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Table 1 Included articles that identify available guidelines for dietitians, KAP of dietitians regarding oral health promotion and current models of oral health care and resources for dietitians

From: Eating disorders and oral health: a scoping review on the role of dietitians

Author (Year)/ Location Article Type Aims Study Design Details of Study Conclusion Focus area
Decker, R.T. (2013)
USA [37]
Position statement To provide the position of The Academy of Nutrition and Dietetics regarding oral health and nutrition as well as describe the roles and responsibilities of dietetics practitioners in oral health education, practice and research. N/A Position statement on the role of the dietitians in oral health promotion • The Academy supports the collaboration and integration of oral health with nutrition services, education and research.
• Skills of screening oral health and making referrals is essential for dietitians.
• Supports education that reinforces and illustrates the role of nutrition in oral health.
• Collaboration between oral health practitioners and dietitians is recommended.
• Eating disorders is highlighted as an at-risk group and some oral health manifestations typical to this population, such as xerostomia are specified. However, no specific information exists to detail the support dietitians should provide to this population.
• A general table is provided where dietitians can identify oral related manifestations of nutrition deficits.
Guidelines and recommendations
Dietitians Australia and Dental Health Services Victoria (2015)
Australia [38]
Joint Position statement To provide evidence based oral health information to dietitians; to guide how oral health can be incorporated into the various roles of dietitians and to provide a framework for workforce capacity building workforce. N/A Joint position statement on the role of the dietitian in oral health promotion • There is consensus that the dietitian’s role, dependent on setting, should: incorporate oral health screening, especially in priority at risk groups; recognize risk factors; provide nutritional management and/or provide guidance/ referral to oral health professionals; develop and deliver health promotion and education messages.
• Specific oral health advice for dietitians is provided for medically compromised/special needs patients including individuals with an eating disorder.
• Specific oral health advice for dietitians is provided for medically compromised/special needs patients including individuals with an eating disorder. Key advice includes encouraging good oral hygiene and providing advice on oral care after vomiting.
Guidelines and recommendations
Faine, M.P. (1995)
USA [39]
Peer reviewed journal article Assess the knowledge of the role of diet in dental caries aetiology in nutritionists and dental hygienists. Cross-sectional 136 registered dietitians and 37 registered dental hygienists • Awareness varied across different topics related to caries-preventative measures. While 95% of nutritionists recognised fluoride uptake into developing teeth makes dental enamel more resistant to dental caries, only 16% understood that fluoride may hinder bacterial activity.
• Most nutritionists (53%) demonstrated awareness of the infectious nature of dental caries but only 38% recognised mothers can transmit bacteria to their children.
• Nearly all nutritionists correctly identified high vs. low cariogenic snack foods. Nearly all (97%) of nutritionists were aware of and discussed childhood caries with clients.
• Two thirds of nutritionists surveyed incorrectly linked the severity of dental decay to concentration of sugars in food.
• Most nutritionists were knowledgeable on recommendations including limiting nighttime bottle feeding to reduce childhood caries risk
Knowledge attitudes and practices
Fuller, L.A. (2014)
USA [40]
Peer reviewed journal article To assess the oral health knowledge, confidence and practices of Virginia personnel in the special supplemental food program for Women, Infants and Children (WIC). Cross-sectional
22-item investigator-designed questionnaire (content validity and reliability established). Some questions sourced from previously tested questionnaires.
159 WIC personnel including -registered dietitians (20%) -nutritionists (33%), −dietetic technicians (5%), −licensed practical nurses (~ 4%) and registered nurses (~ 1%). • WIC respondents who were over 40 years of age and with 10+ years’ experience were more knowledgeable about caries transmission and the dental decay process than younger and less experienced WIC respondents.
• More than half (64%) of respondents were not confident in performing oral screening.
• Respondents with higher academic qualifications were more confident (90%) in oral health counselling.
• One third of respondents were performing oral screenings for decay.
