Practice Paper of the Academy of Nutrition and Dietetics:
Oral Health and Nutrition
June 2014
ABSTRACT
This paper supports the Position of the Academy of Nutrition
and Dietetics: Oral Health and Nutrition published in the
May 2013 Journal of the Academy of Nutrition and Dietetics.
It is the position of the Academy of Nutrition and Dietetics
that nutrition is an integral component of oral health.
The Academy supports integration of oral health with
nutrition services, education, and research. Collaboration
between registered dietitian nutritionists (RDNs); dietetic
technicians, registered (DTRs); and oral health care
professionals is recommended for oral health promotion and
disease prevention and intervention. There is a synergistic
multidirectional association between diet, nutrition, and oral
health. Given that the mouth is the portal of entry into the
body, it is essential that RDNs and DTRs include the oral cavity
in their assessment for nutritional risk factors and deficiencies.
In 2000, Surgeon General David Satcher released a
landmark report, Oral Health in America: A Report of the
Surgeon General (Oral Health in America), that states that
the mouth is the window to all the diseases of the body.1
In 2003, Surgeon General Richard Carmona released A
National Call to Action to Promote Oral Health: A Public-
Private Partnership (National Call to Action) as a continued
effort to improve oral health disparities identified in Oral
Health in America.2 A National Call to Action is directed to
professional organizations and individuals concerned about
oral health in the United States to encourage programs and
activities to promote oral health and prevent oral disease.2
This goal reflects the Healthy People national objectives for
the nation to improve quality and years of life and eliminate
health disparities.3 Healthy People 2020 addresses the
following areas for public health improvement:
increase awareness of the importance of oral health to
overall health and well-being;
increase acceptance and adoption of effective preventive
interventions; and
reduce disparities in access to effective preventive and
dental treatment services.4
The National Call to Action identifies five action strategies,
one of them focused on increasing collaboration, including
Nutrition assessment is vital to identifying dietary intake
and nutritional factors impacting oral health. Conversely,
decreased salivary flow, compromised oral integrity, tooth
decay, or poor periodontal health can impact an individuals
ability to consume an adequate diet. A poor diet can result
in limited intake of nutrients crucial to systemic health and
well-being. The provision of medical nutrition therapy that
incorporates total health, including oral health is a component
of the Standards of Practice for RDNs and DTRs. Inclusion of
didactic and clinical practice concepts that illustrate the role
of nutrition in oral health is essential in education programs
for both professional groups. The multifaceted interactions
between diet, nutrition, and oral health in practice, education,
and research in both dietetics and dentistry merit the need for
collaborative efforts to ensure comprehensive patient care.
diet counseling and health education aimed at pregnant
women and new mothers. The Institute of Medicines
consensus report, Improving Access to Oral Health Care
for Vulnerable and Underserved Populations, provides
several recommendations for improving the nations oral
health. One recommendation addresses the need to provide
education to prevent oral disease including the role of diet
and nutrition in oral disease.5
SCOPE OF PRACTICE
Registered Dietitian Nutritionists (RDNs) and Dietetic
Technicians, Registered (DTRs)
RDNs work in collaboration with other health care team
members with the RDNs scope of practice concentrated
on food, nutrition, and those related services that are
developed, directed, and provided by RDNs to protect the
public and populations; enhance the health and well-being
of patients/clients; and deliver quality products, programs,
and services including medical nutrition therapy (MNT)
across all focus areas.6
Nutrition assessment is the first of four steps of the
Nutrition Care Process. Standard 1.3 indicates that RDNs
should perform a nutrition-focused physical assessment
1
of body systems, muscle and subcutaneous fat wasting,
hair, skin and nails, signs of edema, sucking/swallowing/
breathing ability, appetite, affect, and oral health.68 The
DTRs role is to assist the RDN in gathering assessment
data. The nutrition-focused physical assessment is used to
determine clinical signs or symptoms of nutrient deficiencies
or conditions that may impact oral intake. Based on oral
conditions or compromised oral integrity, RDNs may
need to modify dietary plans and food texture. General
inspection of the head, neck, oral cavity, and cranial nerve
function allows RDNs to further identify risk factors when
developing a nutrition diagnosis to tailor dietary counseling.
Oral Health Care Professionals (OHCPs)
OHCPs are charged with providing education and
maintenance for the health of the mouth, teeth, and
surrounding hard and soft tissues. Identification of dietary
habits that increase risk for oral disease and contribute
negatively to systemic health should be addressed as
a component of comprehensive care. Accreditation
standards for both dental and dental hygiene programs
require graduates to develop competence about the
interrelationships of body systems to provide prevention,
intervention, and educational strategies in the context of
overall health.911 Competencies for OHCPs encourage the
participation of dental team members with other health
care professionals.1214
DYNAMIC DENTAL CARIES PROCESS
Dental caries (tooth decay) is a multifactorial disease and
one of the most common diseases. There are both pathologic
and protective factors that need to be in balance to reduce
the risk for dental caries.
