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from the association ADA REPORTS

Position of the American Dietetic Association: Oral

Health and Nutrition
tions between diet, nutrition, and oral diseases with oral manifestations, im-
ABSTRACT health in practice, education, and re- pact the functional ability to eat as
It is the position of the American Di- search in both dietetics and dentistry well as diet and nutrition status.
etetic Association that nutrition is an merit continued, detailed delineation. Likewise, nutrition and diet may af-
integral component of oral health. J Am Diet Assoc. 2007;107: fect the development and integrity of
The American Dietetic Association 1418-1428. the oral cavity as well as the progres-
supports the integration of oral sion of oral diseases. The Surgeon
health with nutrition services, educa- General’s “Oral Health in America”
tion, and research. Collaboration be- POSITION STATEMENT
It is the position of the American Die- report and “National Call to Action to
tween dietetics and dental profession- Promote Oral Health” highlight the
als is recommended for oral health tetic Association that nutrition is an
integral component of oral health. The roles of diet and nutrition as major
promotion and disease prevention multifactorial environmental factors
and intervention. Scientific and epi- American Dietetic Association sup-
ports the integration of oral health in the etiology and pathogenesis of
demiological data suggest a lifelong craniofacial diseases and disorders
synergy between nutrition and the in- with nutrition services, education,
and research. Collaboration between (1,2,4). The actualization of the syn-
tegrity of the oral cavity in health and ergistic bidirectional relationship can
disease. Oral health and nutrition dietetics and dental professionals is
recommended for oral health promo- be accomplished through the roles of
have a synergistic bidirectional rela- RDs as members of patient health
tionship. Oral infectious diseases, as tion and disease prevention and inter-
vention. care teams in health promotion and
well as acute, chronic, and terminal maintenance as well as disease man-
systemic diseases with oral manifes- agement.

tations, impact the functional ability s a body of knowledge, dietetics
to eat as well as diet and nutrition and nutrition has expanded to
status. Likewise, nutrition and diet impact many segments of health
care. Scientific and epidemiological ORAL INFECTIOUS DISEASE
may affect the development and in- Dental Caries
tegrity of the oral cavity as well as the data show a lifelong synergy between
progression of oral diseases. As we nutrition and the integrity of the oral Dental caries is a major cause of tooth
advance in our discoveries of the links cavity in health and disease (1-6). loss in the United States. Nearly 42%
between oral and nutrition health, Paralleling this cross-disciplinary of children and adolescents (ages 6 to
practitioners of both disciplines must trend is a change in the health care 19 years) and approximately 90% of
learn to provide screening, baseline system toward a patient-centered, in- adults have experienced tooth decay
education, and referral to each other terdisciplinary, team-based approach (8). Although the prevalence and se-
as part of comprehensive client/pa- that requires collaborative effort verity of caries has declined, there
tient care. Dietetics practice requires among health care providers and em- has been no observed reduction in the
registered dietitians to provide medi- phasizes evidence-based practice (7). rate of early childhood caries in in-
cal nutrition therapy that incorpo- Thus, partnerships among registered fants and preschool children (9).
rates a person’s total health needs, dietitians (RDs), dental professionals, Feeding behaviors after prolonged
including oral health. Inclusion of and other health professionals need bottle feeding or breastfeeding and
both didactic and clinical practice to be strengthened, developed, and patterns in the introduction of foods,
concepts that illustrate the role of nu- expanded to encourage integrated when eating behaviors are being es-
trition in oral health is essential in and comprehensive practice; subse- tablished, may influence prevention
both dental and dietetic education quently, educational competencies and treatment of this disease (8). Car-
programs. Collaborative endeavors need to be further developed that em- ies identified in children and young
between dietetics and dentistry in re- brace this approach (7). The multifac- adults and root and coronal caries in
search, education, and delineation of eted interactions between diet, nutri- the elderly cause unnecessary pain
health provider practice roles are tion, and oral health in practice, and expense (2,10). Children with
needed to ensure comprehensive education, and research in both die- craniofacial problems, neurological
health care. The multifaceted interac- tetics and dentistry merit continued, abnormalities, or impaired cognitive
detailed delineation. abilities are at greater risk for oral
Oral health and nutrition have a infectious diseases that can interfere
synergistic bidirectional relationship. with appropriate responses to feeding
Oral infectious diseases, as well as protocols (11).
doi: 10.1016/j.jada.2007.06.003
acute, chronic, and terminal systemic Diet and nutrition have a direct in-

1418 Journal of the AMERICAN DIETETIC ASSOCIATION © 2007 by the American Dietetic Association

nutrient deficiencies (eg, vitamin C

Anticariogenic: Foods or components of foods that can raise salivary pH to an alkaline and magnesium) may compromise the
level and protect the enamel. systemic response to inflammation
Cariogenic: Foods/drinks containing fermentable carbohydrates that can cause a decrease and infection and alter nutrient needs
in salivary pH to ⬍5.5 and demineralization when in contact with microorganisms in the (20,21,27).
mouth. Nutritional status has a direct in-
Cariostatic: Foods that are not metabolized by microorganisms in plaque and do not fluence on the synthesis and release
subsequently cause a drop in salivary pH to ⬍5.5 within 30 minutes. of cytokines and their action. Malnu-
Coronal caries: Decay on the pit and fissure surfaces of permanent teeth. trition is associated with increased
Dental caries (decay): An oral infectious disease of the teeth in which organic acid needs for calories and protein to pro-
metabolites produced by the metabolism of oral microorganisms lead to demineralization mote repletion, wound healing, and
and destruction of the tooth structure. an improved immune response (28).
Maxillary anterior caries or early childhood caries: Previously called baby bottle tooth Malnutrition can cause adverse alter-
decay or maxillary anterior caries. Early childhood caries is one or more primary maxillary ations in the volume, antibacterial,
incisors in children that is decayed, missing, or filled. and physiochemical properties of sa-
Edentulism: Without teeth; complete edentulism refers to missing all teeth. Partial liva (29). A balanced diet consistent
edentulism refers to missing several teeth. with MyPyramid (www.mypyramid.
Gingivitis: Inflammation of the soft tissue component of the periodontium. gov/professionals/index.html) and the
Periodontal disease: Oral disease characterized by inflammation and destruction of the Dietary Guidelines for Americans 2005
attachment apparatus of the teeth, including the ligamentous attachment of the tooth to (www.healthierus.gov/dietaryguidelines)
the surrounding alveolar bone. provides for adequate intake of all nu-
Root caries (decay): Progressive lesions that are confined to the root surface, or involve trients including protein, vitamins C
the undermining of the cemento-enamel junction, but are clinically indicated to be initiated and D, folate, magnesium, and calcium.
on the root surface. There is no evidence to support the use
Tooth erosion: The gradual loss of the outside, hard surface of the tooth due to chemical, of supplemental intake of any nutri-
not bacterial, processes. It is most commonly associated with frequent consumption of ents beyond the Dietary Reference In-
acidic beverages or frequent vomiting or regurgitation as occurs with bulimia or gastro- takes (DRIs) for the prevention or
esophageal reflux disease. treatment of periodontal disease.
Positive relationships between
Figure 1. Definitions of oral health terms.
periodontal disease and other chronic
disease states, including cardiovascu-
fluence on the progression of tooth de- and increase caries risk. Diet educa- lar disease and obesity, have been
cay, a communicable yet preventable tion and counseling for caries preven- shown (6,24). To date, much of the
oral infectious disease (1). The major tion and control should address im- evidence has been based on epidemi-
components of a preventive dental proved dietary habits for good oral ological and cross-sectional retrospec-
regimen are designed to maintain an health and general health and be rou- tive data. Further research is needed
equilibrium in the dynamic deminer- tine components of comprehensive to explore these relationships with
alization–remineralization of the dental care (15,20). Medically com- risk and extent of periodontal disease
tooth surface (12). Included are diet plex patients with caries should be and the impact of alternations in oral
counseling, fluoride therapy (12,13), referred to an RD. tissues associated with aging.
use of sealants, and control of cario-
genic bacteria (12,14). Nutrition edu-
cation by dental professionals and nu- Periodontal Disease MEDICALLY COMPROMISING CONDITIONS
trition counseling by RDs must Periodontal disease is an oral infec- The oral cavity is the entry portal to
address dietary risk factors associ- tious disease involving inflammation the gastrointestinal tract. Thus, risks
ated with oral disease (15). The pri- and loss of bone and the supporting for oral problems increase with many
mary factors to consider in determin- tissue of the teeth. Although the systemic and chronic disease states,
ing the cariogenic, cariostatic, and pathogenesis of periodontal disease changes in health status, and/or
anticariogenic properties of the diet involves bacteria and the host re- adoption of practices that also may
are food form (liquid, solid or sticky, sponse to these bacteria, there are lo- affect diet and nutritional status (3).
slowly dissolving), frequency of con- cal, systemic, and behavioral factors As part of the comprehensive as-
sumption of sugar and other ferment- that influence the severity and pro- sessment of nutrition status, RDs
able carbohydrates, nutrient composi- gression of the disease (6,21-23). Sys- must include a physical assessment of
tion, potential to stimulate saliva, temic influences on disease include oral functional ability and the impact
sequence of food intake, and combina- types 1 and 2 diabetes mellitus, of any planned therapies on sensory
tions of foods (15,16). See Figure 1 for stress, cardiovascular disease, osteo- and functional capacity of the oral
a glossary of related terms. porosis, immune status of the host, cavity (30). When providing medical
Tooth erosion associated with eat- and presence of pathogens associated nutrition therapy (MNT), RDs should
ing disorders such as anorexia ner- with periodontal disease in the sub- consider oral manifestations of dis-
vosa and bulimia nervosa (17), fre- gingival flora (5,6,24-26). Behavioral eases and impact of medications as
quent consumption of acidic foods and risk factors associated with periodon- well as potential oral problems faced
beverages (18), and gastroesophageal tal disease include poor oral hygiene, by patients who wear oral prostheses
reflux (19) can weaken tooth integrity tobacco use, and diet (23,27). Select such as dentures and experience-re-

