Nutrition and Oral Medicine (Nutrition and Health)

194 Part IV / Select Diseases and Conditionstes into MNT as well as refer patients for dental care (70). As a component of the healthhistory and review of systems, the RD can ask about difficulties with biting, chewing, andswallowing, and the presence and severity of oral diseases and conduct a brief oral exam(70,71). The oral exam by the RD should include a screen of the head and neck area,cranial nerves, and intraoral area to note integrity of the soft tissue, dentition, and occlusion(71,72). Although it is not the role of the RD to diagnose or treat oral symptomatologyor disease, it is incumbent on the RD to note any “nonnormal” finding, determine itsimpact on eating ability, and refer patients appropriately to the dentist (72).The RD will also complete a medical history and screen as described in the previoussection and an in-depth diet history. The diet history taken by the RD differs from thatsuggested for the dentist. As clearly elucidated in the American Diabetes Association’snutrition guidelines (73,74), it is the role of the RD to provide MNT but “it is essentialthat all team members be knowledgeable about nutrition therapy and supportive of theperson with diabetes.” The outcome of the RD screen will be one or more of the following:provide MNT for the patient, refer the patient to a dentist for evaluation and treatment,refer the patient to his or her primary care provider, or refer the patient to another healthprofessional. MNT is described in a subsequent section.5.1.2. THE ROLE OF THE DENTISTThe role of the dentist in screening individuals for nutrition risk includes questionsabout metabolic control of their disease, history of hypo- and hyperglycemia incidents,and questions regarding diet. Sample diet history questions are outlined in Chapter 17,Table 4 and Appendix A.Patient responses to questions regarding difficulties with biting, chewing, and swallowingprovide insight into the functional abilities of the oral cavity. Although the dentalprofessional will address these issues as part of a dental treatment plan, it is likewise hisor her responsibility to provide some guidelines on how to eat when dentition or oralfunction is compromised and refer patients as appropriate to an RD. Common scenarioswhere masticatory function can be compromised in a patient with diabetes and appropriateconsultation or referral to an RD is justified include partial or complete edentulism,removable prostheses, postoperative periods when pain may significantly affect oralintake of nutrients, and chronic disorders affecting mastication such as xerostomia andchronic orofacial pain of myofascial, musculoskeletal, neuropathic, or mucosal origins.6. GOALS OF MEDICATION MANAGEMENT OF DIABETES MELLITUS6.1. Tight Control: Revisiting and Redefining an Established ConceptCurrent diabetes treatment goals are summarized in Table 3. Both acute and chronic,prolonged exposure to hyperglycemia is the primary factor responsible for the developmentof diabetic complications (75). The common biochemical basis for complicationsis hyperglycemia-mediated formation of nonenzymatic advanced glycation end products(AGEs). AGEs are chemically irreversible, glucose-derived compounds that form slowlyand continuously in plasma and tissues as a function of blood glucose concentration andhave been linked to the development of diabetic complications such as renal failure (76).The glycated or glycosylated hemoglobin test (HbA1c) is widely used to assess glycemiccontrol (77). It also has prognostic value as shown in the the Diabetes Control and