effects of systemic disease on nutritional status and oral health chapter 17 copyright © 2015,...
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EFFECTS OF SYSTEMIC DISEASE ON EFFECTS OF SYSTEMIC DISEASE ON NUTRITIONAL STATUS AND ORAL NUTRITIONAL STATUS AND ORAL
HEALTHHEALTH
CHAPTER 17CHAPTER 17
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Effects of Chronic Disease on Dietary Intake
Anorexia is a condition in which a person has a poor appetite for various reasons (e.g., cancer treatment)Appetite may decrease because of pain, apathy,
anorexia, drugs, inactivity, or other reasons Malnutrition or other stresses, such as infection, surgery,
or injuries resulting in anorexia, deplete body stores of kilocalories, macronutrients (e.g., protein), and micronutrients (e.g., vitamin C) needed to regenerate and repair cells and sustain immune system
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Effects of Chronic Disease on Dietary Intake
Taste and smell disordersWith a loss of smell patients report eating
lessWith loss of taste patient may require
greater amounts of sodium and sugar
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Effects of Chronic Disease on Dietary Intake
Xerostomia affects nutritional status in several ways: Chewing is difficult because a bolus cannot be formed
without additional moistureChewing is painful because the mouth is soreSwallowing is difficult because of loss of lubrication
from salivaFood intake may decrease because of changes in
taste perception
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Anemias: Iron Deficiency Anemia (IDA)
EtiologyIncreased needs during
growth periods such as infancy or pregnancy
Excessive bleedingInadequate intake
Oral manifestations:Atrophic glossitisAphthous ulcersGingival and mucosal
pallorAngular cheilosisCandidiasisMay impair wound
healingFrom Cawson RA, Odell EW: Cawson’s From Cawson RA, Odell EW: Cawson’s Essentials of Oral Pathology and Oral Essentials of Oral Pathology and Oral
Medicine, ed 8. St. Edinburgh, UK: Churchill Medicine, ed 8. St. Edinburgh, UK: Churchill Livingstone, 2008.Livingstone, 2008.
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Anemias: Iron-Deficiency Anemia (IDA)
Dental hygiene considerationsMay need to postpone invasive nonsurgical
periodontal therapy until IDA improvesEncourage iron-rich foods (e.g., meat)Encourage vitamin C to enhance
absorptionIf iron supplement is liquid, dilute with
water or juice and drink with straw to minimize tooth staining
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Anemias: Megaloblastic Anemia—Vitamin B12
Also called pernicious anemia
EtiologyIncreased needsInadequate intake
B12 only in animal products Vegans at risk of
deficiency
Malabsorption Common in elderly
Oral symptomsAngular cheilosisRecurrent
aphthous ulcersErythematous
mucositis Pale or yellowish oral
mucosa Atrophic glossitis; beefy
red color
From Ibsen OAC, Phelan JA: From Ibsen OAC, Phelan JA: Oral Pathology for the Dental Oral Pathology for the Dental
Hygienist, ed . St. Louis: Hygienist, ed . St. Louis: Saunders, 2014.Saunders, 2014.
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Anemias: Megaloblastic Anemia—Folate
EtiologyPoor dietMedications that
interfere with absorption (e.g., phenytoin or methotrexate)
Oral manifestationsAtrophic glossitisUlcerationsGlossodyniaAngular cheilitisFungal infections
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Anemias: Megaloblastic AnemiaDental hygiene considerations
Encourage folate-rich food sources
and supplement to meet the RDA for folate (400 µg) Large doses of folate can negate effects of anticonvulsants, so
consultation with medical provider is necessary
Encourage intake of foods from animal sources high in vitamin B12 for pernicious anemia For vegans encourage fortified foods or supplements
Patients with permanent gastric or ileal damage need monthly intramuscular or oral vitamin B12 supplementation for life
Refer to a registered dietitian
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Other Hematological Disorders: Neutropenia
EtiologyDrugs (e.g.,
chemotherapeutics)Autoimmune disease
(e.g., rheumatoid arthritis)
Hematologic disease (e.g., leukemia)
Nutritional deficienciesBacterial or viral infection
Oral manifestationsMucositisViral infectionsFungal infections (e.g.,
candidiasis)
From Ibsen OAC, Phelan JA: Oral From Ibsen OAC, Phelan JA: Oral Pathology for the Dental Hygienist, ed 6. St. Pathology for the Dental Hygienist, ed 6. St.
Louis: Saunders, 2014.Louis: Saunders, 2014.