August 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1419


lated problems (31). In patients with tion includes individuals with poor cross-sectional in design (6,35,36).
oropharyngeal cancer, diets may re- glycemic control and those for whom Despite the positive relationships be-
quire alterations in diet consistency, dental (oral) procedures affecting tween anthropometric indices of over-
temperature, and composition be- their functional ability to eat are weight and obesity and periodontal
cause of side effects of therapies. Di- planned. disease in older adolescents and
etary management of xerostomia adults, there is no identified causal
must include strategies for reducing relationship to date; potential mecha-
caries risk. Human Immunodeficiency Virus (HIV) nisms, including health habits, in-
Infection flammatory markers, comorbidities,
The American Dietetic Association’s and hormonal factors, as well as other
Diabetes Mellitus position statement on nutrition inter- oral infectious and soft tissue dis-
Diabetes mellitus is a chronic disease vention in the treatment of HIV infec- eases, need to be explored.
with oral and systemic manifesta- tion supports the role of MNT as a
tions. Poorly controlled diabetes component of health care provided to
(characterized by hyperglycemia, ele- individuals with HIV infection (33). Oral and Pharyngeal Cancer
vated hemoglobin A1c level, and in- Because of the magnitude and impact Oropharyngeal cancers are among
creased salivary glucose) is associated of HIV-associated oral and systemic the 10 most common cancers in the
with greater risk of several diseases diseases on diet intake and nutri- United States (37) and worldwide
and conditions. Microangiopathies, tional status, dental intervention in (38); they are more common in men
altered vascular permeability, and al- conjunction with nutrition manage- and African Americans in the United
tered host response mechanisms con- ment is an essential component of States. The survival rate of these can-
tribute to increased risk of periodon- care starting with diagnosis. People cers in the United States is approxi-
tal disease. Individuals with diabetes with HIV infection are at risk for oral mately 50% (34% among African
mellitus also are at greater risk for diseases and their accompanying nu- Americans). Oropharyngeal cancers
compromised wound healing and in- tritional and systemic consequences, are associated with a high risk of sec-
creased risk and severity of local in- such as oral-pharyngeal fungal infec- ond primary tumors (up to 20-fold) in
fectious diseases, including fungal in- tions, which may cause a burning, the oral cavity (39). The most consis-
fections, gingivitis, periodontal and painful mouth and dysphagia. Oral tent findings on the role of diet and
oral mucosal diseases, and caries (6), viral diseases, including herpes sim- nutrition in the incidence of oropha-
as well as xerostomia, burning plex and cytomegalovirus, may lead ryngeal cancers (40-41) are the pro-
tongue/mouth sensations, and other to chronic, painful ulcerations. These tective effects of high consumption of
dysesthesias. Caries risk is further conditions, along with stomatitis, fruits and vegetables. Pavia and col-
exacerbated by xerostomia. Success of may be painful and can impact qual- leagues (40) conducted a meta-analy-
select dental procedures, including ity and quantity of oral intake (34). sis of relevant studies published
surgery and denture placements, are Esophagitis and oral and esophageal through 2005; of the 16 studies that
dependent on glycemic control, which candidiasis result in painful biting, met the criteria for inclusion, a signif-
is to a great degree contingent on diet chewing, and swallowing and nega- icant relationship between fruit (par-
and weight management. Periodontal tively affect appetite and intake. Ka- ticularly citrus fruit) and vegetable
disease can compromise the meta- posi’s sarcoma comprises oral intake consumption and reduced risk of oro-
bolic control of individuals with dia- as well as increases nutrient needs. pharyngeal cancer was shown. Green
betes mellitus (6,32). The metabolic tea polyphenols may have chemopre-
pathways responsible for these pro- ventive effects in prevention of oral
cesses deal with the catabolic nature Overweight and Obesity leukoplakia and oral and gastrointes-
of infections, increasing serum glu- Overweight and obesity in adults as tinal cancers (42). The lack of biomar-
cose values, and other factors (6,32). well as at risk of overweight and over- kers to measure intermediate out-
Improved periodontal health in indi- weight in children are risk factors for comes and a paucity of scientifically
viduals with both type 1 and type 2 several chronic diseases, including sound studies on the role of individual
diabetes mellitus may lead to im- type 2 diabetes mellitus, cardiovascu- micronutrients in foods or supple-
proved metabolic control and reduced lar disease, hypertension, dyslipide- ment form support the need for pro-
risk of further sequelae. mia, and metabolic syndrome. Rela- spective studies to determine biomar-
Xerostomia results in a loss of pro- tionships between weight status and kers and examine the role of select
tective mechanisms of saliva; salivary oral health are a growing area of re- food groups and nutrients in cancer
hyperglycemia provides a potential search. Genco and colleagues (6) pro- prevention and management.
substrate for fungal growth. These posed a model in which obesity is a Cancer therapies may cause oral
contribute to the development of oral predictor of periodontal disease and complications that compromise appe-
candidiasis, an opportunistic fungal insulin resistance as a result of the tite and intake and consequently nu-
infection commonly associated with proinflammatory state caused by obe- tritional status. Radiation treatment
hyperglycemia in individuals with di- sity. Studies have shown significant of the oropharyngeal area may result
abetes mellitus. It is incumbent on positive correlations between abdom- in tooth loss, painful stomatitis, xero-
dental professionals to screen pa- inal obesity and body mass index with stomia, fibrosis of the muscles of mas-
tients with diabetes mellitus for nu- periodontal disease (35,36) in older tication, and loss of sense of taste.
trition risk and refer those at risk to adolescents (36) and adults (35). How- Surgical resections and reconstruc-
an RD for MNT. The at-risk popula- ever, the research to date has been tion, depending on the extent and se-