Pathologic Factors
Pathologic factors involved in the disease process include
presence of acid producing bacteria in plaque biofilm,
reductions in salivary flow, and cariogenic dietary factors.
All of these factors must be present for the demineralization
of the tooth surface (loss of mineral content from the tooth)
to occur; however, the process is reversible until the tooth
structure is compromised. All the pathologic factors can be
managed to reduce risk for dental caries.
Plaque Biofilm. Thorough daily oral hygiene is an integral
component of reducing the bacterial load. OHCPs are best
equipped to provide individuals with education on oral
hygiene. However, RDNs and DTRs can assist individuals
in reducing risk for dental caries by recognizing changes
in salivary flow, cariogenic food and beverage choices, and
eating behaviors.
Saliva. Healthy salivary glands produce saliva
supersaturated with calcium and phosphorus to aid in
buffering acids (see Figure 1). Calcium and phosphorus
can remineralize areas of the tooth surface during the early
phase of tooth decay.15 Certain conditions (eg, Sjgrens
syndrome), treatments for medical conditions (eg, radiation
therapy to the head and neck), and medications (eg,
antihypertensive, antidepressant, antipsychotic) that cause
significant reductions in salivary flow.15 Reductions in saliva
production (hyposalivation or xerostomia) can lead to an
increased risk for dental caries.16 Rapidly progressive and
widespread formation of dental caries, often called rampant
caries, is a potential problem in individuals with reduced
salivary flow. Early preventive measures are essential in
helping to reduce these individuals risk for dental caries (see
Figure 2).
Dietary Factors. All carbohydrates can be cariogenic. A
strong relationship exists between sucrose consumption and
caries prevalence and incidence.1719 Type of carbohydrate,
food combinations, the carbohydrates physical form,
and frequency and timing of consumption of foods
containing sucrose are important factors in dental caries
development.18,19 Fructose and lactose are less cariogenic
than sucrose.19 Processed, cooked starches alone or in
combination with sucrose are cariogenic because of a process
called gelatinization that allows salivary amylase to begin
breaking down starches in the oral cavity.20 The resulting
carbohydrate is metabolized by plaque bacteria to produce
acid and begin demineralization of the tooth surface.20,21
Certain food combinations may reduce the cariogenic
potential of fermentable carbohydrates. For example, a
meal with a combination of foods containing protein,
fat, and fermentable carbohydrate is less carogenic than
a meal of foods containing only sugars or starches.22 The
presence of protein, fat, and other nutrients like calcium
and phosphorus appear to increase the plaque pH. In
the presence of calcium, phosphorus, and fluoride in
foods, the remineralization potential is enhanced.23,24 The
Buffering capacity
Provides an antibacterial action
Aids in remineralization of enamel
Lubricates oral tissues
Assists in chewing, swallowing, digestion, and speaking
Removes debris from teeth
Affects the rate of dental plaque biofilm formation
Influences taste
Figure 1. Benefits of saliva. Adapted from references 15, 58, and 75.
2

Rinse with water
Chew sugarless gum to stimulate saliva flow
Consume fluids with meals
Consume fluids throughout the day
Suck on ice chips throughout the day
Use products to relieve xerostomia
Use lip balm to keep lips moist
Choose moist, nutrient-dense foods
Avoid dry, coarse, or hard foods
Avoid sticky, sugary foods and choose foods/beverages with
sugar alcohols and nonnutritive sweeteners
o Caution with excessive use of sugar alcohols
Choose tart, sour, sweet, bitter, and citrus food/beverages to
stimulate saliva flow
o Caution with excessive use of acidic foods/beverages
Avoid alcohol and alcohol-containing products
Avoid products with caffeine
Figure 2. Best practices for xerostomia. Adapted from references 58
and 76.
carbohydrates physical form provides another consideration
in potential caries development. Carbohydrates that
stick to the tooth surface (eg, raisins, bananas, bread,
crackers, pretzels, potato chips) may be more cariogenic
than carbohydrates in liquid form, like juices. Other
factors in caries risk are: 1) frequent snacking on foods
containing processed starch and 2) total number of
snacks consumed.1719,25,26 RDNs and DTRs can identify
cariogenic eating and feeding practices, encourage optimal
oral hygiene, and provide information about food forms
and patterns of eating that can contribute to caries risk
and help families plan and structure meals and snacks to
achieve a balanced diet that promotes total body health and
minimizes risk for oral disease. MNT for some conditions
may require frequent consumption of foods and beverages;
in these situations, a consultation with an OHCP may
be helpful in individualizing preventive approaches to
minimize risk for caries.
Protective Factors
In addition, it is necessary to understand the protective
factors to reduce an individuals risk for caries. Protective
factors are related to saliva (see Figure 1), good oral
hygiene, exposure to fluoride (eg, fluoride varnish, fluoride
toothpaste), consumption of foods containing fluoride and
other nutrients, and consumption of cariostatic food.
