Nutrition and Oral Medicine (Nutrition and Health)

Chapter 14 / Autoimmune Diseases 247impacts quality of life, adjuvant analgesic medications for neuropathic pain (low dosesof tricyclic antidepressants and/or clonazepam) provide relief in the majority of patients.Periodic aphthous ulcerations can be managed by early and brief treatment with moderateto potent topical steroid ointments such as clobetesol or triamcinalone; patients withfrequent or persistent lesions should be referred to a dentist oral medicine specialist foradditional care.3.1.5.2. Nutritional ManagementMNT for the management of PA, like other diseases or disorders, begins with acomprehensive nutrition assessment (refer to Chapter 17 for a more detailed discussion)by an RD. Although the dentist may detect oral nutrition manifestations and difficultieseating, the level of nutrition intervention required for such individuals should be providedonly by an RD. The dentist should provide baseline education relative to managementof eating difficulties (see Appendix E ) and refer patients to an RD.Nutrition assessment of such individuals includes a thorough diet history including theuse of any dietary supplements or special diets that may impact vitamin B 12 absorption,metabolism, or excretion as well as overall nutrition and GI status. Signs and symptomsof oral dysfunction should be explored for impact on oral function (biting, chewing, andswallowing). Other concurrent diseases or surgical histories (e.g., gastrectomy) that mayaffect B 12 status should also be explored. A clinical and physical assessment of nutritionstatus should be completed to determine overall nutritional well-being. Energy andnutrient needs should be based on goals for weight (gain, loss, and maintenance), priorintake, and estimated needs in light of current therapies. Use of dietary supplements andother forms of complementary and alternative medicine by individuals with autoimmunediseases is common and should be questioned in detail (see Chapter 9). Select supplementscan impact oral health and function as well as interact with medications to affectnutritional well-being. Individuals should be cautioned against the use of any supplementsthat can affect vitamin B nutriture and immune function.The tables at the end of this chapter and the diet education materials in Appendix Eprovide detailed instructions on diet management of oral sequellae. Nutritional managementshould be planned concurrently with the treating physician to complement pharmacologictherapies. Diet management must address oral dysfunction, side effects of anymedications, concurrent diseases, and cultural and personal preferences. Constant monitoringby an RD is necessary to achieve goals. Oral function, appetite, side effects ofmedications, clinical parameters, level of fatigue, nutrient intake (via computerizedassessment of energy and nutrient intake), and weight should be monitored regularly bythe RD. The dentist in practice should monitor patient weights; question patients regardingoral function, appetite, and intake; and refer accordingly to an RD.3.2. Pemphigus Vulgaris (PV)3.2.1. PATHOGENESISPV is a mucocutaneous autoimmune bullous disease. Although there are several typesof pemphigus (vulgaris, foliaceous, vegetans, and paraneoplastic), 80% of all patientswith pemphigus have PV (8,9). PV affects both sexes equally and is more common amongJews, particularly Ashkenazi Jews. Although rare pediatric cases have been reported,PV most commonly develops during the fourth to sixth decade of life (8,9). PV is char-