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Other Hematological Disorders: Neutropenia
Dental hygiene considerationsInvasive dental treatment contraindicated until white
blood cell counts risePalliative care such as nonalcohol chlorhexidine rinse
may help reduce bacterial load until patient can perform more thorough oral self-care
Stress importance of frequent oralprophylaxis and meticulous oral hygienecare once muscositis pain subsides
Refer to a registered dietitian
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12
Gastrointestinal Problems: Gastroesophageal Reflux Disease (GERD)
Lower esophageal sphincter (LES) allows gastric contents to enter the esophagus
EtiologyHiatal herniaObesityPregnancy
RecommendationsAvoid foods causing
GERD (e.g., fatty foods)Eat small mealsKeep patient in semisupine
positionAssist with tobacco
cessationWeight loss as needed
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Gastrointestinal Problems: Malabsorptive Conditions
EtiologyCrohn’s diseaseUlcerative colitisCystic fibrosisGluten-sensitive
enteropathy (sprue or celiac disease)
AIDS
Oral manifestationsSwollen, bleeding,
erythematous gingivaDiffuse pustular eruptions
on buccal gingivaOral ulcerationsSwelling of the lipsCobblestone-like, raised
hypertrophic lesionsMetallic dysgeusia
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Gastrointestinal Problems: Malabsorptive Conditions
Dental hygiene considerationsConsult with healthcare provider about patient’s need
for supplemental steroids and prophylactic antibiotics before the dental appointment
Encourage patient to eat a nutrient-rich, well-balanced diet to enhance healing
Healthcare provider or registered dietitian may recommend vitamin and mineral supplementation
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Cardiovascular Conditions: Cerebrovascular Accident (CVA)
CVA or stroke results if occlusion or ischemia occurs in an artery supplying the brain or if hemorrhaging in the brain occurs
Oral manifestationsDysphagiaFacial muscle
weaknessSlurred speech
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Cardiovascular Conditions: Cerebrovascular Accident (CVA)
Dental hygiene considerationsMonitor blood pressureUsing water for rinsing or ultrasonic instrumentation
may be contraindicated during dental care if dysphagia is present
Neurological deficits may cause some to be unaware of the presence of food in the mouth, so the mouth should be checked for any pocketed foods after meals
Excellent oral self-care is needed to prevent caries; patient may have a softer, more cariogenic diet
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Cardiovascular Conditions: Hypertension
Dental hygiene considerationsMinimize stress for the appointmentMonitor blood pressureManage medication-induced xerostomiaRecommend fruits and vegetables, low-fat/nonfat dairy
products; to limit sodium, alcohol, caffeine; tobacco cessation; exercise; lose weight; reduce stress Direct to information about the DASH diet on the NHLBI
website
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Cardiovascular Conditions: Hyperlipidemia
Dental hygiene considerationsRecommend reducing total fat, saturated fat, dietary
cholesterolEncourage noncariogenic, low-fat snacksLong-term use of bile acid sequestrants
(cholestyramine and colestipol) to lower serum lipids may cause malabsorption of fat-soluble vitamins and folic acid Encourage food sources rich in these nutrients
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Skeletal SystemEtiology
Osteoporosis Bisphosphonates used to treat
osteoporosis and multiple myeloma increases risk for osteonecrosis (bone death of the jaw)
HyperparathyroidismPaget’s disease or fibrous
dysplasia
From Ibsen OAC, Phelan JA: Oral From Ibsen OAC, Phelan JA: Oral Pathology for the Dental Hygienist, ed 6. St. Pathology for the Dental Hygienist, ed 6. St.
Louis: Saunders, 2014.Louis: Saunders, 2014.
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Skeletal SystemOral manifestations
Increase in size or alteration in contour of maxilla or mandible
Alteration in radiographic patternMobility of individual teeth without significant
periodontal diseasePain or discomfort in jaw without obvious dental
pathologyIncreased sensitivity of teeth without obvious dental or
periodontal diseaseChanges in the occlusion of the teethAbnormal sequence of deciduous tooth loss or eruption
of permanent molars in youngCopyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Skeletal SystemDental hygiene considerations
Provide guidance to ensure that the patient obtains adequate calcium and vitamin D
Avoid alcohol consumption
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Metabolic Problems: Diabetes Mellitus
SymptomsFruity-smelling breath
(more prevalent in type 1 diabetes)
3 P’s Polydipsia: increased thirst Polyphagia: hunger Polyuria: frequent urination
Unexplained weight loss
Oral manifestations in poorly controlled DMPoor healing More severe
periodontal diseaseTissue necrosis from
minor traumaXerostomiaCandidiasis
From Ibsen OAC, Phelan JA: Oral From Ibsen OAC, Phelan JA: Oral Pathology for the Dental Hygienist, ed 6. St. Pathology for the Dental Hygienist, ed 6. St.
Louis: Saunders, 2014.Louis: Saunders, 2014.