• Most (87%) respondents who were older and more experienced were providing oral health counselling to parents on toothbrushing and were also more likely to provide referrals to dentists.
Knowledge, attitudes and practices
Gold, J.T. (2016)
USA [41]
Peer reviewed journal article Assess the oral health knowledge, practices and attitudes of staff in the Special Supplemental Nutrition Program for Women, Infant and Children (WIC) in north central Florida. Cross-sectional
28 item questionnaire- developed and validated from previously validated questionnaires.
39 WIC staff including, 9 nutritionists/dietitians. • Majority of nutritionists (> 78%) were knowledgeable about the importance of maintaining good oral health in children, risk factors and the role of caregivers.
• Poor knowledge (33%) around the use of fluoridated toothpaste in children under the age of 2 and nighttime on demand breastfeeding as a risk factor.
• All nutritionists were confident in providing oral health counselling for women and children and dental referral if required.
• All nutritionists discussed the relationship between dietary choices and caries with parents.
• More than two thirds (67%) of nutritionists regularly provided counselling on the importance of tooth brushing and dental visits.
• None of the nutritionists were undertaking oral health risk screenings of children and less than half (44%) were referring women and children to dentists.
Knowledge attitudes and practices
Koerber, A. (2006) USA [42] Peer reviewed journal article Explore the attitudes and practices of health professionals in a Latino community regarding the association between diabetes and periodontitis to guide interventions for oral health promotion. Qualitative Participants (N = 14)
- 50% Nurses (n = 7)
- 36% Dentists (n = 5)
- 14% Nutritionist (n = 2)
Nutritionist years of experience: ~ 13-20 yrs.
• Knowledge on the relationship between diabetes and its associated symptoms and caries risk was adequate but lacked depth.
• All nutritionists considered oral health and diabetes to be important.
• Nutritionists were eager to provide oral health education.
• None of available resources used by nutritionists discussed the need for oral health and self-care prevention measures with diabetic patients.
• Nutritionists were not referring to dentists but demonstrated willingness to do so.
• Nutritionists requested more training and suggested development of guidelines and new protocols on the diabetes-periodontitis association as well as patient information handouts and videotapes.
Knowledge attitudes and practices
Shick EA. (2005)
USA [43]
Peer reviewed journal article Examine the effects of knowledge and confidence on dental referral practices among WIC nutritionists in North Carolina. Cross-sectional
118 item questionnaire- developed from previously tested questionnaires and pilot tested
324 nutritionists • Most nutritionists were knowledgeable about basic oral hygiene and caries related diet recommendations.
• Nutritionists were less aware (33%) of potential caries transmission from carers and importance of fluoride for children.
• Nutritionists were very confident about providing oral health counselling and dental referrals (90–96%). They were Less confident (39.3%) about undertaking oral health risk screenings of children.
• Confidence in undertaking oral health risk screenings (OR2.12), and making dental referrals (OR 3.02) was associated with more frequent referrals.
Models of care and resources
Karmally W. (2014)
USA [44]
Webinar Provide education on the association between nutrition and oral health conditions and discuss practical strategies for dietitians to integrate oral health information with nutrition counselling. N/A Webinar approved for continued professional education • Webinar discusses the relationship between nutrition, disease and oral health and provides strategies on how dietitians can incorporate oral health into the nutrition assessment (including oral health screening). Models of care and resources
Brody R.A. (2014)
Israel [45]
Peer reviewed journal article To assess the changes in knowledge and practice of dietitians, working in geriatric care in Israel, following a training program in nutrition focused physical assessment of the oral cavity. Prospective pilot study using a pre- posttest design.
Investigator designed 29 item knowledge pre-test (face and content validity established) and patient data collection forms (practices)
30 dietitians completed the pre-and post-test questionnaires. Testing conducted pre-training, immediately post-training and 12 months post-training (3 timepoints)
Training was provided to dietitians which included oral related anatomy, performing extra-oral and intra-oral examination and screening for dysphagia and vitamin deficiencies
• Pretesting suggests that dietitians had limited nutrition focused physical assessment oral health knowledge. At each timepoint following training, knowledge had increased.