1420 August 2007 Volume 107 Number 8


verity, can cause temporary and per- on oral function, duration of any im- supported dentures in comparison to
manent alterations in masticatory pairment, and nutritional well-being traditional dentures on masticatory
and swallowing function and signifi- of the individual before surgery. The function and diet quality has been
cantly increases energy and nutrient dental professional should provide studied with mixed results (48-50).
needs for healing (43). Chemotherapy diet guidelines to surgical patients on Although some studies have found
regimens may affect the integrity of a balanced diet and appropriate tex- that patients with implant-supported
the oral cavity and the subsequent ture or consistency modifications for dentures consumed more varied and
ability to eat and drink. RDs’ compre- wound healing. Patients who may not nutritionally adequate diets, others
hensive nutrition assessment must be able to meet all of their needs by have found no significant difference
include physical assessment of oral oral diet alone or who have an acute between the diets of those using im-
sensory and functional abilities, nu- or chronic disease affecting their diet plant-supported dentures vs tradi-
trition-related quality of life, appe- or nutrient needs should be referred tional dentures. The initial diet after
tite, and nutrient needs (30,43). En- to an RD for MNT. Nutrient deficien- placement of traditional or implant-
teral tube feedings may be necessary cies may compromise the integrity of supported dentures should be a nutri-
to manage and prevent malnutrition the immune response, resistance to tionally adequate diet with gradual
and dehydration following recon- infection, and wound healing (47); advancement in food texture and con-
structive surgery or during and after however, there is a paucity of scien- sistency from finely cut, easily masti-
radiation therapy. tifically sound research that supports cated foods that do not disperse easily
nutrient supplementation beyond the in the mouth (such as rice) to a varied
DRIs in well-nourished individuals. diet of whole foods.
Osteoporosis Micronutrients and antioxidants in-
According to the Surgeon General’s cluding vitamins E and C and zinc
report on “Bone Health and Osteopo- HIGH-RISK GROUPS THROUGHOUT THE
play an important role in wound heal- LIFE SPAN
rosis” (44), by the year 2020, one in ing; supplemental use of these nutri-
two American adults over the age of Infants and Children
ents has not been shown to enhance
50 will have or will be at high risk of response to surgery or promote Adequate nutrients are needed pre-
developing osteoporosis. Bone resorp- wound healing. Nutrient needs after natally, perinatally, and postnatally
tion and loss are common denomina- surgery are an active research area in for normal growth and development
tors for periodontal disease and osteo- systemic health; such research also is of the oral cavity (2,20,51). Craniofa-
porosis. Cross-sectional (45) and needed in relation to oral surgery. cial malformations in infants and
longitudinal studies (25) have shown children such as cleft lip with or with-
significant relationships between Implants. Dental implants are an al-
out cleft palate have been associated
tooth loss, periodontal disease, low ternative to dental bridges, crowns, with cigarette smoking and folate de-
calcium intake, and osteoporosis in and dentures. A dental implant is a ficiency in pregnant women. Women
older men and women. Dietrich (45) titanium metal post surgically placed of childbearing age should consume
found that higher serum 25(OH)D3 in the alveolar bone that is then al- adequate folate to meet the DRI or
levels are associated with a lower rate lowed to osseointegrate into the bone take a folic acid supplement to de-
of periodontal attachment loss in (fuse). Once osseointegration is com- crease the incidence of cleft lip/palate
adults over the age of 50 years. Sev- plete, a plastic or porcelain crown or in infants (52). One episode of mild to
eral theories linking periodontal dis- bridge is placed over the metal posts. moderate malnutrition in the first
ease and osteoporosis beyond the Diet and nutrition relative to dental year of life is associated with both
common denominator of bone loss and implants merits consideration in sev- increased incidence of caries in pri-
resorption have been postulated eral areas, including surgical wound mary and permanent teeth later in
(26,27). Although studies have shown healing, integrity of the alveolar life and salivary gland atrophy and
positive correlations between bone bone, nutritional status of the pa- reduced saliva, important in reducing
mineral density of the mandible with tient, and the patient’s ability to eat dental plaque acid activity (51). Max-
that of the lumbar spine and femoral after the surgery (short term and long illary anterior caries manifested in
neck (27,46), a causal relationship term). There is no published research early childhood caries caused by feed-
has not been found. Further research supporting the need for nutrients be- ing practices is the major nutrition-
is needed to determine the nature of yond the DRI for individuals under- related oral disease found in young
the relationship between bone min- going implant surgery. Diet modifica- children and the socially disadvan-
eral density and bone loss with the tion in the immediate days after taged (minority, poor, rural, immi-
onset of periodontal disease and the surgery depends on the number and grant) (51,53). A combination of in-
roles of calcium and vitamin D in location of implants placed. Anterior fant/child feeding practices and
periodontal disease risk reduction implants may impact the ability to repeated sequential consumption of
and management. bite food, whereas posterior ones may fermentable carbohydrates, such as
hamper chewing ability. Oral opening sweetened beverages or highly pro-
may be limited because of the location cessed starchy/sugary foods increases
Surgical Conditions and extent of sutures placed. Diet caries risk. The American Academy of
Oral Surgery. Diet and nutrient needs guidelines should address food tex- Pediatrics and the American Acad-
for oral surgery are to a large extent ture and consistency in the context of emy of Pediatric Dentistry support
dependent on the extent of the surgi- a balanced diet adequate in fluids. breastfeeding during the first year,
cal procedure, extent of impairment The long-term impact of implant- recommend limited access to sweet-