Fluoride and Other Nutrients. The value of fluoride in
preventing dental caries is well established. Once a tooth
erupts, fluoride has a significant impact. Fluoride can
be received systemically (eg, fluoridated water, fluoride
supplements) and topically (eg, fluoridated toothpastes,
mouthrinses, fluoride applied in the dental office). The
role of RDNs and DTRs is to encourage individuals in
communities with fluoridated water to consume tap water
and receive regular preventive care from an OHCP. All
health care professionals should support community water
fluoridation based on strong evidence for caries reduction
and lack of evidence of harm (see the Position of the
Academy of Nutrition and Dietetics: The Impact of Fluoride
on Health27).
Other trace minerals like zinc, iron, copper, nickel,
selenium, and molybdenum may be significantly higher in
healthy teeth. Developing research also indicates a possible
reduction caries-causing bacteria in Streptococci mutans
(S. mutans) and Streptococci sobrinus (S. sobrinus) with the
incorporation of probiotics.2830
Cariostatic Food Factors. These factors work to decrease
caries risk by increasing salivary flow, increasing buffering
capacity, or decreasing the growth of caries causing bacteria.
Foods like cheese, milk, and yogurt without added sugar
may raise the plaque pH and concentrations of calcium,
phosphorus, casein, and protein to assist in buffering the
acids and encourage tooth remineralization.
Polyols have been shown to reduce dental caries. In a pooled
analysis conducted for a systematic review, xylitol, sorbitol,
and xylitol-sorbitol chewing gum reduced caries by 59%,
53%, and 20%, respectively.31
Plant polyphenols, like those found in coffee, red wine,
berries, olives, tea, and cocoa have antioxidant functions
that have been shown in vivo and in vitro studies to
decrease growth of S. mutans.32 A limited number of
human studies suggest an anti-caries and anti-plaque
effect, but reduction in dental caries has not been directly
measured, so evidence for use of polyphenols to prevent
caries is minimal and more research is needed.
DENTAL EROSION
Another dental issue in which diet or dietary behavior
has an impact is dental erosiona loss of tooth structure
due to exposure to acid in the absence of plaque bacteria.
Dental erosion can be localized to one tooth or generalized
to multiple or all teeth. The individual may complain of
sensitivity to temperature or touch. Prevalence of dental
erosion seems to be increasing and is estimated to be 30% to
70% worldwide.33
3
Etiology
Erosion may occur from extrinsic (eg, diet, some occupations
with exposure to acid fumes), and/or intrinsic (eg, disease,
habits) sources. The primary extrinsic sources include
consumption of soft drinks, sports drinks, energy drinks,
fruit juices, pickled foods, sour candies, citrus fruit, and
wine. A neutral and safe pH is 7.0 in the oral cavity, while a
critical pH is considered to be 5.5 or less, capable of causing
demineralization. The pH of soft drinks ranges from 2.38 to
2.92 and of fruit juices from 2.77 to 3.30.34 The pH of energy
and sports drinks ranges from 2.76 to 2.84.35 These drinks
create an acidic oral environment. Intrinsic factors commonly
leading to erosion include gastroesophageal reflux disease
(GERD), eating disorders, and other issues involving frequent
vomiting and rumination.16,33
Risk Factors
Risk factors for dental erosion and resulting caries include
poor eating habits and hyposalivation. Frequency and
duration of exposure to acidic beverages or foods along
with the method of consumption (eg, sipping, using a
straw), impact the amount of time the acid remains in the
mouth and in contact with tooth surfaces.16.33 Suggestions
for individuals who vomit frequently or who experience
sensitivity when consuming acidic foods and beverages
can be found in Figure 3.
Populations at High Risk for Dental Erosion
Individuals who vomit frequently are at risk for dental
erosion. The pH of gastric contents is approximately
3.8, well below the critical pH of 5.5, where tooth
demineralization occurs. A neutral pH is 7.0. Frequent
vomiting with decreased salivary flow sets the stage for a
low pH environment favoring erosion.
GERD is a common gastrointestinal disorder that may result
in exposure of the teeth to gastric acid.36 Gastric acid has a
pH of 1.2, but the pH is modified by partially digested food
and bile acids.37 Case-control studies suggest that 20% to
30% of individuals with GERD have tooth erosion.37
PERIODONTAL DISEASE
Periodontal disease is multifactorial, making it difficult to
determine the effect of suboptimal nutrition on initiation and/
or progression of disease. The impact of nutritional status on
immune response may be an important modifying factor in the
progression of the disease and healing of periodontal tissues.
Implications of Nutrition
Gingivitis. One of the dental plaque-induced gingival
diseases in the American Academy of Periodontology
Classification System for Periodontal Diseases and Conditions
is gingival disease modified by malnutrition.38 Studies suggest
that vitamin C, vitamin D, and calcium, may reduce gingival
inflammation, but further research is needed.3941
Periodontitis. Nutrition, which can impact immunity and
wound healing, is the mechanism most likely to influence
the severity of periodontal disease. Epidemiologic studies
suggest that inadequate intakes of calcium, vitamin C,
vitamin D, folic acid, protein, n-3 fatty acids, and probiotics
are associated with the severity of periodontal disease.3945 In
addition, evidence suggests the use of probiotics to inhibit
growth of dental plaque biofilm and pathogens associated
with periodontal disease. To impact periodontal disease
selection of the correct strain and strength, mode, and time
of administration, health of the individual, and retention
and exposure times in the oral cavity are considerations.4648
Pre- and Postoperative Periodontal Surgery
Considerations. Individuals at nutritional risk
need guidance in attaining optimal nutritional status
to enhance healing following periodontal surgery.
