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CDHO Advisory: Nutritional Disorders









Use of the dental hygiene interventions of scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons1 with nutritional disorders.


Cite as College of Dental Hygienists of Ontario, CDHO Advisory Nutritional Disorders, 2020-04-19


Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions (“the Procedures”).



Nutritional disorders


Advanced practice nurses
Dental assistants
Dental hygienists
Health professional students
Public health departments
Regulatory bodies


To guide dental hygienists at the point of care relative to the use of the Procedures for persons who have nutritional disorders, chiefly as follows.

  1. Understanding the medical condition.
  2. Sourcing medications information.
  3. Taking the medical and medications history.
  4. Identifying and contacting the most appropriate healthcare provider(s) for medical advice.
  5. Understanding and taking appropriate precautions prior to and during the Procedures proposed.
  6. Deciding when and when not to proceed with the Procedures proposed.
  7. Dealing with adverse events arising during the Procedures.
  8. Record keeping.
  9. Advising the patient/client.


Child (2 to 12 years)
Adolescent (13 to 18 years)
Adult (19 to 44 years)
Middle Age (45 to 64 years)
Aged (65 to 79 years)
Aged 80 and over
Parents or guardians of children and young persons with nutritional disorders.


For persons who have nutritional disorders: to maximize health benefits and minimize adverse effects by promoting the performance of the Procedures at the right time with the appropriate precautions, and by discouraging the performance of the Procedures at the wrong time or in the absence of appropriate precautions.



Nomenclature of nutritional disorders

Adapted from

Among centres and authorities, terminology varies as does the meaning ascribed to key terms. The following represents broad but not necessarily universal usage.