August 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1421


ened low-nutrient-quality beverages, have one or more chronic diseases agulants in patients taking both.
and recommend a dental evaluation and/or other conditions that can affect Similarly, metabolic stimulants such
after the first 6 months of life (54). their dental treatment. Impaired den- as guarana may enhance actions of
Increased intake of sugar-sweet- tition defined by the number of pairs epinephrine. It may be prudent in
ened beverages among children has of occluding teeth and evidence of dentistry to follow the recommenda-
been identified as a risk factor for complete dentures has been associ- tions used by physicians regarding di-
dental disease (55). For school-age ated with compromised nutritional etary supplement use and surgery; it
children, meal and snack behaviors status (62,63). Because today’s older is recommended that patients discon-
should involve healthful food and bev- adults tend to retain more of their tinue all dietary supplements 2 to 3
erage choices that promote oral natural teeth, new patterns of oral weeks before any scheduled surgery
health (55). Other conditions that diseases, including root and coronal (66). RDs and dental professionals
may affect oral health include devel- decay, are becoming more common. should ask patients about the use of
opmental anomalies that alter eating Oral manifestations of chronic dis- all dietary supplements, be familiar
ability and require specialized feed- eases, xerostomia, side effects of with resources on these products, and
ing strategies (12,56) and craniofacial polypharmacy on the oral cavity, os- guide patients appropriately about
surgery, which causes increased en- teoporosis, menopause, and eating potential side effects and risks caused
ergy, protein, and nutrient needs for problems associated with denture by disease, medication, or oral mani-
wound healing and may require mul- placement are examples of the scope festations as a result of their use.
tiple feeding modes, including oral of oral nutrition problems faced by Catechins in tea have antistrepto-
supplements and tube feedings. older adults (5,62-65). The negative coccal activity against cariogenic bac-
effect of tooth loss, edentulism, and teria such as Streptococcus mutans
removable prostheses on eating hab- and Streptococcus sobrinus; although
Adolescents and Young Adults its, masticatory function, sense of the evidence on the degree of activity
Eating patterns associated with life- taste, and gastrointestinal disorders is varied, it does support that these
styles of adolescents can contribute to has been documented (64). Moynihan catechins may have inhibitory and
caries risk. Frequent consumption of and colleagues (65) found that com- bactericidal action (42). Translational
caffeinated, carbonated beverages plete denture wearers have about and outcomes research trials in hu-
has been shown to be associated with 20% the chewing ability of their den- mans are needed before making any
increased caries risk (57). Consump- tate counterparts. Salivary flow and practical recommendations regarding
tion of sports drinks to complement composition do not change in healthy, the role of tea as a chemopreventive
physical activities should be ad- unmedicated older adults; however, agent.
dressed (58-60). Although total con- disease processes and polypharmacy
sumption alone has not been defini- can result in diminution in saliva that
tively associated with dental erosion can alter mastication and swallowing Nutrition in Dental Education
(58), frequent consumption of such (65). Despite clear evidence of the re- The Institute of Medicine and the
acidic beverages can increase risk of lationship between diet and nutri- Pew Health Professions Commission
tooth erosion (59,60). Snacking pat- tional status and oral problems faced (67) support comprehensive training
terns to meet increased energy needs by older adults, diet intervention is of dental professionals to ensure that
of teens and young adults should ad- not a routine part of dental care of the they can manage ”the whole patient”
dress oral health promotion. elderly. Dietary quality can be (68) as well as the need for preventive
Eating disorders are the “third achieved when diet education is a health measures, including improved
most common chronic illness in ado- routine component of dental practice feeding practices (68). Competencies
lescent females” (61); the relationship (65). (69) for predoctoral dental education
between eating disorders, in particu- by the American Dental Association’s
lar bulimia, and integrity of the oral Commission on Dental Accreditation
cavity is based on local factors. The EVOLVING ISSUES IN NUTRITION AND (70) are broad-based competency
increased insult of acidic gastrointes- ORAL HEALTH statements that do not address spe-
tinal contents from “purging” can lead Dietary Supplements cific sciences such as nutrition. How-
to tooth erosion of the lingual and oc- Dietary supplements of concern rela- ever, they do state that schools must
clusal surfaces on maxillary teeth. In tive to oral health include those with “ensure an in-depth understanding of
addition to erosion, enlarged parotid local effects that are antimicrobial or basic biological principles, consisting
glands may be evident. For further anti-inflammatory in nature and of a core of information on fundamen-
information on eating disorders, spe- those with systemic impacts that af- tal structures, functions and interre-
cifically anorexia nervosa and bu- fect immune status, serve as meta- lationships of the body systems” (69).
limia, the reader is referred to the bolic stimulators, have an anticoagu- In-depth information must be pro-
2006 American Dietetic Association lant effect, or affect cognition. Herbs vided to develop understanding of
position on eating disorders (61). that are metabolized using the P450 oral and oral-related disorder epide-
enzyme pathway can show pharmaco- miology, etiology, diagnosis, preven-
dynamic or pharmacokinetic interac- tion, and treatment with no specific-
Older Adults tions with drugs. Supplements with ity to the clinical sciences such as
Older adults are the fastest growing anticoagulant properties (eg, gingko nutrition that provide the knowledge
population segment in the United biloba, garlic, vitamin E, n-3 fatty ac- base for related skills and values. Fig-
States. Elderly patients frequently ids) can enhance the action of antico- ure 2 outlines didactic topics and clin-

1422 August 2007 Volume 107 Number 8


Dietetics education Dental education

1. Baccalaureate program 1. Predoctoral program

a. Didactic topics a. Didactic topics
● Oral anatomy and physiology ● Nutritional biochemistry
● Oral manifestations of acute, chronic, terminal, and ● Nutrition and oral health throughout the lifespan
systemic diseases ● Diet education and intervention relative to oral health/
● Oral sequellae of medications, chemo and radiation disease
therapies ● Effect(s) of oral disease(s), symptomatology and their
● Primary diseases of the oral cavity and their effects on treatment(s) on diet and nutrition status
taste, smell, and mastication ● Relationship between diet/nutrition and oral health in
b. Clinical experiences acute and chronic diseases and disorders
● Field visits to dental schools/clinics ● Diet/nutrition screening, education and referral in dental
● Work with dental students/professionals in practice
clinical/community settings ● Diet/nutrition risk factors and management strategies of
● Oral health screening questions as a component of high risk patients
nutrition assessment activities b. Clinical and research experiences
● Self evaluation of diet
● Education and training in patient diet evaluation and
● Nutrition risk screening and diet education relative to oral
health of patients
● Consultation and supervised practice with registered
dietitians and or dietetic technicians, registered in diet
evaluation and education
● Participate in oral health and nutrition/diet research
2. Dietetic internship/coordinated program competencies
● Conduct nutrition screening and diet counseling in dental
school and community dental clinic rotations
● Integrate oral health screening questions into nutrition care
process tasks (screening, assessment, intervention,
● Integrate appropriate oral health guidelines into the conduct
of diet counseling and education
● Participate in oral health and nutrition research
● Perform basic physical assessment including oral and cranial
nerve screening exams
● Design nutrition care plans for patients with compromised
oral health
3. Graduate education 3. Graduate programs
● Design, conduct, and participate in oral health and nutrition ● Design, conduct, and participate in oral health and nutrition
research research
● Perform oral physical assessment exams including intra/ ● Integration of nutrition screening and diet education into
extra oral screening and cranial nerve examinations dental and oral disease specialty practice
● As appropriate, partner with dental students/professionals in ● Collaborative education endeavors on related topics with
clinical experiences dietetics programs
4. Continuing professional education 4. Continuing professional education
● Collaboration between food and nutrition and dental ● Collaboration between dietetics and dental professionals in
professionals in case presentations, multidisciplinary care case presentations, multidisciplinary care meetings,
meetings, conferences about diseases and the lifespan, conferences about diseases and the lifespan,
multidisciplinary seminars, and publications multidisciplinary seminars, and publications
● Training opportunities using different media (eg, distance ● Training opportunities using different media (eg, distance
learning, CD-ROMs, videotapes/DVDs) learning, CD-ROMs, videotapes/DVDs)

Figure 2. Didactic and practice components of a curriculum model for dietetics and dental education programs to promote collaboration and
multiskilling in nutrition and oral health.