• Three months post training, dietitians were more likely to perform oral health screenings rather than not assessing or obtaining history from the medical record.
• Dietitians were 5.7 x more likely to refer to other allied health professionals 3 months post-training.
Models of care and resources
Jeganathan, S. (2010)
Australia [46]
Peer reviewed journal article Develop and validate a 3-item oral health assessment questionnaire (OHQ) for use by dietitians to screen individuals with HIV at risk of dental complications for referral to dental health services. Cross-sectional Tool to be validated: 3 item oral health assessment questionnaire (OHQ) and the Oral health Impact profile 14 (OHIP-14) was administered to 273 clients • Questionnaire completed by 273 participants.
• The OHQ was found to be a valid and sensitive screening tool for dietitians to initiate further investigation for oral health screening and referral to dental professionals.
• The sensitivity for the OHQ was 84% and the specificity was 55%.
• Compared to the ‘Gold Standard’ Oral health Impact profile-14 (OHIP), the OHQ demonstrated adequate validity (rho = 0.617 (95% CI 0.54, 0.69), P < 0.0001).
Models of care and resources
The Albion Centre, oral health promotion working group - NSW Health (2015)
Australia [47]
Oral health resource Oral health screening and referral tool for health professionals (including dietitians) working with individuals with HIV. N/A Oral health resource includes three item oral health assessment tool, take home advice for clients, referral pathways and information about common dental problems encountered by individuals with HIV N/A Models of care and resources
Pac West MCH - distance Learning Network, University of Washington (2005) USA [48] Oral health education and screening resource Provides actions that non-dental and dental health professionals can take to identify individuals at risk of oral health complications and provides guidelines for action. N/A Module 5 of an online resource for actions that non-dental health professionals can consider when addressing oral health complications which includes: potential oral health screening and prevention activities, suggestions for screening tools for nutrition related oral health problems, mechanisms for referral and further resources and initiatives N/A Models of care and resources
Author (Year)/ Location Article Type Aims Study Design Details of Study Conclusion Focus area
Decker, R.T. (2013)
USA [37]
Position statement To provide the position of The Academy of Nutrition and Dietetics regarding oral health and nutrition as well as describe the roles and responsibilities of dietetics practitioners in oral health education, practice and research. N/A Position statement on the role of the dietitians in oral health promotion • The Academy supports the collaboration and integration of oral health with nutrition services, education and research.
• Skills of screening oral health and making referrals is essential for dietitians.
• Supports education that reinforces and illustrates the role of nutrition in oral health.
• Collaboration between oral health practitioners and dietitians is recommended.
• Eating disorders is highlighted as an at-risk group and some oral health manifestations typical to this population, such as xerostomia are specified. However, no specific information exists to detail the support dietitians should provide to this population.
• A general table is provided where dietitians can identify oral related manifestations of nutrition deficits.
Guidelines and recommendations
Dietitians Australia and Dental Health Services Victoria (2015)
Australia [38]
Joint Position statement To provide evidence based oral health information to dietitians; to guide how oral health can be incorporated into the various roles of dietitians and to provide a framework for workforce capacity building workforce. N/A Joint position statement on the role of the dietitian in oral health promotion • There is consensus that the dietitian’s role, dependent on setting, should: incorporate oral health screening, especially in priority at risk groups; recognize risk factors; provide nutritional management and/or provide guidance/ referral to oral health professionals; develop and deliver health promotion and education messages.
• Specific oral health advice for dietitians is provided for medically compromised/special needs patients including individuals with an eating disorder.
• Specific oral health advice for dietitians is provided for medically compromised/special needs patients including individuals with an eating disorder. Key advice includes encouraging good oral hygiene and providing advice on oral care after vomiting.
