From dental caries to eating disorders, the first signs of poor nutrition often manifest in the mouth. Many nutrition researchers believe that dentists have the perfect opportunity to screen and refer nutritionally compromised patients for education and counseling.
“The practice of dentistry is changing,” says registered dietitian Connie C. Mobley, PhD, RD, professor of nutrition and associate dean of research at the University of Nevada’s School of Dental Medicine. “Dentists are functioning more as dental doctors, responsible for oral care and also for associated conditions like chronic disease ... and a bridge exists between nutrition and dentistry that can lead to better health.”
Dental caries, or cavities, is a common example of the relationship between nutrition and oral health. Caries is directly linked to the consumption of specific foods, known as fermentable carbohydrates, and typical examples include crackers, pretzels, soda, energy drinks and candy. However, dental caries prevention includes more than providing patients with a simple list of foods to avoid. Understanding the total diet and helping patients to formulate realistic meal plans will lead to improvements in both oral and general health.
“My students work with the families, educating them on healthy foods and snacks and the frequency of their meal patterns,” explains registered dietitian Lisa Sasson, MS, RD, dietetic internship director and clinical associate professor of nutrition and food studies at New York University, where students take part in an oral health rotation in the dental school’s pediatric program. “They create meal plans that are healthy, practical, culturally appropriate and also make sense in terms of oral health,” says Sasson.
Periodontal disease is an infectious disease of the mouth with strong ties to nutrition and general health. Certain deficiencies, such as vitamin C and magnesium, are linked to periodontal disease, and the severity of periodontal disease can be influenced by diabetes, cardiovascular disease and osteoporosis.
In fact, periodontal disease is sometimes referred to as the sixth complication of diabetes. Studies suggest that patients with lower risk for periodontal infection tend to have better control over their blood sugar levels. Conversely, uncontrolled blood sugar puts a patient at greater risk for periodontal disease. “Diabetics might see a dentist before other health practitioners because many early signs of diabetes may show up in the mouth first,” according to registered dietitian Riva Touger-Decker, PhD, RD, FADA, department chair of nutritional sciences at the University of Medicine and Dentistry of New Jersey and director of the division of nutrition at the New Jersey Dental School.
Eating Disorders and Beyond
Likewise, says Touger-Decker, dentists frequently are the first health professionals to encounter patients with undiagnosed eating disorders. Enamel defects and oral lesions detected by a dentist also may be early signs of celiac disease.
At Tufts University, dental students are taught to refer medically compromised patients to other health-care practitioners. According to registered dietitian Carole Palmer, EdD, RD, LDN, division head of nutrition and oral health promotion at Tufts, dentists should refer to RDs “when they see that there are issues that warrant further care: diabetes with an indication of poor glucose control, hypertension or obesity. Any underlying health condition needs a referral to a physician or dietitian.”
Dentists Combating Childhood Obesity
With obesity rates on the rise, many health-care practitioners favor a comprehensive approach to the prevention of obesity, especially in children. This approach includes a close working relationship between registered dietitians and dentists. “Everyone needs to be responsible and take charge to solve this [pediatric obesity epidemic], including dentists, physicians, educators and RDs,” says Sasson, adding that she believes dentists serve as key players by screening patients for high BMIs and working with RDs to educate families on healthy eating.
“The commonality between poor oral health and obesity is a poor quality diet,” says Mobley, who also supports screening for pediatric obesity by dentists. She has noticed a shift in attitude over the last 10 years, and dental students are interested in methods for incorporating nutrition into their practices. “Dentists are doing more to address the entire health of their patients, not just their teeth.”
A study in the November 2010 Journal of the American Dental Association assessed dentists’ attitudes about addressing obesity with patients and found at least half agreed that they were interested in offering obesity-related services to their patients. However, less than 5 percent of the dentists already offer some form of a counseling service.