August 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1423


ical and research experiences based tetics Education standards (76). The health professionals (79). Oral health
on these competencies and recom- standards do require that entry-level and nutrition educators should assume
mendations from professional associ- dietetics education programs with a leadership roles in promoting this dual
ations and initiatives and prior re- nutrition therapy emphasis address content area in their respective curric-
search (67,68,71). Knowledge of the competency in the performance of basic ula. The 1995 Institute of Medicine re-
principles and clinical application of physical assessment (76). However, be- port “Dental Education at the Cross-
diet and nutrition for health promo- cause oral health is essential for nor- roads” recommends: “To prepare future
tion, disease prevention, and as part mal mastication and digestion, oral practitioners for more medically based
of comprehensive care provides the health concepts should be incorporated modes of oral health care and more
underpinning for several of the dental into didactic coursework and clinical medically complicated patients, dental
education competencies. A core cur- training in baccalaureate, preprofes- educators should work with their col-
riculum that integrates didactic sional, and graduate levels of dietetics leagues in medical schools and aca-
coursework with clinical training in education at differing degrees (Figure demic health centers” (68). Knowledge
nutrition (Figure 2) over the 4 years 2). Given the functional and sensory of the synergy between oral health and
of predoctoral work is needed. Al- roles of the structures of the head, diet and nutrition should be promoted
though the fundamentals of macronu- neck, and oral cavity in diet and nutri- in health education programs and prac-
trients and micronutrients in human tion, basic physical assessment educa- tice (1,2,38,71). Dental professionals
metabolism and oral health are tion and training should include a and RDs are key professionals who can
taught in biochemistry and pathology screening examination of the head, advance initiatives that promote the
courses, integration into the other ba- neck, and oral cavity (77,78). The out- roles of oral health and nutrition in re-
sic and clinical science courses can comes of the examination for entry- lation to systemic health.
provide an orientation and transla- level training should include identifica-
tion of nutrition and diet into clinical tion of nutrition and diet-related risk Nutrition and Oral Health Research
dental practice. factors (nonnormal conditions of the
It is essential that a body of knowl-
Accreditation standards for the ad- hard and soft tissue affecting the abil-
edge that supports practice in dietet-
vanced specialty postdoctoral educa- ity to eat or drink) to incorporate into
ics and dentistry be delineated to
tion programs vary in the specificity MNT or referral to a dentist for further
ensure health promotion and compre-
with which they address nutrition (72- intervention. Competencies for the con-
hensive health care. The determination
74). Periodontics and pediatric den- duct of oral screening examinations
of biomarkers and behavioral and out-
tistry postdoctoral programs specify (head/neck, intraoral/extraoral assess-
comes markers are needed along with
nutrition knowledge in relation to pa- ment, and cranial nerves) are needed
translational and outcomes research to
tient evaluation, disease processes, for students in the preprofessional set-
explore and demonstrate relationships
wound healing, and caries prevention ting in conjunction with the standard-
between nutrition, diet, and oral health
and intervention, respectively (72,73). ized language diagnostic codes and re-
and disease in prevention and inter-
Although other program competencies lated oral-defining characteristics (30).
vention (56,80,81). Nutrigenomics and
do not specify nutrition, it is implied Dietetic interns and coordinated pro-
metabolomics are growing areas of re-
within stated competencies addressing gram students should be given oppor-
search (80) and will undoubtedly lead
comprehensive management of medi- tunities to work with dental students/
to applications relative to oral health
cally compromised and surgical pa- residents in the clinical setting to
and nutrition.
tients (74). provide nutrition and diet intervention
The bidirectional relationships be-
The Commission on Dental Educa- as a component of oral health manage-
tween oral health/disease and nutri-
tion’s Accreditation Standards for ment. Graduate and continuing educa-
tion/diet need to be explored in trans-
Dental Hygiene Education Programs tion programs should include research
lational research and outcomes studies.
(75) specify that the curriculum in- and applications as they relate to med-
Concepts such as optimal diet manage-
clude nutrition risk assessment and ical and nutrition management of pa-
ment of dental implants and other re-
counseling. Patient care competen- tients with oral diseases or oral mani-
constructive surgeries and determina-
cies specific to nutrition (Standard festations of systemic diseases.
tion of outcomes markers to qualify and
2-19) state that graduates must be
quantify both sides of the bidirectional
able to conduct nutrition risk assess-
Collaborative Approach to Nutrition and relationship between diet and nutrition
ments and counseling. Dental hygien-
Oral Health Education and oral health merit further research,
ists as well as other allied dental and
which will undoubtedly advance both
dietetics personnel are cogent mem- The changing social and economic real- professions.
bers of the oral health care team in ities of today’s health care system have
health maintenance and disease had a dramatic effect on the prepara-
management. tion and training of health providers, Partnerships in Practice
including RDs, dentists, and allied den- Collaborative efforts within the oral
tal personnel (7,67,68). A joint World health and nutrition disciplines will
Oral Health in Dietetics Education Health Organization/Food and Agricul- foster successful strategies related to
Oral health education is not outlined as tural Organization expert consultant’s oral health and nutrition. The inte-
a specific competency or criterion re- recommendation encouraged interna- gration of oral and nutrition health
quirement for entry-level practice in tional organizations (79) to recognize care management, including assess-
the American Dietetic Association’s nutrition as an essential part of train- ment and counseling as part of the
Commission on Accreditation for Die- ing for dental, dietetic, and other treatment provided by both food

1424 August 2007 Volume 107 Number 8


Food and nutrition professional Dental professional

Clinical setting Clinical setting

● Include oral health screening as a component of nutrition care ● Include diet screening, education, and referral for oral
process tasks—nutrition screening, nutrition assessment (eg, infectious disease prevention/control, optimal masticatory
cranial nerve function, occlusion, soft tissue, edentulism, function and management of other oral diseases/treatments as
masticatory ability, swallowing, salivary adequacy, intervention, a component of comprehensive dental care
and monitoring) ● Collaborate with food and nutrition professionals in delivery of
● Recognize oral manifestations of systemic diseases and provide oral health care in long-term care settings
patients with guidelines to maximize oral intake ● Provide diet and nutrition guidelines for health promotion and
● Confer with and refer patients (via consults) to dental disease prevention to patients and provide guidelines for diet to
practitioners for management of oral diseases and or risk maximize oral intake
factors for oral diseases ● Consult with and refer patients (via consult) to food and
● Consult with dental professionals in interpretation of oral- nutrition professionals for management of nutrition risk factors
nutrition assessment findings and planning in the long-term and diet due to compromised oral health (eg, caries,
care setting immunosuppressive disorders, xerostomia, diabetes, oral
surgery, cancer)
Community setting Community setting
● Establish partnerships with dental professionals in community ● Establish partnerships with food and nutrition professionals in
and private practice settings community and private practice settings to promote nutrition/
● Develop and implement collaborative oral health and nutrition diet screening and education in dental practice
screening/education programs in schools, worksites, community ● Develop and implement collaborative oral health and nutrition
events, and health maintenance organizations screening/education initiatives in schools, worksites, and health
● Promote collaborative education and practice regarding nutrition care organizations
and oral health among food and nutrition and dental ● Promote collaborative education on nutrition and oral health
professionals among food and nutrition and dental professionals
● Develop nutrition education messages that encourage oral ● Develop oral health messages that integrate nutrition and diet
health education
● Promote oral health in school and community nutrition ● Promote diet and nutrition as a component of school and
programs community oral health programs
Research setting Research setting
● Promote collaborative nutrition and oral health research ● Promote collaborative oral health and nutrition research
initiatives initiatives
● Design, conduct, and participate in nutrition/diet components of ● Design, conduct, and participate in oral health component of
oral health research initiatives nutrition/diet research initiatives
● Identify and support integration of oral health issues (eg, ● Identify and support integration of nutrition topics as a
screening, disease, management, education) as a component of component of oral health research as appropriate
nutrition research

Figure 3. Food and nutrition and dental professionals role modeling to achieve effective integration of oral health and nutrition service in health
promotion and in disease prevention and intervention.