Nutritional status pre-surgery, severity and duration of
periodontal infection, and postperative dietary intake are
all important aspects of nutrition that can affect optimal
outcomes of periodontal surgery.49, 50
DIET AND DENTAL CONNECTIONS FOR SPECIFIC
POPULATIONS
Pregnant Women
Nutrition during pregnancy is key to the oral health of the
woman and future child. To achieve optimal pregnancy
outcomes, adequate oral hygiene (eg, daily homecare
regimen) and regular dental appointments are encouraged.
Community-based programs like the Special Supplemental
Nutrition Programs for Women, Infants, and Children
(WIC) and Early Head Start that provide care for pregnant
women with low incomes present an ideal opportunity
for OHCPs and RDNs and DTRs to work collaboratively
to help ensure that pregnant women achieve optimal oral
health. Being a minority and having a low income are
common deterrents to dental services utilization.51 Women
with low income are more likely than those with higher
incomes to give birth prematurely to have an infant with
low birth weight. RDNs can provide pregnant women
with education about preventive oral care throughout the
pregnancy and can also refer pregnant women to OHCPs.52
Nausea, Vomiting, and Oral Implications. Over 80% of
pregnant women suffer from nausea and vomiting during
the first trimester of pregnancy.53,54 These symptoms may
be eased by consuming cariogenic foods like crackers, dry
toast, or cereal. Muffins, cake, and cookies and carbonated
4
 Prevention of dental caries:
o minimize snacks containing sugars or processed starches
o optimal oral hygiene after cariogenic foods
o chew xylitol or sorbitol gum after meals or snacks when
thorough oral hygiene is not possible
o consume dairy products to neutralize the acidic pH
and provide sources of calcium and phosphorus for
remineralization
o fluoridated water, mouthrinses, and toothpaste at home
Establish a dental home with an oral health care
professional for regular dental care
For those who experience frequent vomiting:
o avoid toothbrushing immediately after the episode
o rinse with sodium bicarbonate after an acidic event to
neutralize pH
o follow prevention of dental caries guidelines
Rinse the mouth with water when unable to brush
Acidic foods/beverages:
o limit consumption
o consume with meals to minimize the acidic changes in pH.
o do not brush immediately after exposure33the enamel
is softened from the acidic environment and prone to
damage from brushing, even with a soft-bristled brush.
Prevention of periodontal disease:
o consume dairy products including yogurt with active
cultures, citrus fruit, and proteins in addition to usual
healthy eating recommendations for individuals
undergoing periodontal treatment.
Figure 3. Recommendations to prevent and manage oral disease. Adapted from reference 58.
a
WIC=Supplemental Nutrition Program for Women, Infants, and Children.
beverages are other cariogenic foods and beverages that
may also provide relief. Frequency of vomiting can increase
the risk for dental erosion and subsequent risk for dental
caries. Frequent consumption of cariogenic foods and and
carbonated beverages to abate nausea can increase risk for
caries.53 Recommendations that RDNs can provide to all
pregnant women and others experiencing frequent vomiting
can be found in Figure 3.
Folate Consumption. Inadequate folate consumption in
the months before conception and during the first 2128
days of the pregnancy can lead to oral cavity defects. Cleft
lip or palate, which result from incomplete formation of
the cranial bones, are common oral cavity defects associated
with insufficient folate deficiency.55 During pregnancy, 600
micrograms/day of folate are recommended. RDNs and
DTRs should provide pregnant women with education
about foods rich in folate and should encourage daily
supplementation, not to exceed the Recommended Daily
Allowance to ensure adequate intake.