  1. Acidic oral fluids, as defined for this Advisory, includes those that 
    1. usually are ingested, such as
      1. acidic beverages
      2. citrus fruits
    2. result from fermentation to lactic and other acids of sucrose and other non-milk sugars in food items, other than fresh fruits and vegetables, by plaque-bacterium Streptococcus mutans 
    3. occasionally originate as gastric contents, with
      1. gastroesophageal reflux disease
      2. vomiting of a recurrent nature, as in
        1. bulimia 
        2. vomiting associated with repeated, excessive consumption of alcohol.
  2. Anorexia, a type of eating disorder that may
    1. arise from 
      1. dental problems that restrict the ability to chew and therefore digest food
      2. swallowing problems associated with 
        1. dry mouth 
        2. neurological disorders, such as stroke
        3. esophageal candidiasis
      3. poverty in extreme conditions, such as famine or war
      4. association with various medical conditions
      5. functional impairment of activities of daily living
    2. may also involve psychological disorders, such as 
      1. anorexia nervosa, which particularly affects girls and young women
      2. anorexia associated with
        1. loneliness, especially in the elderly
        2. depression
  3. Body mass index, BMI, measure of body fat based on height and weight (defined as an individual’s body weight in kg divided by the square of his/her height in metres; standard unit of measure is thus kg/m2).2
  4. Bulimia, also called bulimia nervosa, an eating disorder of psychological origin, characterized by episodes of secretive excessive eating (bingeing) followed by inappropriate methods of weight control such as
    1. self-induced vomiting
    2. abuse of laxatives and diuretics
    3. excessive exercise.
  5. Catabolism, with various meanings, including 
    1. breakdown of complex substances, such as proteins in the body or food, into simpler ones together with release of energy
    2. a destructive type of metabolism.
  6. Cachexia, wasting that results from chronic disease; signals include 
    1. weight loss
    2. loss of muscle mass
    3. loss of appetite.
  7. Cancrum oris, noma, orofacial gangrene, gangrenous stomatitis, which causes progressive and devastating destruction of the infected tissues
    1. occurs almost exclusively in children, chiefly in those under 10 years
    2. seen almost only in developing countries.
  8. Cytokines, regulatory proteins, such as the interleukins and lymphokines, released by immune-system cells; act as intercellular mediators in the generation of an immune response.
  9. Dental erosion, tooth erosion, irreversible loss of tooth enamel due to chemical processes that do not involve bacterial action.
  10. Enamel hypoplasia, characterized by hypoplastic grooves, with or without pits in the enamel, often horizontal or linear in appearance, and enamel opacities.
  11. Gluten enteropathy (celiac disease), a chronic disease of the digestive tract that interferes with the digestion and absorption of gluten, a protein commonly found in wheat, rye, and barley.
  12. Hyperphagia, abnormally increased appetite for and consumption of food.
  13. Lean body mass, the weight of the body minus the fat. 
  14. Malnourishment, occurs when the
    1. diet fails to provide adequate calories and protein for growth and maintenance
    2. body is unable to fully utilize the food consumed 
    3. person consumes too many calories.
  15. Metabolic syndrome, a combination of risk factors for cardiovascular disease and type 2 diabetes, especially
    1. excess intra-abdominal fat
    2. insulin resistance
    3. some combination of 
      1. elevated plasma triglyceride levels
      2. decreased high density lipoprotein (HDL) 
      3. hypertension.
  16. Malnutrition, malnourishment, commonly used to mean undernutrition, but technically also refers to overnutrition; occurs when
    1. the diet does not provide adequate calories and protein for growth and maintenance
    2. illness impairs the full utilization of food consumed
    3. excess of calories are consumed.
  17. Obesity, excess body fat, the effects of which depend not only on the absolute amount but also on the distribution of the fat.
  18. Overnutrition, an increasing problem in North America which
    1. is caused by 
      1. dietary imbalances and excesses
      2. insufficient exercise
    2. increases as a risk when the body weight is 20 percent greater than the appropriate norms for age and height
  19. Nutritional disorder, nutrition disorder, caused by
    1. insufficient or excessive intake of food or certain nutrients
    2. inability of the body to absorb and use nutrients
    3. overconsumption of certain nutrients.
  20. Nutritional Support
    1. required for undernourished person to increase lean body mass
    2. may involve 
      1. oral feeding
      2. behavioural approaches
      3. tube feeding
      4. enteral tube feeding
      5. parenteral nutrition
  21. Protein-energy undernutrition, occurs in
    1. the institutionalized elderly
    2. persons with disorders that decrease appetite or impair nutrient digestion, absorption, or metabolism
    3. in young children at the time of weaning in developing countries, resulting from inadequate intake of protein and calories, characterized by emaciation; is related to starvation evidenced as
      1. marasmus
      2. kwashiorkor. 
  22. Stoss therapy, a regimen of vitamin D supplementation.
  23. Type 2 diabetes, begins with insulin resistance, a condition in which fat, muscle, and liver cells do not use insulin properly; is related to obesity; eventually the pancreas loses the ability to produce sufficient insulin for meals.
  24. Undernutrition, a form of malnutrition
    1. variously defined 
      1. as a consequence of consuming too few essential nutrients
      2. as a consequence of the body’s using or excreting essential nutrients more rapidly than they can be replaced
      3. as the outcome of insufficient food intake and repeated infectious diseases
      4. in comparison to the norms for the person’s age and height
        1. as underweight 
        2. too short 
        3. dangerously underweight 
      5. deficient in vitamins and minerals.
    2. results from
      1. inadequate ingestion of nutrients
      2. malabsorption
      3. impaired metabolism
      4. loss of nutrients  through
        1. diarrhea
        2. excessive sweating
        3. hemorrhage
        4. kidney failure
      5. restriction of nutrient intake because of
        1. age-related illnesses and conditions
        2. excessive dieting
        3. severe injury
        4. serious illness
        5. lengthy hospitalization
        6. substance abuse
      6. increased nutritional requirements resulting from
        1. infection
        2. trauma
        3. hyperthyroidism
        4. extensive burns
        5. prolonged fever
      7. any condition that increases cytokines, which may be accompanied by muscle loss, lipolysis, low albumin levels, and anorexia
    3. progresses in stages; each stage usually takes time to develop
      1. early stage: nutrient levels in blood and tissues change
      2. mid-stage: intracellular changes in biochemical functions and structure
      3. advanced stage: symptoms and signs

Overview of nutritional disorders

Adapted from

Disorders caused by nutritional imbalance, either overnutrition or undernutrition, include