and nutrition and dental profession- management as components of oral lated services. Alleviating physical,
als, is an excellent example of collab- health maintenance education as cultural, racial, ethnic, social, edu-
orative, comprehensive, and cost-effec- well as adequate dietary calcium for cational, health care delivery, and
tive care. Figure 3 presents strategies oral and systemic health. In pa- environmental barriers that prevent
for RDs and dental professionals to tients with orally compromising people from achieving healthful oral
use in addressing oral health and conditions impacting eating ability functioning, and research exploring
nutrition issues in practice. RDs can or nutrition status, the dental pro- new ways of improving oral health,
use these strategies in counseling fessional should determine diet/nu- are included in this report as well as
when caries risk is high, as a com- trition risk, educate patients on diet in the US Surgeon General’s “Na-
ponent of MNT for diabetes melli- relative to oral health, and, when tional Call to Action to Promote Oral
tus, or as a component of healthful in-depth nutrition evaluation and Health” (80). Health promotion and
lifestyle counseling (30,77,78). diet counseling is needed, refer pa- disease prevention initiatives by na-
When counseling women regarding tients to an RD for MNT. tional dental organizations, federal
osteoporosis management or risk re- The US Department of Health and and state agencies, and private
duction, RDs should emphasize the Human Services’ Healthy People 2010 foundations to meet these objectives
importance of bone health for oral Objectives for the Nation (81) specifi- will contribute to improved nutri-
health. Likewise, the dental profes- cally addresses the prevention and tional status (2,4,44,81). Opportuni-
sional can address the dietary control of oral and craniofacial diseases/ ties to carry nutrition into the oral
guidelines and healthful weight conditions/injuries and access to re- health arena are open to RDs.

August 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1425


SUMMARY AND FUTURE DIRECTIONS 4. US Department of Health and Human Ser- 20. DePaola DP, Mobley C, Touger-Decker R. Nu-
vices. National Call to Action to Promote Oral trition and oral medicine. In: Berdanier CD,
Credentialed RDs and dental profes- Health. Rockville, MD: US Department of ed. Handbook of Nutrition and Food. Boca
sionals should pursue opportunities Health and Human Services, Public Health Raton, FL: CRC Press; 2002:1113-1134.
to create a conceptual framework that Service, National Institutes of Health, Na- 21. Nishida M, Grossi SG, Dunford RG, Ho AW,
integrates optimal oral and nutrition tional Institute of Dental and Craniofacial Trevisan M, Genco RJ. Dietary vitamin C
Research. NIH Publication No. 03-5303. and the risk for periodontal disease. J Peri-
health care to improved oral, nutri- Spring 2003. Available at: http:// odontol. 2000;71:1215-1223.
tional, and systemic health status www.surgeongeneral.gov/topics/oralhealth/ 22. American Academy of Periodontology. Acad-
(Figures 2 and 3). To prepare profes- nationalcalltoaction.htm. Accessed September emy report position paper: Epidemiology of
sionals with the skills and knowledge 4, 2006. periodontal disease. J Periodontol. 2005;76:
5. Ritche C, Joshipura K, Hung HC, Douglas C. 1406-1419.
that exemplify this paradigm in prac- Nutrition as a mediator in the relation be- 23. Al-Zahrani MS, Borawski EA, Bissada NF.
tice, dietetics and dental educators tween oral and systemic disease: Association Periodontitis and three health-enhancing
must assume responsibility for inte- between specific measures of adult oral behaviors: Maintaining normal weight, en-
grating oral health, diet, and nutri- health and nutrition outcomes. Crit Rev gaging in recommended level of exercise,
Oral Biol Med. 2002;13:291-300. and consuming a high-quality diet. J Peri-
tion topics and clinical/community ex- 6. Genco R, Grossi S, Ho A, Nishimura F, Mu- odontol. 2005;76:1362-1366.
periences in education, respectively. rayama Y. A proposed model linking inflam- 24. Schillinger T, Kluger W, Exner M, Mlekusch
Figure 2 provides a foundation for mation to obesity, diabetes, and periodontal W, Sabeti S, Amighi J, Wagner O, Minar E,
these initiatives. Changes in the epi- infections. J Periodontol. 2005;76:2075- Schillinger M. Dental and periodontal status
demiology of oral disease and oral 2084. and risk for progression of carotid athero-
7. Institute of Medicine. Health professions sclerosis: The inflammation and carotid ar-
manifestations of systemic diseases, education: A bridge to quality. National tery risk for atherosclerosis study dental
new findings in nutrition/diet and Academy of Sciences, 2003. Available at: substudy. Stroke. 2006;37:2271-2276.
oral health research, along with pop- http://www.nap.edu/books/0309087236/ 25. Yoshihara A, Seida Y, Hanada N, Miyazaki
ulation shifts, advances in pharmaco- html/. Accessed May 28, 2007. H. A longitudinal study of the relationship
8. Harris R, Nicoll AD, Adair PM, Pine CM. between periodontal disease and bone min-
logical and surgical management of Risk factors for dental caries in young chil- eral density in community-dwelling older
diseases and disorders, and new tech- dren: A systematic review of the literature. adults. J Clin Periodontol. 2004;31:680-684.
nology, have major implications for Community Dent Health. 2004;21(suppl 1): 26. Dervis E. Oral implications of osteoporosis.
the future of dentistry and dietetics. 71-85. Oral Surg Oral Med Oral Pathol Oral Ra-
9. Beltrán-Aguilar BD, Barker LK, Canto MT, diol Endod. 2005;100:349-356.
Collaboration between dietetics Dye BA, Gooch BF, Griffin SO, Hyman J, 27. Pihlstrom B, Michalowicz B, Johnson N.
and dentistry in research, education, Jaramillo F, Kingman A, Nowjack-Raymer Periodontal diseases. Lancet. 2005;366:
and practice is needed to ensure com- R, Selwitz RH, Wu T; Centers for Disease 1809-1820.
prehensive health care to persons Control and Prevention. Surveillance for 28. Enwonwu CO, Phillips RS, Falkler WA. Nu-
dental caries, dental sealants, tooth reten- trition and oral infectious diseases: State of
with oral infectious disease and/or tion, edentulism, and enamel fluorosis— the science. Compend Contin Educ Dent.
oral manifestations of systemic dis- United States, 1988-1994 and 1999-2002. 2002;23:431-434, 436, 438.
eases. The burden of responsibility for MMWR Surveill Summ. 2005;54:1-43. 29. Dodds WJ, Johnson DA, Yeh C. Health ben-
health professionals to provide com- 10. Steele JG, Sheiham A, Marcenes W, Fay N, efits of saliva: A review. J Dent. 2005;33:223-
Walls AW. Clinical and behavioral risk indi- 233.
prehensive health care is rapidly in- cators for root caries in older people. Gerod- 30. American Dietetic Association. Nutrition Di-
creasing (4,7,67,68,81). As we ad- ontology. 2001;18:95-101. agnosis: A Critical Step in the Nutrition
vance in our discoveries of the links 11. American Dietetic Association. Position of Care Process. Chicago, IL: American Dietetic
between oral and nutrition health, the American Dietetic Association: Provid- Association; 2006.
professionals of both disciplines must ing nutrition services for infants, children, 31. Mobley CC. Nutrition issues for denture pa-
and adults with development disabilities tients. Quintessence Int. 2005;36:627-631.
learn to provide screening, baseline and special health care needs. J Am Diet 32. Kawamura M, Tsurumoto A, Fukuda S,
education, and referrals to each other Assoc. 2004;104:97-107. Sasahara H. Health behaviors and their re-
as part of comprehensive client/pa- 12. Featherstone JDB. The science and practice lation to metabolic control and periodontal
tient care (Figure 3). Continued col- of caries prevention. J Am Dent Assoc. 2000; status in type 2 diabetic patients: A model
131:887-899. tested using a linear structural relation pro-
laborative research will provide the 13. American Dietetic Association. Position of gram. J Periodontol. 2001;72:1246-1253.
critical findings needed to continue to the American Dietetic Association: The im- 33. American Dietetic Association, Dietitians of
advance oral health and nutrition in pact of fluoride on dental health. J Am Diet Canada. Position of the American Dietetic
practice and education. Assoc. 2005;105:1620-1628. Association and Dietitians of Canada: Nutri-
14. Leme AF, Koo H, Bellato CM, Bedi G, Cury tion intervention in the care of persons with
JA. The role of sucrose in cariogenic dental human immunodeficiency virus infection.
biofilm formation-new insight. J Dent Res. J Am Diet Assoc. 2004;104:1425-1441.
References 2006;85:878-887. 34. Patel AS, Glick MI. Human immunodefi-
1. US Department of Health and Human Ser- 15. Sanders TAB. Diet and general health: Di- ciency virus. In: Touger-Decker R, Sirois
vices. Oral Health in America: A Report of etary counseling. Caries Res. 2004;38(suppl DA, Mobley C, eds. Nutrition and Oral
the Surgeon General. Rockville, MD: US De- 1):3-8. Medicine. Totowa, NJ: Humana Press; 2005:
partment of Health and Human Services, 16. Mobley CC. Nutrition and dental caries. 223-240.
National Institute of Dental and Craniofa- Dent Clin North Am. 2003;47:319-336. 35. Wood N, Johnson RB, Streckfus CF. Com-
cial Research, National Institutes of Health; 17. Frydrych AM, Davies GR, McDermott BM. parison of body composition and periodontal
2000:1-13. Eating disorders and oral health: A review of disease using nutritional assessment tech-
2. US Department of Health and Human Ser- the literature. Aust Dent J. 2005;50:6-15. niques: Third National Health and Nutri-
vices. Surgeon General’s conference on 18. Lussi AM, Jaeggi T, Zero D. The role of diet tion Examination Survey (NHANES III).
children and oral health. June 12-13, 2000. in the aetiology of dental erosion. Caries Res. J Clin Periodontol. 2003;30:321-327.
Available at: http://www.nidcr.nih.gov/ 2004;38:34-44. 36. Reeves A, Rees JM, Schiff M, Hujoel P. Total
AboutNIDCR/SurgeonGeneral/Children.htm. 19. Ersin NK, Oncag O, Tumgor G, Aydogdu, body weight and waist circumference associ-
Accessed April 19, 2007. Hilmioglu S. Oral and dental manifestations ated with chronic periodontitis among ado-
3. Slavkin H, Baum B. Relationship of dental of gastroesophageal reflux disease in chil- lescents in the U.S. Arch Pediatr Adolesc
and oral pathology to systemic illness. dren: A preliminary study. Pediatr Dent. Med. 2006;160:894-899.
JAMA. 2000;284:1215-1217. 2006;28:279-284. 37. US Cancer Statistics Working Group. United