Guidelines and recommendations
Faine, M.P. (1995)
USA [39]
Peer reviewed journal article Assess the knowledge of the role of diet in dental caries aetiology in nutritionists and dental hygienists. Cross-sectional 136 registered dietitians and 37 registered dental hygienists • Awareness varied across different topics related to caries-preventative measures. While 95% of nutritionists recognized fluoride uptake into developing teeth makes dental enamel more resistant to dental caries, only 16% understood that fluoride may hinder bacterial activity.
• Most nutritionists (53%) demonstrated awareness of the infectious nature of dental caries but only 38% recognized mothers can transmit bacteria to their children.
• Nearly all nutritionists correctly identified high vs. low cariogenic snack foods. Nearly all (97%) of nutritionists were aware of and discussed childhood caries with clients.
• Two thirds of nutritionists surveyed incorrectly linked the severity of dental decay to concentration of sugars in food.
• Most nutritionists were knowledgeable on recommendations including limiting nighttime bottle feeding to reduce childhood caries risk
Knowledge attitudes and practices
Fuller, L.A. (2014)
USA [40]
Peer reviewed journal article To assess the oral health knowledge, confidence and practices of Virginia personnel in the special supplemental food program for Women, Infants and Children (WIC). Cross-sectional
22-item investigator-designed questionnaire (content validity and reliability established). Some questions sourced from previously tested questionnaires.
159 WIC personnel including -registered dietitians (20%) -nutritionists (33%), −dietetic technicians (5%), −licensed practical nurses (~ 4%) and registered nurses (~ 1%). • WIC respondents who were over 40 years of age and with 10+ years’ experience were more knowledgeable about caries transmission and the dental decay process than younger and less experienced WIC respondents.
• More than half (64%) of respondents were not confident in performing oral screening.
• Respondents with higher academic qualifications were more confident (90%) in oral health counselling.
• One third of respondents were performing oral screenings for decay.
• Most (87%) respondents who were older and more experienced were providing oral health counselling to parents on toothbrushing and were also more likely to provide referrals to dentists.
Knowledge, attitudes and practices
Gold, J.T. (2016)
USA [41]
Peer reviewed journal article Assess the oral health knowledge, practices and attitudes of staff in the Special Supplemental Nutrition Program for Women, Infant and Children (WIC) in north central Florida. Cross-sectional
28 item questionnaire- developed and validated from previously validated questionnaires.
39 WIC staff including, 9 nutritionists/dietitians. • Majority of nutritionists (> 78%) were knowledgeable about the importance of maintaining good oral health in children, risk factors and the role of caregivers.
• Poor knowledge (33%) around the use of fluoridated toothpaste in children under the age of 2 and nighttime on demand breastfeeding as a risk factor.
• All nutritionists were confident in providing oral health counselling for women and children and dental referral if required.
• All nutritionists discussed the relationship between dietary choices and caries with parents.
• More than two thirds (67%) of nutritionists regularly provided counselling on the importance of tooth brushing and dental visits.
• None of the nutritionists were undertaking oral health risk screenings of children and less than half (44%) were referring women and children to dentists.
Knowledge attitudes and practices
Koerber, A. (2006) USA [42] Peer reviewed journal article Explore the attitudes and practices of health professionals in a Latino community regarding the association between diabetes and periodontitis to guide interventions for oral health promotion. Qualitative Participants (N = 14)
- 50% Nurses (n = 7)
- 36% Dentists (n = 5)
- 14% Nutritionist (n = 2)
Nutritionist years of experience: ~ 13-20 yrs.
• Knowledge on the relationship between diabetes and its associated symptoms and caries risk was adequate but lacked depth.
• All nutritionists considered oral health and diabetes to be important.
• Nutritionists were eager to provide oral health education.
• None of available resources used by nutritionists discussed the need for oral health and self-care prevention measures with diabetic patients.
• Nutritionists were not referring to dentists but demonstrated willingness to do so.
• Nutritionists requested more training and suggested development of guidelines and new protocols on the diabetes-periodontitis association as well as patient information handouts and videotapes.
