hypoglossal nerve (tongue range of motion and strength) (16,27).

The soft-tissue component of the nutrition- focused oral screen includes examination of the tongue, palate, and oral mucosa for any non-normal coloration, lesions, or alterations in appearance. Normally, mucosa is pink and moist, without lesions or infection. Any non-normal findings should be referred to the dentist. Oral manifestations of systemic disease may also be identified through the soft-tissue exam. Uncontrolled diabetes may be manifested by burning mouth (15) and candidiasis. A vitamin B-12 or folate deficiency may present with mucositis, aphthous ulcer, sore burning mouth, halitosis, and taste changes (24). Table 9.3 (46) lists some of the oral manifestations and mechanisms of common nutrient deficiencies (24). In summary, the nutrition-focused oral screen includes examination of the hard and soft tissues of the oral cavity, salivary gland function, and sensory and motor functions as well as observation of dentition and tissue in the oral cavity. RDNs can attend courses for instruction on these skills or can seek individualized instruction from a licensed dentist. Competencies in these skills should become a routine part of dietetics practice.

TABLE 9.3 Identification of Nutrient Deficits in the Oral Cavity Component

Nutritional Risk Symptoms Face

Malar pigmentation (dark skin over cheeks and under eyes)

Bitemporal wasting Pale

Lips

Gingiva Tongue

Cheilosis (red/swelling) Angular fissures

Spongy, bleeding, abnormal redness

a. Glossitis (red, raw, fissured) b. Pale, atrophic, smooth/slick (filiform papillary atrophy) c. Magenta color

Nutrient Implications Niacin, B vitamins (riboflavin, vitamin B-6)

Protein deficiency Inadequate iron

Inadequate niacin, riboflavin

Inadequate niacin, vitamin B-6, riboflavin, iron

Inadequate vitamin C

Inadequate folate, niacin, riboflavin, iron, zinc, vitamins B-6 and B-12

Source: Touger-Decker R, Mobley C, Epstein JB. Approaches to Oral nutrition health risk screening and assessment. In: Nutrition and Oral Medicine. 2nd ed. New York, NY: Humana Press; 2014:358.