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Metabolic Problems: Diabetes Mellitus
Dental hygiene considerationsEncourage frequent periodontal
maintenance/meticulous oral self-carePrevent hypoglycemia by treating patient in
the morning, ensuring patient ate at usual time and took medications
Have access to a glucometer and glucose source
Recognize and treat hypoglycemia quickly with the rule of 15’s
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Metabolic Problems: Hypopituitarism
EtiologyCongenitalTumorHead traumaStrokeRadiationBrain infection
Oral manifestationsDecreased skeletal
growth results in disproportionate retardation of mandibular growth
Delayed eruptionMalocclusion
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Metabolic Problems: Cushing’s Syndrome
SymptomsHigh blood pressurePre-diabetes or diabetesObesityMuscle weaknessBruise easilyAcneHirsutismOsteoporosisDepression
Oral manifestationsDiabetes and
osteoporosis may affect management of periodontal disease and associated bone loss
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Metabolic Problems: Hypothyroidism
EtiologyInadequate consumption of
iodineInborn error of metabolismHigh intake of goitrogenTreatment of
hyperthyroidismThyroid gland disorderDeficient secretion of TSH
Oral manifestationsIn children
Short stature Intellectual disabilities Delayed eruption Severe malocclusion Risk for caries
Macroglossia
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Metabolic Problems: Hyperparathyroidism
Hypersecretion of the parathyroid hormone (PTH), leading to alterations in calcium, phosphorus, and bone metabolism
Oral manifestationsIncreased osteoclastic
bone resorptionBrown tumors occur in
the head and neck, especially the mandible May affect ability to
consume an adequate diet
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Metabolic Problems: Renal Disease
EtiologyPrimary glomerular
diseaseSecondary glomerular
disease (hypertension, diabetes, lupus)
Vascular diseaseTubulointerstitial disease
(e.g., polycystic kidneys)
Oral manifestationsPlatelet abnormalities
may cause gingival bleeding
Gingival pallorSlow wound healingBad taste (from urea)MalodorStomatitisHairy leukoplakia
From Ibsen OAC, Phelan JA: Oral Pathology for the From Ibsen OAC, Phelan JA: Oral Pathology for the Dental Hygienist, ed 6. St. Louis: Saunders, 2014.Dental Hygienist, ed 6. St. Louis: Saunders, 2014.
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Metabolic Problems: Renal Disease
Dental hygiene considerationsMedical consult needed because of bleeding tendency
and to determine need for antibiotic prophylaxis to prevent endocarditis and/or infection of vascular access site for dialysis
Minimize water due to fluid restrictionsSchedule dental appointment day after dialysis
treatmentMeticulous oral self-care and frequent care
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Neuromuscular Problems: Parkinson’s Disease
SymptomsInvoluntary muscle tremorsBradykinesia (slowness of
movement)Muscular weaknessRigidityStooped postureDecreased fine motor
coordinationOrthostatic hypotension
Oral manifestationsAbnormal chewing
and swallowing pattern
Holding food in mouth for extended periods
Frequent droolingTremor of mandible,
lips, tongue
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Neuromuscular Problems: Parkinson’s Disease
Dental hygiene considerationsEducate patient and/or caregiver on use of electric
toothbrush if difficulty holding conventional toothbrushAfter supine positioning, sit patient upright for >2
minutes before standing to avoid orthostatic hypotension
Minimize use of water due to swallowing problemsEncourage adequate protein intake and overall healthy
diet to maintain weight and bone health
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Neuromuscular Problems: Developmental Disabilities
Cerebral palsy, muscular dystrophy, Down syndrome may be associated with abnormal oral-motor developmentOral-motor impairment is associated with:
Tongue retraction Tongue thrust Tonic bite reflex Oral hypersensitivity Hyperactive gag reflex
All make feeding difficult, as well as performing dental and self-care
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Neuromuscular Problems: Epilepsy
Epilepsy does not usually result in any specific oral or feeding problems, but the phenytoin used to treat it can affect oral health as well as nutritional statusGingival hyperplasia makes oral self-care challengingPhenytoin increases the need for vitamins D, K, and
folate and can affect bone mass long term Refer to healthcare provider for nutrition counseling because
supplements can affect effectiveness of phenytoin
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NeoplasiaNutritional requirements for persons with
neoplasms generally increased to maintain lean body mass and immune responsesOral symptoms or signs may be secondary to
malnutrition or nutrient deficiencies (e.g., changes in taste perception)
Intake reduced in those with cancer of the oral cavity, pharynx, or esophagus because of odynophagia (pain on swallowing) or dysphagia
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Neoplasia: Kaposi’s Sarcoma
Highly malignant tumor of blood vessel origin that occurs on the skin and oral mucosaRed-purple macular lesions in the
mouth may progress to raised, indurated lesions with central areas of necrosis and ulceration
Appear in many HIV-positive patients
From Ibsen OAC, Phelan JA: Oral From Ibsen OAC, Phelan JA: Oral Pathology for the Dental Hygienist, ed 6. St. Pathology for the Dental Hygienist, ed 6. St.