o a high-calorie, high-protein, mechanically-altered diet may
be used post-surgery to enhance healing in medically
compromised individuals and those at nutritional risk
o for individuals with ulcerated lesions and those unable
to eat a normal diet for extended periods, a liquid or
mechanically-altered diet may be indicated until they have
had adequate healing
o optimal oral hygiene
Dental prosthesis:
o start chewing on your molars and progress forward
o avoid biting on one side of mouth; distribute food evenly
o incorporate best practices for xerostomia
o liquid and mechanically-altered foods may be indicated if
chewing is difficult initially
o increased consumption of protein foods may be
recommended for optimum healing
Pregnant women:
o optimal oral hygiene
o schedule dental visits at regular intervals throughout the
pregnancy to monitor peridontal health and overall oral
health status.53
o prevent periodontal disease
o Enforce best practices for prevention of early childhood
caries
o optimal dietary intake for healthy growth and development
of the fetus, infant, and young childs oral cavity
o When working with pregnant patients at WICa clinics, RDNs
can educate about optimal oral hygiene and the potential
impact for the developing fetus
Periodontal DiseaseLow Birthweight Infants/
Premature Births/Miscarriage. Hormones and blood
supply increase during pregnancy, resulting in a higher
occurrence of gingival inflammation.56 This commonly
presents as pregnancy gingivitis. Evidence suggests there
may be a relationship between periodontal disease and low
birth weight, premature births, and miscarriage. All health
care professionals working with pregnant women must
understand the relationship of meal and snack patterns,
overall nutrient intake, oral health status in relation to health
of the infant, and potential oral health concerns.55
Nutrient Needs for Growth and Development of
Fetus Oral Cavity. Maternal nutrient intake is
essential to the developing organs and the oral cavity
of the fetus. For example, vitamin C is important for
collagen formation and magnesium and phosphourus are
important for tooth mineralization of teeth. Inadequate
maternal consumption of calcium and vitamin D can
result in poor calcification of the developing teeth
5
of the fetus and in pitting once the teeth have fully
erupted. And inadequate protein consumption can
result in delayed tooth eruption and impaired salivary
function. Increased caries susceptibility can occur if
there is inadequate consumption of vitamin A, fluoride,
iron, zinc, and protein. It is also important to note
that consuming too much vitamin A can impair oral
mucosal epithelium development. As discussed in the
Position of the Academy of Nurition and Dietetics:
The Impact of Fluoride on Health,27 consumption of
excessive amounts of fluroide may contribute to dental
fluorisis. Inadequate iodine consumption can result in
macroglossia (large protruding tongue), malocclusion,
and delayed tooth eruption.57
Infants and Young Children
Nutrient Needs for Growth and Development of the Oral
Cavity. Adequate consumption of nutrient-rich foods is
necessary for growth and development of oral soft and hard
tissues. Development of the oral musculature may be delayed
if food textures are not appropriatedly introduced, which can
also impact the childs ability to speak.58 RDNs and DTRs
can incorporate information about feeding practices into
anticipatory guidance given to new mothers.
Early Childhood Caries. Early childhood caries, formerly
referred to as baby bottle tooth decay or nursing bottle
caries is defined by the American Academy of Pediatric
Dentistry as the presence of one or more decayed (non-
cavitated or cavitated lesions), missing (due to caries), or
filled tooth surface in any primary tooth in children between
birth and 5 to 6 years of age.59 Figure 3 provides best
practices for RDNs and DTRs when counseling pregnant
women and new mothers.
Children, Adolescents, and Young Adults
Dental caries risk. Adequate consumption of nutrient-
rich foods is necessary for growth and development and for
repair of oral soft and hard tissues. According to the Centers
for Disease Control and Prevention, prevalence of untreated
dental caries in the permanent teeth of children 6 to 19 years
of age has decreased.60 Although strides are being made in
prevention of tooth decay, dental caries remains a problem
for some racial and ethnic and lower socioeconomic groups
who have more treated and untreated tooth decay compared
with other groups. For example, only 27% of children from
families with incomes at less than 200% of the poverty level
have had a dental visit in the past year. Refer to Prevention
of Dental Caries in Figure 3 for suggestions that RDNs and
DTRs can provide to help parents prevent dental caries in
their children and adolescents.
Common Nutrition Concerns Related to Oral Health
1. Inadequate fruits and vegetables consumption: A diet
high in fruits and vegetables is associated with decreased
risk for chronic disease as well as having anticarcinogenic
properties. The Centers for Disease Control and
Prevention has reported 28.5% of high school students
consume fruit less than once/day, and approximately
33% consume vegetables less than once/day.61
2. Inadequate dairy consumption; Dairy intake is
important for strong bones and teeth. Inadequate dairy
consumption puts children, adolescents, and adults
at long-term risk for osteopenia, osteoporosis, and
periodontal disease.
3. Consumption of sugar-sweetened beverages (SSBs):
Dental caries, obesity, risk for cardiovascular disease,
and future risk for osteoporosis or fractures have been
identified as concerns associated with excessive SSB
consumption. Although a decreased consumption
and decreased frequency of SSBs has been reported,
SSBs still account for an average of 150 calories or 9
teaspoons of added sugar per person each day.62
Orthodontics. Bones and tissue must be healthy to
allow periodontal ligament and bone to respond positively
to orthodontic tooth movement.63 Dietary guidance for
individuals with orthodontia should focus on consumption
of nutrient-dense foods to promote oral health. Adequate
quantities of food sources of protein, calcium, vitamin C,
and vitamin D are recommended. Sticky and hard foods
should be avoided. Food retention can occur around
orthodontic brackets and bands, which increases risk of
demineralization. When orthodontic appliances are placed
or adjusted, the mouth may be sore and tender, which can
affect ability to chew. A mechanically altered diet may be
recommended until a regular diet can be consumed. In
such cases, fresh fruits should be cut up, corn cut off the
cob, and meat cut off the bone to reduce biting force.