  1. Obesity, which 
    1. occurs
      1. in childhood
        1. in which it may be a greater concern than in adults
        2. results in complications that include
          1. poor self-esteem
          2. social difficulties
          3. depression
          4. musculoskeletal complications
          5. obesity-related conditions when obese children become adults
      2. in the elderly
        1. in whom it is increasing in incidence
        2. favours complications, the risk of which is increased by 
          1. abdominal obesity
          2. duration and severity of the obesity
          3. loss of skeletal muscle mass and its replacement by fat
    2. is caused by 
      1. genetic predisposition
      2. persistent imbalance of
        1. energy intake
        2. energy utilization for basic metabolic processes
        3. energy expenditure from physical activity
      3. pregnancy factors, including
        1. maternal obesity
        2. a permanent gain of 9 kg or more with each pregnancy in some 15 percent of women
      4. obesity that persists beyond early childhood, which acts to constrain weight loss in later life
      5. eating disorders 
        1. binge eating disorder 
          1. is consumption of large amounts of food quickly coupled with a sense of loss of control during the binge and distress after 
          2. does not include compensatory behaviours such as vomiting (as in bulimia)
          3. occurs in 
            1. 1 to 3 percent of both sexes
            2. 10 to 20 percent of persons entering weight-reduction programs
          4. is characterized by 
            1. severe obesity
            2. loss or gain of large amounts of weight
            3. psychological disturbances
        2. night-eating syndrome, which
          1. comprises
            1. morning anorexia
            2. evening hyperphagia
            3. insomnia
          2. occurs in some 10 percent of persons seeking treatment for severe obesity 
          3. is characterized by consumption of a quarter or more of the daily food intake after the evening meal
          4. is more extreme that nocturnal eating, which also contributes to excess weight gain.
        3. medications
    3. is diagnosed and assessed by
      1. body mass index 
      2. family history of 
        1. type 2 diabetes 
        2. premature cardiovascular disease
      3. growth charts for children
      4. body weight classification charts for adults
      5. waist circumference for adults
      6. blood pressure, fasting plasma glucose, and lipid levels
    4. is associated with complications, including
      • cardiovascular disorders
      • deep venous thrombosis
      • diabetes
      • fatty liver and cirrhosis
      • gallstones, gallbladder disease
      • gastroesophageal reflux disease
      • mental health problems
      • obstructive sleep apnea
      • osteoarthritis
      • premature death
      • pulmonary embolism
      • reproductive disorders, both sexes
      • skin disorders
      • sleep insufficiency
      • social and mental health problems
      • various cancers
    5. is treated by
      1. physical activity
      2. dietary and nutrition management
      3. behavioural modification
      4. drugs
      5. surgery
    6. is prevented by
      1. regular physical activity and healthy eating to 
        1. improve general fitness
        2. control weight
        3. help control diabetes 
        4. decrease risk of cardiovascular disorders
      2. sufficient good-quality sleep
      3. management of stress
      4. moderation of alcohol intake.
  2. Metabolic syndrome
    1. is a serious and increasing problem, which affects children and adults
    2. resembles obesity in causes, complications, diagnosis, and treatment.
  3. Undernutrition 
    1. occurs in association with
      1. social deprivation
      2. cachexia
      3. certain phases of life
        1. infancy, childhood and adolescence, because of high demand for energy and essential nutrients
        2. pregnancy and breastfeeding
        3. institutionalization of the elderly, as 
          1. protein-energy undernutrition, which is common
          2. replacement of lost muscle mass by fat, which accounts for many of the complications of undernutrition
          3. anorexia
      4. various diseases and medical procedures, such as
        1. diabetes
        2. some chronic disorders that affect the gastrointestinal tract
        3. intestinal resection, and certain other gastrointestinal surgical procedures that may impair absorption of vitamins
        4. gluten enteropathy 
        5. pancreatic insufficiency
        6. liver disorders
        7. kidney disorders
    2. particular diets, including
      1. vegetarian diets, which may lead to nutritional deficiencies, such as
        1. ovo-lacto vegetarian
        2. vegan
        3. fruit-only
      2. fad diets, which may lead to nutritional deficiencies
    3. alcohol or substance abuse because of
      1. neglect of nutritional needs
      2. impairment of absorption and metabolism of nutrients 
    4. medications
    5. may result in complications such as
      1. iron deficiency
      2. osteoporosis
      3. impaired storage of vitamins 
      4. interference with metabolism of protein and energy sources
      5. protein, iron, and vitamin deficiencies 
    6. is identified and assessed by
      1. questionnaire
      2. reference to norms for weight for age and sex, or height
        1. growth charts for children
        2. body weight classification charts for adults
      3. clinical status
    7. treated with nutritional support.