Knowledge attitudes and practices
Shick EA. (2005)
USA [43]
Peer reviewed journal article Examine the effects of knowledge and confidence on dental referral practices among WIC nutritionists in North Carolina. Cross-sectional
118 item questionnaire- developed from previously tested questionnaires and pilot tested
324 nutritionists • Most nutritionists were knowledgeable about basic oral hygiene and caries related diet recommendations.
• Nutritionists were less aware (33%) of potential caries transmission from carers and importance of fluoride for children.
• Nutritionists were very confident about providing oral health counselling and dental referrals (90–96%). They were Less confident (39.3%) about undertaking oral health risk screenings of children.
• Confidence in undertaking oral health risk screenings (OR2.12), and making dental referrals (OR 3.02) was associated with more frequent referrals.
Models of care and resources
Karmally W. (2014)
USA [44]
Webinar Provide education on the association between nutrition and oral health conditions and discuss practical strategies for dietitians to integrate oral health information with nutrition counselling. N/A Webinar approved for continued professional education • Webinar discusses the relationship between nutrition, disease and oral health and provides strategies on how dietitians can incorporate oral health into the nutrition assessment (including oral health screening). Models of care and resources
Brody R.A. (2014)
Israel [45]
Peer reviewed journal article To assess the changes in knowledge and practice of dietitians, working in geriatric care in Israel, following a training program in nutrition focused physical assessment of the oral cavity. Prospective pilot study using a pre- posttest design.
Investigator designed 29 item knowledge pre-test (face and content validity established) and patient data collection forms (practices)
30 dietitians completed the pre-and post-test questionnaires. Testing conducted pre-training, immediately post-training and 12 months post-training (3 timepoints)
Training was provided to dietitians which included oral related anatomy, performing extra-oral and intra-oral examination and screening for dysphagia and vitamin deficiencies
• Pretesting suggests that dietitians had limited nutrition focused physical assessment oral health knowledge. At each timepoint following training, knowledge had increased.
• Three months post training, dietitians were more likely to perform oral health screenings rather than not assessing or obtaining history from the medical record.
• Dietitians were 5.7 x more likely to refer to other allied health professionals 3 months post-training.
Models of care and resources
Jeganathan, S. (2010)
Australia [46]
Peer reviewed journal article Develop and validate a 3-item oral health assessment questionnaire (OHQ) for use by dietitians to screen individuals with HIV at risk of dental complications for referral to dental health services. Cross-sectional Tool to be validated: 3 item oral health assessment questionnaire (OHQ) and the Oral health Impact profile 14 (OHIP-14) was administered to 273 clients • Questionnaire completed by 273 participants.
• The OHQ was found to be a valid and sensitive screening tool for dietitians to initiate further investigation for oral health screening and referral to dental professionals.
• The sensitivity for the OHQ was 84% and the specificity was 55%.
• Compared to the ‘Gold Standard’ Oral health Impact profile-14 (OHIP), the OHQ demonstrated adequate validity (rho = 0.617 (95% CI 0.54, 0.69), P < 0.0001).
Models of care and resources
The Albion Centre, oral health promotion working group - NSW Health (2015)
Australia [47]
Oral health resource Oral health screening and referral tool for health professionals (including dietitians) working with individuals with HIV. N/A Oral health resource includes three item oral health assessment tool, take home advice for clients, referral pathways and information about common dental problems encountered by individuals with HIV N/A Models of care and resources
Pac West MCH - distance Learning Network, University of Washington (2005) USA [48] Oral health education and screening resource Provides actions that non-dental and dental health professionals can take to identify individuals at risk of oral health complications and provides guidelines for action. N/A Module 5 of an online resource for actions that non-dental health professionals can consider when addressing oral health complications which includes: potential oral health screening and prevention activities, suggestions for screening tools for nutrition related oral health problems, mechanisms for referral and further resources and initiatives N/A Models of care and resources