Older Adults
By 2030, Americans 65 years of age and older will make
up 20% of the population. Complex medical histories and
polypharmacy reinforce the need for an interprofessional
approach to care for this population. RDNs and DTRs
should incorporate nutrition screening into assessments of
all older adults, regardless of oral health status. Individuals
with oral health problems that may negatively affect ability
to consume a balance of nutrients from all food groups
should be referred to an OHCP.
Tooth Loss. Tooth loss, which is preventable, impacts
individuals ability to consume a balance of nutrients from
all food groups.64 Socioeconomic disparities may also play
6
a role in tooth loss. Key findings from the National Health
and Nutrition Examination Survey 20092010 found 34%
of adults living below the poverty level were edentulous,
compared with only 13% of adults living above the poverty
level were edentulous.65 With each loss of a tooth comes a
greater risk for malnutrition.
Osteoporosis and Alveolar Bone Loss. Osteoporosis
and periodontal disease share several common risk factors,
including older age and smoking. Inadequate intake of
calcium and vitamin D may also be a common denominator.
Osteoporosis independently influences alveolar bone
height.66 RDNs and DTRs should encourage older adults
to consume food sources of calcium and vitamin D and/or
possibly supplementation of calcium plus vitamin D. RDNs
can also provide education about the connection of dietary
intake to oral health status.
Dental Prostheses (Dentures and Implants).
Overdentures, complete dentures, implant supported
dentures, and partial dentures are examples of removable
prostheses. Use of prostheses can result in taste and
temperature alteration, increased risk for choking, and an
overall adjustment to dietary consumption. A randomized
control trial demonstrated that implant supported
overdentures increased the ability to chew and maintain
normal food habits.67 RDNs and DTRs can follow the
suggestions for individuals with dental prostheses found in
Figure 4.
Recession. Gingival recession occurs when the margin of
the gingiva pulls away from the tooth, leaving exposed roots.
Gingival recession increases risk for dental caries, referred to
as root caries. Causes of recession include abnormal tooth
position, aggressive toothbrushing, gingival trauma, and
peridontal disease. Exposed roots lack enamel and can easily
be abraded by brushing. The prevalence of root caries is
much higher in older adults than in younger adults, since
they are maintaining their natural dentition (permanent
teeth). Issues with dexterity as well as changes in the
periodontium such as gingival or gum recession can create
challenges for adequate maintenance of oral hygiene and
contribute to inceased risk of root caries.
Along with root caries, dentinal hypersensity is a result of
recession. Xerostomia, acidic foods and beverages, and acid
influx contribute to dentinal hypersensitivity. Extreme hot
or cold food temperatures can be very painful to individuals
with dentinal hypersensitivity.58
When RDNs or DTRs need to recommend liquid
supplementation to individuals with recession, it is
important to note the carbohydrate content of supplements.
Encouraging optimal oral hygiene following consumption
of these supplements will decrease the risk for root caries.
Babies should not be put to bed or nap with a bottle containing
anything other than water.
Infants should consume only 4-6 oz of fruit juice per day.
Fruit juices or other beverages sweetened with sugar (eg, fruit
drinks, fruit punch) should not be given in bottles or sippy cups
that a child can sip on throughout the day.
Children should see a dentist shortly after the first tooth erupts
and no later than 12 months of age.
Encourage infants to drink from a cup by 12 months; infants
should be weaned from a bottle at 12 to 14 months of age.
Toothbrushing should be performed by a parent twice daily with
an age appropriate soft bristle or soft cloth. Children do not have
the fine motor skills to clean their teeth well until about age 7 to 8
years. Toothbrushing should be supervised by an adult.
For children under age 2 at moderate or high risk of caries, a
smear of fluoridated toothpaste is recommended.
Children age 2 to 5 years may use a pea-sized amount of
fluoridated toothpaste; parental guidance is still suggested.
Figure 4. Best practices for the prevention of early childhood caries.
Adapted from reference 58, 77, and 78.
Sipping on supplements throughout the day can increase
caries risk. RDNs and DTRs that serve older populations
should perform a thorough nutrition-focused physical
assessment that includes an observation of the oral cavity.
Asking questions about senstivity of teeth to hot, cold, or
sweets allow RDNs or DTRs to better tailor an individuals
dietary intake to meet nutrient needs.
Institutionalized Long-Term Care PopulationDiet and
Oral Implications. Research suggests an association between
poor oral hygiene, respiratory problems, pathogens, and risk
for aspiration pneumonia in institutionalized long-term care
populations.68, 69 Working in conjunction with nursing assistants
and nurse advisors, RDNs and DTRs who oversee dietary
programs at long-term care institutions can help reinforce the
importance of daily oral hygiene for residents to reduce the
presence of pathogenic bacteria that contribute to oral disease
risk and potential of systemic complications. A nutrition-
focused physical assessment with emphasis on identifying
alterations in the oral cavity and making appropriate referrals to
OHCPs is warranted in this population.
Other systemic conditions connected to oral health can be
found in Figure 5. which also discusses the role of the RDN
and DTR.