Comorbid conditions are those which co-exist with nutritional disorders but which are not believed to be caused by it; associated conditions and complications are those that may have some link with of nutritional disorders.

Oral health considerations

Adapted from

  1. Oral healthcare
    1. as an important healthcare strategy is a recurrent theme in the literature on nutritional disorders
    2. is important in nutritional disorders because of interactions
      1. between nutritional disorders and the state of oral health
      2. that involve some combination of nutritional disorders, the state of oral health, medical conditions and medications
    3. is provided to populations in which social and demographic factors influence nutrition and its disorders and therefore forms part of the integrated approach to prevention, detection of and care for nutritional disorders, especially for
      1. children
      2. seniors.
  2. Effects of diet on oral health include
    1. Early eruption of the first primary tooth may be linked with Stoss therapy.
    2. Cancrum oris, which occurs mainly in children with malnutrition, poor oral hygiene and debilitating concurrent illness.
    3. Decalcification of teeth and the ensuing caries associated with acidic oral fluids.
    4. Delayed eruption resulting from early childhood malnutrition
      1. is established for the primary teeth
      2. is not established for the permanent teeth
    5. Dental caries 
      1. in primary dentition appear to be associated with early childhood malnutrition
      2. in permanent dentition are not firmly linked with early childhood malnutrition
      3. result from in-mouth fermentation of food-related acidic oral fluids, which causes decalcification, in combination with the associated breaking up of proteins 
      4. in early childhood (early childhood caries) may be associated with
        1. poor oral hygiene
        2. the practice of adding sugar to the content used for bottle-feeding.
    6. Dental erosion results from chemical attack on the mineralized, hard-enamel protection of the tooth by acidic oral fluids the effects of which
      1. are normally neutralized by saliva, but this protection may fail if the acid attack occurs too frequently
      2. in  gastroesophageal reflux disease may be reduced by
        1. plaque control
        2. reduction of intake of refined carbohydrates and carbonated beverages to maximize the potential for
          1. remineralization
          2. optimization of the neutralizing effects of saliva
      3. eventually erode the enamel if the erosion is allowed to progress, exposing small areas of dentine 
      4. require consideration of 
        1. what foods and beverages are consumed because natural foods and beverages, such as apples and fruit juice, may through acidity cause erosion if consumed in excessive quantities
        2. how foods and beverages are consumed because frequent consumption repeated over short periods is most harmful because it limits the time available for the saliva to neutralize the acidity
      5. may be the result of past rather than current dietary habits
      6. may require review of tooth-brushing habits because
        1. tooth-brushing shortly after consumption of acids may cause damage to teeth to a greater extent than after, say, 30 minutes because it removes from the teeth the saliva that would have neutralized the acidity
        2. brushing teeth before meals may be more protective than after them, when acidic food and drink are consumed.
    7. Enamel hypoplasia in
      1. primary dentition is associated with malnutrition in early childhood
      2. permanent dentition is not firmly linked with malnutrition in early childhood.
    8. Salivary insufficiency may 
      1. be associated with early childhood malnutrition through a possible linkage involving 
        1. salivary flow rates
        2. buffering capacity and the protein composition/content of saliva
      2. increase caries risk.
    9. Tooth pain may result from thermal stimulation or from sweet or sour food or drink when caries reaches the dentine.
    10. Tooth wear, attrition of the occlusal surfaces, may arise from a combination of acid erosion, abrasion and attrition, but the interaction among them is unclear.
  3. Effects of oral health on nutrition
    1. Oral health problems may 
      1. impair the
        1. ability to eat
        2. appetite or desire to eat
      2. create undernutrition which then 
        1. causes additional symptoms
        2. may exacerbate existing or create new further oral health problems.
    2. Edentulism
      1. carries the risk of  compromised nutrition 
        1. because of 
          1. difficulty chewing 
          2. dietary modification in response to chewing difficulties
        2. in persons who 
          1. are elderly
          2. have chronic medical conditions
          3. have serious mental health disorders
      2. may be treated with oral rehabilitation with simple mandibular-implant overdentures for persons wearing conventional dentures. 