Louis: Saunders, 2014.Louis: Saunders, 2014.
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Neoplasia: Acute Leukemia
Generalized malignant disease characterized by distorted proliferation and development of white blood cells (WBCs)
Oral manifestationsGingiva may become
severely inflamed with tissue hyperplasia, areas of ulcerations, necrosis, and spontaneous bleeding
Delayed wound healingIncreased susceptibility
to infectionFrom Ibsen OAC, Phelan JA: Oral From Ibsen OAC, Phelan JA: Oral
Pathology for the Dental Hygienist, ed 6. St. Pathology for the Dental Hygienist, ed 6. St. Louis: Saunders, 2014.Louis: Saunders, 2014.
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Neoplasia: Cancer TreatmentsChemotherapy effects
include:Stomatitis or mucositisOral ulcerationsDecreased absorptive
capacityChanges in taste
sensation
Radiation therapy to head and neck affects:General appetite lossNausea, vomiting,
diarrhea Loss of taste sensationXerostomiaDifficulty in swallowingBurning sensation in the
mouth
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Neoplasia: Cancer Treatments
Dental hygiene considerationsUsing antimicrobial mouth rinse (nonalcohol
chlorhexidine), meticulous oral self-care, frequent careSoft and/or bland diet may be necessary; encourage
protein intakeAvoid alcohol and hot, spicy, and acidic foods when
oral lesions are presentCaution against eating hard candy or drinking
beverages containing fermentable carbohydrates to relieve the xerostomia
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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AIDS
SymptomsWith HAART, classic
wasting is less evident, although wasting and anorexia may be present
Opportunistic infectionMultiple nutrient
deficienciesProtein-energy
malnutrition
Oral manifestationsOral candidiasisOral hairy leukoplakiaHerpetic ulcerationsKaposi’s sarcomaMay have more
severe periodontitisXerostomia
From Ibsen OAC, Phelan JA: From Ibsen OAC, Phelan JA: Oral Pathology for the Dental Oral Pathology for the Dental
Hygienist, ed 6. St. Louis: Hygienist, ed 6. St. Louis: Saunders, 2014.Saunders, 2014.
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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AIDSAIDSDental hygiene considerations
Encourage to maintain the highest possible level of oral self-care and regular preventive dental care
To promote healing, encourage attention to adequate nutrient intake (e.g., kilocalories, protein)
Use nutritional supplements or instant breakfast drinks as snacks for those needing added nutrition
Limit caffeine- and alcohol-containing beverages if xerostomia exists
Refer to RD and/or medical provider as needed
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Mental Health Problems: Anorexia Nervosa
Primarily affecting adolescent and young adult females who have an exaggerated, intense fear of becoming fatZealous, self-imposed
restriction leads to extreme weight loss
Criteria for diagnosisWeight loss equal to or
exceeding 15% below expected or original body weight
Amenorrhea Excessive desire for
slimness with distorted body image
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Mental Health Problems: Bulimia
Eating disorder not necessarily associated with significant weight loss, may be slightly overweightBingeing and purging
Binges may occur several times/day in late afternoon or evening
Most common method of purging is self-induced vomiting
Oral manifestationsErosion of enamel
(lingual maxillary anterior teeth)
Palatal bruisesEnlarged parotid
glandsDentin
hypersensitivityPerimolysis
From Ibsen OAC, Phelan JA: Oral From Ibsen OAC, Phelan JA: Oral Pathology for the Dental Hygienist, ed 6. St. Pathology for the Dental Hygienist, ed 6. St.
Louis: Saunders, 2014.Louis: Saunders, 2014.
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
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Mental Health Problems: Mental Illness
Many types of mental illnesses: schizophrenia, depression, bipolar disorder or mania
Drugs frequently prescribed to treat the conditions may have side effects that affect oral statusAntipsychotics (haloperidol, thioridazine) and
anticholinergics (tricyclics, MAO inhibitors, trazodone) frequently cause xerostomia
Trazodone can cause unpleasant taste
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Mental Health ProblemsDental hygiene considerations
Increased caries rate indicative of high-carbohydrate bingeing and low pH of saliva from vomiting
Must recognize signs and symptoms of suspected eating disorder and refer patients to health care provider or eating disorder facility for care
Caution the patient against brushing immediately after vomiting
Rinse with sodium bicarbonate to neutralize the oral environment after vomiting
Encourage daily fluoride and hypersensitivity products
Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
HEALTH APPLICATIONHUMAN PAPILLOMA VIRUS (HPV)Discuss why HPV is on the riseDiscuss what HPV is a risk factor forDiscuss possible treatmentsDiscuss ways to prevent HPV
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