Examining the Effect of Oral Health on Nutrition Status and Wound Healing

INTRODUCTION Every nutrition assessment form has a place to indicate the patient’s dental status. This space is primarily used to note whether the patient is edentulous or wears dentures. The completed form typically does not include much commentary or further exploration into issues such as gum disease or mouth sores because registered dietitian nutritionists, nurses, and even physicians are not dental professionals. That said, if a patient’s dental or oral status interferes with meal consumption, any wounds that are present may not heal in a timely fashion because of difficulty in meeting daily caloric and protein goals. Poor oral health can hinder a person’s ability to chew properly, which can eventually lead to malnutrition. In addition, bacteria from gum infections can enter the bloodstream, increasing the risk for heart disease and other conditions.1 The link between oral health and nutrition status often is not discussed in the wound care setting, yet it can play a role in whether or not a wound heals. Many well-designed, published studies have investigated connections between oral health and cardiovascular disease, Alzheimer disease, nutrition status, functional status, and many more medical conditions. Atherosclerotic cardiovascular disease is a leading cause of disability and death, and researchers have identified a link with periodontal disease.2 Periodontal disease is a chronic infection with inflammatory and immune-mediated mechanisms that appear to affect the cardiovascular system. Further, according to a 2023 study published in Neurology,3 having a missing tooth was the equivalent of nearly a year of brain aging (measured by brain shrinkage), and severe gum disease was equal to 1.3 years of brain aging. The affected area of the brain is involved in cognition, thus linking dental problems to loss of cognitive function and even Alzheimer disease. The reality is that many patients who reside in skilled nursing facilities, even those without Alzheimer disease or dementia, often have missing teeth, periodontal disease, and various mouth pains. Most long-term care facilities do not have a dentist on the premises, so it is up to the care team to provide routine mouth/dental care and advocate for dental consultations as needed. Long-term care professionals and wound care providers will not replace dental professionals, but it is helpful for nurses, nursing assistants, and registered dietitian nutritionists to become acquainted with some basic oral health assessments, particularly if patients are not eating adequately to meet the increased nutrient goals needed to fuel the wound-healing process. Dental and oral health training can prove beneficial because these are possibly new areas for team members. DENTAL HISTORY AND ORAL ASSESSMENT Across the continuum of care, the assessment process should include dental history and an oral assessment. The assessment should note the last time the patient visited a dentist, any changes in the mouth or teeth, any loose or sensitive teeth, and any pain or bleeding in the teeth or gums. It also should document chewing and swallowing difficulties, taste and flavor problems, dry mouth, and mouth sores, as well as denture fit and alignment for patients who wear dentures or partial dentures. An oral health screening is a visual and manual inspection of the mouth that is conducted to identify oral disease or other oral conditions that may require management by oral health professionals (eg, dentists and dental hygienists). A 2- to 3-minute screening includes an inspection of the lips, tongue, teeth, gums, inside of the cheeks, roof of the mouth, and throat.4 Conducting a screening provides a risk assessment but does not involve making diagnoses that lead to a treatment plan. Oral health professionals or other trained health professionals can perform screenings to assess oral disease risk. During these screenings, oral health or trained health professionals should: observe the face and neck for skin discoloration, moles, sores, or asymmetry; palpate the temporal mandibular joint, noticing if there is a popping or clicking of the joint; palpate the lymph nodes; palpate the salivary glands; examine the lips; examine the buccal mucosa to look for infections, ulcers, and traumatic injuries; examine the tongue, including the back, sides, and bottom of the tongue for suspicious lesions (to examine the bottom of the tongue, ask patients to touch the roof of the mouth with the tongue); examine the floor of the mouth; and note the general condition of the teeth for calculus, decay, fillings, and breaks. DENTURES Many patients wear dentures, which can mean full or partial upper and/or lower dentures. Sometimes patients own dentures but do not wear them for various reasons, including improper fit and resultant mouth pain. The patient’s health record should include documentation of this issue, as well as the plan to address the situation. It is important to never underestimate the importance of well-fitting dentures. A good set of dentures preserves the facial appearance; makes adequate nutrition with a regular diet possible; and enables proper enunciation, thereby facilitating social interaction. Denture wearers commonly complain that their dentures have become loose. Loose or ill-fitting dentures are identified by a “clicking” sound that is heard when the wearer is talking or eating. Many people believe that once they have lost all of their natural teeth and have full dentures, they no longer need to visit a dentist. This is a myth. The bone under the gum, which supports the denture, gradually reduces in size, and continues to undergo remodeling, which leads to a poor fit. Denture fit is also affected by weight change, as little as 10 pounds. It is important that all denture wearers have periodic dental visits to refit the dentures. Another common problem that can occur with dentures is that they are easily misplaced. Patients frequently wrap removable dentures or bridges in a tissue, which is then inadvertently discarded. Patients must not leave their dentures on meal trays, on bedside tables, or in pockets. The use of proper storage containers for each patient, labeled with name and room number, helps prevent loss. When dentures are lost, it is important to update the medical record promptly. MOUTH CARE Twice daily mouth care is essential for all patients. Better dental care may even reduce the risk of pneumonia in older adults. Anaerobic bacteria from the periodontal pockets can become isolated in the lungs.5 The mechanism of infection is possibly the aspiration into the lungs of oral pathogens, which can cause pneumonia. To minimize this risk, it is important to brush teeth and dentures in the morning and evening. The Table lists guidelines for brushing teeth properly. Table. - GUIDELINES FOR BRUSHING TEETH Brush twice a day with a small amount of fluoride toothpaste. Use a soft bristle brush with a small head, which makes it easier to clean around the back teeth. Replace brush every 3 months or after a severe respiratory infection. Brush teeth in a circular massaging motion. Make sure to brush all sides and the biting surface of each tooth. Do not brush the tongue because it can cause irritation. Scrape the tongue with a tongue scraper to remove bacteria. Encourage independent mouth care by using built-up handles on toothbrushes. Elastic or hook and loop bands can help patients hold the toothbrush. Consider using automatic or battery-powered toothbrushes to help promote independence. Label all items so that toothbrushes are not shared. Adapted from National Institute of Dental and Craniofacial Research (2018).6 Daily flossing and rinsing with mouthwash can further eliminate bacteria. Alcohol-free mouthwash is the best choice because it does not dry out the oral cavity. Many patients may already have problems with saliva production and dry mouth (ie, xerostomia) as an adverse effect of medications. Mouthwash containing alcohol may exacerbate this dry mouth condition. Even with proper daily mouth care, a professional cleaning is recommended at least annually. The healthcare team should communicate the importance of yearly professional dental visits to patients and document these education sessions. THE NUTRITION LINK The provision of optimal nutrition for patients with wounds is challenging, even under the best of circumstances. When a patient is suffering from ill-fitting or missing dentures, dry mouth, mouth pain from bacterial colonies, or any other oral problem, the meal process often becomes even more frustrating for both the healthcare team and the patient. It is up to the entire team to recognize the major role that oral and dental health play in the maintenance of proper nutrition status. Without proper nutrition, wound healing can become delayed or even halted. The healthcare team should always ask about oral health and seek the help of a dental professional when necessary.