Individuals with Special Needs
Individuals with special needs commonly have difficulties
with sucking, swallowing, chewing, and independent
feeding.58 A collaborative effort between OHCPs, RDNs
7
Systemic condition Oral concerns
Heart disease Loss of dentition due to advance periodontal
disease
Limited ability to consume fresh fruits,
vegetables, and lean meat
Consumption of softer diet high in fat and
refined grains
Increased caries risk may occur as a result
of healthier lifestyle modifications such as
juicing and consumption of diet beverages
Recommendations for RDNs and DTRs
Nutrition focused physical exam that includes assessment of the
oral cavity
Consider number of teeth present and chewing ability when
providing dietary prescription
Determine nutritional adequacy of the diet; modify diet as
needed to encourage optimal nutrient intake
Educate on alternative methods of preparation and solutions
to include more fruits and vegetables: cook to increase softness,
encourage frozen varieties, or incorporation of canned fruits and
vegetables as indicated

Osteoporosis Alveolar bone loss evidenced clinically or
radiographically
Smoking, excessive use of alcohol or caffeine
Educate patients about the need to rinse with water or chew
xylitol gum after consuming acidic foods and beverages
Hypoparathyroidism may result in alveolar bone loss
Educate gastric bypass patients about impaired calcium absorption
and implications for oral health and whole body health
Provide lactose intolerant clients with alternative list of calcium
containing foods
Recommend sugar free calcium supplements

Diabetes Progressive periodontal disease may impact
glycemic control in clients with diabetes
Poor glycemic control may enhance progression of periodontal
disease
Encourage regular preventive dental care and daily regimen of
brushing twice and flossing at least once
More frequent recall intervals (every 3 to 4 months) may be
indicated dependent on a clients periodontal status.

Oral cancer/head and neck cancer
Risk of oral cancer increases with age;
head and neck cancer is more prevalent in
individuals over age 50
Men have two times the risk of oral cancer
than women
Ability to chew, swallow, or talk may be
impaired by treatment modality for head and
neck cancer
Mucositis, glossitis, dry mouth, thickened
saliva, changes in taste, and nausea may
occur
Stiffness of the jaw may occur and make it
difficult to open mouth wide
Perform nutrition focused physical assessment of oral cavity to
include examination of the oropharynx area, lateral borders of
dorsal surface of the tongue, face, lips, and palpation of lymph
nodes.
Encourage tobacco cessation programs for smokers
Recommend mouth rinses to minimize mucositis such as
chorhexidine, baking soda, or salt water
Modify diet as necessary based on oral conditions assessed
during and after therapeutic treatments :
o incorporate high-protein, nutrient-dense soothing foods for
clients experiencing mucositis
o limit spicy or citrus foods
o do not consume coarse textured foods
Encourage frequent intake of water or salivary substitutes as
needed

Obesity Increased body mass Index is an associated
risk factor for periodontal disease
Post bariatric surgery:
o dietary alterations required after bariatric
surgery may contribute to increased caries
risk
o dentin hypersensitivity
o enamel erosion
Educate bariatric surgery clients about the importance of
effective plaque removal
Encourage discussion with oral health care provider about the
use of topical fluorides
Xylitol products may be recommended for caries prevention

Figure 5. Selected chronic conditions and recommendations for registered dietitian nutritionists (RDNs) and dietetic technicians, registered (DTRs) to
support oral health.

8
and DTRs, physicians, and other health care professionals is
recommended to provide individualized care for those with
special needs. Special diet and nutrient considerations and
oral health considerations is indicated in those with chewing
and swallowing difficulties; increased/decreased metabolic
needs; or other health problems like diabetes, heart disease,
or digestive disorders, or those taking certain medications.70
Populations with Low Incomes. Limited income or
other barriers (eg, decreased access to food) may negatively
impact adequate intake of fresh fruits and vegetables, lean
meats, whole grains, and dairy products.71 Low income
can also impact access to oral health care. A prospective
cohort study using cross-sectional data demonstrating a
positive association between low income and reduced levels
of oral health literacy in a WIC population.72 Oral health
literacy is defined as the degree to which individuals have
the capacity to obtain, process, and understand basic oral
health information and services needed to make appropriate
health decisions.73 Poor dietary choices coupled with
lack of knowledge and understanding about how to keep
teeth and mouth health may increase risk for oral disease.
Collaborative opportunities exist for OHCPs, RDNs, and
DTRs who work with WIC and Head Start participants and
other programs that serve populations with low incomes
to identify alternative methods of message delivery and
methods of education to ensure adequate understanding of
how oral health relates to overall health. Regular dental visits
and daily homecare should also be reinforced.
Eating Disorders. A mutlidiscliplinary approach is
recommended for the effective treatment of individuals
eating disorders. When vomiting is used as a means of
purging, the disorder is often detected orally. Thinning
enamel on the edges of the anterior teeth and lingual
surfaces of maxillary molars, raised amalgams, swollen
parotid glands, damage to the oropharyngeal area, and
petechiae are common oral signs of frequent vomitting.