Opportunities for RDs and Dentists
“One of the most common things dentists say is that they don’t know who to refer patients to, which means that we [RDs] are not getting out there,” says Touger-Decker. “We all have a role in patient care, but we need to market ourselves because they don’t know about us.”
Registered dietitian June Levine, MS, RD, CDN, CDE, project manager for the Biobehavioral Early Childhood Caries Team Project at Columbia University, works on a team that is developing a program for iPads which will assist allied health professionals such as community health workers to determine a child’s risk for developing caries through a series of interactive questions, including a diet recall widget. “I am discovering the gaps that registered dietitians can fill,” says Levine. “This example of partnership between RDs and dentists is one that is not often promoted, but may benefit both professions and their client bases.”
Private practice RDs interested in working with dentists should begin establishing referral relationships with local dentists. “Dentists are not going to take the initiative,” says Mobley. “RDs need to visit dentists in their area and talk to them about including nutrition in their practices. Dentists have a role to screen their patients, then pick up the phone and call the RD for a referral.”
Dentists with extra office space may even prefer to have an on-site RD easily accessible to their patients. Registered dietitian Deb Indorato, RD, LDN, CLT, whose private practice is in Virginia Beach, is establishing a partnership with her dentist. Indorato will rent space and expects a very natural referral system. “My dentist is aware of the need for patients with periodontal disease, eating disorders and tooth decay to receive nutritional guidance,” says Indorato. “She feels she will refer many of her patients to me.”
For dentists who provide nutrition brochures and handouts to their at-risk patients, RDs can help to create patient education materials, website copy and nutrition screening tools. RDs working in community settings can team up with dentists to provide nutrition education in schools, worksites, health fairs and community health centers.
In medicine, studies clearly show the relationship between diet and disease. But dental research is just beginning to examine the link. “Dentists don’t always see the relationship between nutrition and dentistry,” notes Mobley, “and some dentists believe that nutrition falls outside their scope of practice.” Additionally, dentists have limited time with their patients, which serves as a barrier for dentists to provide nutrition assessment, education and referrals.
In the Journal of the American Dental Association study, about dentists’ perceived roles in addressing obesity, more than 50 percent noted a fear of offending their patients as a major barrier for offering obesity interventions in their office. Additional barriers included a lack of nutrition knowledge and training, fear of appearing judgmental and a lack of trained personnel.
“As a health-care provider, I care about the overall health of my patients, but I don’t know enough about nutrition to educate my patients,” says Richard Lusby, DDS, a dentist in Zephyr Cove, Nev., who does not offer nutrition resources to his patients, but is open to the idea of incorporating a registered dietitian into his practice and to learning more about nutrition at professional conferences. “I do recognize that childhood obesity is out of control in our country and I should be involved in trying to solve the problem.”
According to Mobley, the key to overcoming these barriers is education. “At UNLV, we teach dentists a partnership model between dentists and RDs,” she says. “Nutrition and dentistry go together, and when dentists are educated about the role of nutrition, they have a greater appreciation for it.”
Educating Future Dentists and Dietitians
New York University, Tufts University and the University of Medicine and Dentistry of New Jersey are examples of schools that offer a dental rotation during their dietetic internship programs. “Educating dental and nutrition students on the linkage of the two disciplines is important to establish early so they can build upon this knowledge when they enter the work force,” says Levine.
Internship preceptors interested in a dental rotation should meet with dental faculty to find common ground for developing a program. “It is important to be practical and show the breadth and depth of benefit that dental students will get from working with nutrition students,” suggests Sasson.
Dental rotations could also provide settings for internships with a shortage of practice sites. Dietetic interns help dental students with nutrition education and handouts, and dental students provide the dietetic students with an understanding of oral health. The end result is increased awareness for both disciplines and overall improved patient care. “Dentists and RDs both practice to improve health,” adds Levine. “By expanding these professional relationships patients have the benefit of belonging to a health care environment that is working together to improve their health.”