1426 August 2007 Volume 107 Number 8


States Cancer Statistics: 1999–2002 Incidence during early embryogenesis. Toxicol Appl able at: http://www.ada.org/prof/ed/accred/
and Mortality Web-based Report. Atlanta, GA: Pharmacol. 2004;198:75-85. commission/index.asp. Accessed July 6, 2007.
US Department of Health and Human Services, 53. Vargas CM, Ronzio CR. Disparities in early 71. Touger-Decker R. Dannon Institute Award
Centers for Disease Control and Prevention, childhood caries. BMC Oral Health. 2006; Lecture: Nutrition in dental and medical ed-
National Cancer Institute; 2005. Available at: 6(suppl 1):S3. ucation: Innovation through curriculum in-
http://www.cdc.gov/cancer/npcr/uscs/pdf/ 54. Nainar SMH, Mohummad S. Role of infant tegration. Am J Clin Nutr. 2004:79:198-203.
2002_USCS.pdf. Accessed May 28, 2007. feeding practices on the dental health of 72. Commission on Dental Accreditation, Amer-
38. World Health Organization. The World children. Clin Pediatr. 2004;43:129-133. ican Dental Association. Accreditation Stan-
Health Report 2003—Shaping the future. 55. Marshall TA. Diet and nutrition in pediatric dards for Advanced Specialty Education
Available at: http://www.who.int/whr/2003/ dentistry. Dent Clin North Am. 2003;4:279- Programs in Periodontics. Chicago, IL: Com-
en/index.html. Accessed April 19, 2007. 303. mission on Dental Accreditation, American
39. National Institute of Dental and Craniofa- 56. Glenny AM, Hooper L, Shaw WC, Reilly S, Dental Association. Available at: http://
cial Research. The Oral Systemic Health Kasem S, Reid J. Feeding interventions for www.ada.org/prof/ed/accred/standards/perio.
Connection. Spectrum Series. Washington, growth and development in infants with pdf. Updated July 28, 2006. Accessed Febru-
DC: National Institute of Dental and cleft lip, cleft palate or cleft lip and palate. ary 2, 2007.
Craniofacial Research; May 1999. Cochrane Database Syst Rev. 2004;3: 73. Commission on Dental Accreditation, Amer-
40. Pavia M, Pileggi C, Nobile CGA, Angelillo CD003315. ican Dental Association. Accreditation Stan-
IF. Association between fruit and vegetable 57. Majewski RF. Dental caries in adolescents
dards for Advanced Specialty Education
consumption and oral cancer: A meta-anal- associated with caffeinated carbonated bev-
Programs in Pediatric Dentistry. Chicago,
ysis of observational studies. Am J Clin erages. Pediatr Dent. 2001;23:198-203.
IL: Commission on Dental Accreditation,
Nutr. 2006;83:1126-1134. 58. Coombes JS. Sports drinks and dental ero-
American Dental Association. Available at:
41. Tavani A, Gallus S, La Vecchia C, Talamini sion. Am J Dent. 2005;18:101-104.
R, Barbone F, Herrero R, Franceschi S. Diet 59. von Faunhofer JA, Rogers MM. Effects of http://www.ada.org/prof/ed/accred/standards/
and risk of oral and pharyngeal cancer: An sports drinks and other beverages on dental ped.pdf. Updated July 28, 2006. Accessed Feb-
Italian case-control study. Eur J Cancer enamel. Gen Dent. 2005;53:28-31. ruary 2, 2007.
Prev. 2001;10:191-195. 60. Sohn W, Burt BA, Sowers MR. Carbonated 74. Commission on Dental Accreditation, Amer-
42. Lee MJ, Lambert JD, Prabhu S, Meng X, Lu soft drinks and dental caries in the primary ican Dental Association. Accreditation Stan-
H, Maliakal P, Ho CT, Yang CS. Delivery of dentition. J Dent Res. 2006;85:262-266. dards for Advanced Education Programs in
tea polyphenols to the oral cavity by green 61. American Dietetic Association. Position of General Practice Residency. Chicago, IL:
tea leaves and black tea extract. Cancer Epi- the American Dietetic Association: Nutri- Commission on Dental Accreditation, Amer-
demiol Biomarkers Prev. 2004;13:132-137. tion intervention in the treatment of an- ican Dental Association. Available at: http://
43. Ravasco P, Monteiro-Grilo I, Vidal PM, orexia nervosa, bulimia nervosa, and other www.ada.org/prof/ed/accred/standards/gpr.
Camilo ME. Impact of nutrition on out- eating disorders. J Am Diet Assoc. 2006;106: pdf. Updated July 28, 2006. Accessed Febru-
come: A prospective randomized controlled 2073-2082. ary 2, 2007.
trial in patients with head and neck cancer 62. Sahyoun NR, Lin C, Krall E. Nutritional 75. Commission on Dental Accreditation, Amer-
undergoing radiotherapy. Head Neck. status of the older adult is associated with ican Dental Association. Accreditation Stan-
2005;27:659-668. dentition status. J Am Diet Assoc. 2003;103: dards for Dental Hygiene Education Pro-
44. Public Health Service, US Department of 61-66. grams. Chicago, IL: Commission on Dental
Health and Human Services. Bone Health 63. Marshall TA, Warren JJ, Hand JS, Xie X, Accreditation, American Dental Association.
and Osteoporosis: A Report of the Surgeon Stumbo P. Oral health, nutrient intake and Available at: http://www.ada.org/prof/ed/
General. Rockville, MD: Office of the Sur- dietary quality in the very old. J Am Dent accred/standards/dh.pdf. Updated July 28,
geon General; 2004. Assoc. 2002;133:1369-1379. 2006. Accessed February 2, 2007.
45. Dietrich T. Association between serum con- 64. Bailey RL, Ledikwe JH, Smiciklas-Wright 76. Commission on Accreditation for Dietetics
centrations of 25-hydroxyvitamin D3 and H, Mitchell DC, Gordon L, Jensen GL. Per- Education. 2002 Eligibility Requirements
periodontal disease in the US population. sistent oral health problems associated with and Accreditation Standards. Chicago, IL:
Am J Clin Nutr. 2004;80:108-113. comorbidity and impaired diet quality in Commission on Accreditation for Dietetics
46. Taguchi A, Suei Y, Sanada M, Ohtsuka M, older adults. J Am Diet Assoc. 2004;104: Education, American Dietetic Association;
Nakamoto T, Sumida H, Ohama K, Tani- 1273-1276. 2006:10-16. Available at: http://www.
moto K. Validation of dental panoramic 65. Moynihan P, Bradbury J. Compromised den- eatright.org/ada/files/2002_ERAS-Web-
radiography measures for identifying post- tal function and nutrition. Nutrition. 2001; updated_8-06.pdf. Updated August 2006.
menopausal women with spinal osteoporo- 17:177-178. Accessed September 26, 2006.
sis. Am J Roentgenol 2004;183:1755-1760. 66. Debusk R, Rigassio Radler D. Complemen- 77. Mackle T, Touger-Decker R, O’Sullivan
47. Winkler M, Makowski S. Wound healing. In: tary and alternative medicine practices and Maillet J, Holland B. Registered dietitians’
Touger-Decker R, Sirois D, Mobley C, eds. their impact on oral and nutritional health. use of physical assessment parameters in
Nutrition and Oral Medicine. Totowa, NJ: In: Touger-Decker R, Sirois D, Mobley C, practice. J Am Diet Assoc. 2003;103:1632-
Humana Press; 2005:273-286. eds. Nutrition and Oral Medicine. Totowa,
48. Morais JA, Heydecke G, Pawliuk J, Lund NJ: Humana Press; 2005:143-166.
78. Rigassio Radler D, Touger-Decker R. Nutri-
JP, Deine JS. The effects of mandibular two- 67. O’Neil EH; and the Pew Health Professions
tion screening in oral health. Top Clin Nutr.
implant overdentures on nutrition in elderly Commission. Recreating Health Professional
edentulous individuals. J Dent Res. 2003;82: Practice for a New Century: The Fourth Re-
53-58. port of the Pew Health Professions Commis- 79. World Health Organization, Food and Agri-
49. Allen PF, Thomason JM, Jepson NJA, Nohl sion. San Francisco, CA: Pew Health Profes- culture Organization of the United Nations.
F, Smith DG, Ellis J. A randomized con- sions Commission; 1998. Diet, nutrition and the prevention of chronic
trolled trail of implant-retrained mandibu- 68. Institute of Medicine. Dental education at diseases. Geneva, Switzerland: World Health
lar overdentures. J Dent Res. 2006;85:547- the crossroads—Summary. J Dent Educ. Organization; 2003. Technical Support Series
551. 1995;59:7-15. #916. Available at: http://whqlibdoc.who.int/
50. Feine JS, Lund JP. Measuring chewing 69. Commission on Dental Accreditation, trs/WHO_TRS_916.pdf. Accessed October 5,
ability in randomized controlled trails American Dental Association. Accredita- 2006.
with edentulous populations wearing im- tion Standards for Dental Education Pro- 80. Trujillo E, Davis C, Milner J. Nutrigenom-
plant prostheses. J Oral Rehabil. 2006;33: grams. Chicago, IL: Commission on Dental ics, proteomics, metabolomics, and the prac-
301-308. Accreditation, American Dental Associa- tice of dietetics. J Am Diet Assoc. 2006;106:
51. Alvarez JO. Nutrition, tooth development, tion. Available at: http://www.ada.org/prof/ 403-413.
and dental caries. Am J Clin Nutr. 1995; ed/accred/standards/predoc.pdf. Revised 81. US Department of Health and Human Ser-
61(suppl 2):410S-416S. January 25, 2007. Accessed April 26, 2007. vices. Healthy People 2010: Understanding
52. Finnell RH, Shaw GM, Lammer EJ, Brandl 70. Commission on Dental Accreditation. Com- and Improving Health. 2nd ed. Vol I and II.
KL, Carmichael SL. Bene-nutrient interac- mission on Dental Accreditation Introduction. Washington, DC: US Government Printing
tions: Importance of folates and retinoids The American Dental Association. Avail- Office; 2000.

August 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1427


ADA Position adopted by the House of Delegates on October 29, 1995, and reaffirmed on June 22, 2000, and June
30, 2005. This position is in effect until December 31, 2010. The American Dietetic Association authorizes
republication of the position statement/support paper, in its entirety, provided full and proper credit is given.
Requests to use portions of the position must be directed to ADA Headquarters at 800/877-1600, ext 4835, or
Authors: Riva Touger-Decker, PhD, RD, FADA (University of Medicine and Dentistry of New Jersey, Newark,
NJ); Connie C. Mobley, PhD, RD (University of Nevada Las Vegas, School of Dental Medicine, Las Vegas, NV).
Reviewers: American Association for Dental Research (Dominick P. DePaola, DDS, PhD, The Forsyth Institute,
Boston, MA); American Dental Association (Jane S. McGinley, RDH, MBA, Chicago, IL); American Dental
Hygienists’ Association (Margaret Lappan Green, RDH, MS, Newport News, VA); Saroj M. Bahl, PhD, RD
(University of Texas, Houston, TX); Consultant Dietitians in Health Care Facilities dietetics practice group
(Cheryl M. Bales, Spokane, WA, and Edna Cox, RD, Carolina Nutrition Consultants, Inc, Lexington, SC); Sharon
Denny, MS, RD (ADA Knowledge Center, Chicago, IL); Katrina Holt, MPH, MS, RD (Georgetown University,
Washington, DC); Lisa F. Harper Mallonee, MPH, RD, LD (Baylor College of Dentistry, Dallas, TX); Pediatric
Nutrition dietetic practice group (Cristine M. Trahms, MS, RD, FADA, University of Washington, Seattle, WA).
Association Positions Committee Workgroup: Helen Lane, PhD, RD (chair); Naomi Trostler, PhD, RD; and Linda
D. Boyd, RDH, RD, EdD (content advisor).

1428 August 2007 Volume 107 Number 8