Individuals should be encouraged not to brush immediately
after purging but instead to rinse with 1 tsp of sodium
bicarbonate mixed in 8 oz of water. RDNs and DTRs need
to be aware of oral manifestations of eating disorders and to
collaborate with OHCPs as needed. The role of OHCPs is
to provide palliative care until the disorder is under control.
Figure 3 provides best practices for RDNs and DTRs to use
in counseling individuals concerning prevention of dental
caries and excessive vomiting.
Interprofessional Teams
Education. The interrelationship of diet, oral health,
and general health is a fundamental concept that should
be introduced in dietetic, dental, and dental hygiene
professional programs. Shah and colleagues assessed
the knowledge of dental and dietetic students and
found that OHCPs need further training in general
health, while nutrition and dietetics students need more
training in oral health.74
Research. Many studies demonstrate an association
between dietary intake, oral health, and systemic
health. However, more studies demonstrating how
oral conditions are impacted by diet and nutrients and
conversely how alterations in the peridontium and
surrounding oral cavity can impact dietary quality are
needed. Areas of research include:
identifying potential benefits of prebiotics and
probiotics in the prevention and control of periodontal
disease and dental caries;
identifying the role of macro and micronutrients
in periodontal issues, like adequacy of vitamin D,
calcium, and protein in periodontal issues;
determining if periodontal treatment impacts birth
outcomes and sytemic disease;
determining the cost effectiveness, cost benefit, or
economic savings of utilizing the services of RDNs or
DTRs in dental practices; and
determining effective dietary protocols for individuals
who have undergone reconstructive surgeries or
who have prosthetics like partial dentures, complete
dentures, or dental implants.
SUMMARY
RDNs and DTRs can be instrumental in identifying
cariogenic eating and feeding practices, encouraging
optimal oral hygiene, providing information about
food forms and patterns of eating that can contribute
to caries risk, and helping families plan and structure
meals and snacks to plan a balanced diet to promote
total body health and minimizes oral disease risk. There
are many opportunities for RDNs, DTRs, and OHCPs
to work collaboratively. It is essential to integrate oral
health education and interprofessional opportunities into
didactic programs and internships for dietetics students.
Conversely, nutrition education and interprofessional
opportunities should be components of classroom
education and clinical requirements for oral health
students. Recommended professional partnerships
for RDNs and OHCPs include establishing a referral
relationship with general dentists or specialty dental
practices like pediatric dentists, periodontists, and oral
maxillofacial surgeons. Individuals facing periodontal
or oral maxillofacial surgery, especially those with MNT
needs, would benefit greatly from referral to an RDN
prior to surgery. Other collaborative avenues include
9
providing joint presentations at local, state, and national
professional meetings or developing joint educational
materials. Bridged efforts among RDNs and DTRs and
OHCPs can significantly impact the publics health.
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Acknowledgements
The Academy of Nutrition and Dietetics authorizes
republication of the practice paper, in its entirety, provided
full and proper credit is given. Commercial distribution is
not permitted without the permission of the Academy and
any distribution should not be used to indicate endorsement
of product or service. Requests to use portions of the paper
must be directed to the Academy headquarters at 800/877-
1600, ext. 4835, or ppapers@eatright.org. This paper will be
up for review December 31, 2016.
Authors: Lisa F. Harper Mallonee, MPH, RDH, RD, LD
(Texas A&M University, Baylor College of Dentistry, Dallas,
TX); Linda D. Boyd, EdD, RDH, RD (MCPHS University,
Forsyth School of Dental Hygiene, Boston, MA); Cynthia
Stegeman, EdD, RDH, RD, LD, CDE (University of
Cincinnati Blue Ash, Cincinnati, OH).
Reviewers: Jeanne Blankenship, MS, RD (Academy
Policy Initiatives & Advocacy, Washington, DC); Sharon
Denny, MS, RD (Academy Knowledge Center, Chicago,
IL); Pediatric Nutrition dietetic practice group (Beth
Ogata, MS, RD, CSP, University of Washington, Seattle,
WA); Jane McGinley, MBA, RDH (American Dental
Association, Chicago, IL); Alison Steiber, PhD, RD
(Academy Research & Strategic Business Development,
Chicago, IL); Lori A. Stockert, MS, RDH (Silverdale, PA);
Pamella Vodicka, MS, RD (Maternal and Child Health
Bureau, Health Resources and Services Administration,
Rockville, MD); Public Healthy/Community Nutrition
dietetic practice group (Victoria Warren-Mears, PhD, RD,
Northwest Portland Area Indian Health Board, Portland,
OR); Academy Quality Management Committee (Paulina
Williams, PhD, MPA, RDN, CD, Brigham Young
University, Provo, UT).
Academy Positions Committee Workgroup: Katrina Holt,
MPH, MS, RD (chair); Karen R. Greathouse, PhD, RD;
Cynthia Stegeman, EdD, RD, RDH, LD, CDE (content
advisor).
We thank the reviewers for their many constructive
comments and suggestions. The reviewers were not asked to
endorse this practice paper.
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