Sourcing medications information

  1. Adverse effect database
  2. Specialized organizations
  3. Medications considerations
    All medications have potential side effects whether taken alone or in combination with other prescription medications, or as over-the-counter (OTC) or herbal medications.
  4. Information on herbals and supplements 

Types of medications


Individual medications may be subject to important warnings, which

  1. change from time to time
  2. may affect the appropriateness, efficacy or safety of the Procedures
  3. are accessible via the links to the particular medications listed below or through the specialized organizations listed above
  4. through the links, should be viewed by dental hygienists in the course of their familiarizing themselves about a medication or combination of medications identified in the patient/client’s medical and medications history.


  1. Medications with effects such as 
    1. appetite suppression as the therapeutic purpose
      1. such as
        phentermine (Adipex-P®,  Ionamin®)
        diethylpropion (Tenuate®,  Tenuate Dospan)
      2. should be used with a reduced-calorie diet and appropriate exercise, which must be continued after the weight has been lost
    2. weight loss as the therapeutic purpose
      1. such as
        orlistat (Alli®, Xenical®)
    3. appetite suppression as a side effect
    4. impairment of absorption of nutrients
    5. appetite stimulation as the therapeutic purpose, such as
      megestrol (Megace®)
      dronabinol (Marinol®)
    6. appetite stimulation as a side effect
    7. increasing catabolic action
    8. interactions with food, which may 
      1. affect appetite, taste, and food intake
      2. affect excretion
      3. alter the ways medications are absorbed, utilized or detoxified in the body
      4. cause nausea and vomiting
      5. change with aging, when
        1. medications are not metabolized as well as in earlier years, and vulnerability to side effects increases
        2. multiple medications compound the risk for nutritional deficiencies.
    9. medications that impair absorption or metabolism of nutrients
  2. Vitamins and mineral supplements 
    1. are used as medication for the treatment of 
      1. specific, well-documented risk of deficiencies
      2. diagnosed diseases arising from deficiencies
    2. have limited usefulness in the prevention and treatment of systemic diseases 
    3. are misused on the assumption that they prevent various diseases or even cure them.

Side effects of medications

The following resource supports exploration of oral and nutritional side effects of particular medications.

US National Library of Medicine and the National Institutes of Health Medline Plus Drug Information


The medical  and medications history-taking should 

  1. Focus on screening the patient/client prior to treatment decision relative to
    1. key symptoms
    2. medications considerations
    3. contraindications
    4. complications
    5. comorbidities
    6. associated conditions.
  2. Explore the need for advice from the appropriate primary care provider(s).
  3. Inquire about
    1. the patient/client’s understanding and acceptance of the need for oral healthcare
    2. symptoms indicative of nutritional disorders
    3. medications considerations, including over-the-counter medications, herbals and supplements
    4. problems with previous dental/dental hygiene care
    5. problems with infections generally and those specifically associated with dental/dental hygiene care
    6. how the patient/client’s state of health is at this moment
    7. how the patient/client’s current symptoms relate to
      1. oral health
      2. health generally
      3. recent changes in the patient/client’s condition.


Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain medical or other advice pertinent to a particular patient/client

  1. Record the name of the physician/primary care provider most closely associated with the patient/client’s healthcare, and the telephone number.
  2. Obtain from the patient/client or parent/guardian written, informed consent to contact the identified physician/primary healthcare provider.
  3. Use a consent/medical consultation form, and be prepared to securely send the form to the provider.
  4. Include on the form a standardized statement of the Procedures proposed, with a request for advice on proceeding or not at the particular time, and any precautions to be observed.


Infection Control

Dental hygienists are required to keep their practices current with infection control policies and procedures, especially in relation to

  1. the CDHO’s Infection Prevention and Control Guidelines (2022)
  2. relevant occupational health and safety legislative requirement
  3. relevant public health legislative requirements
  4. best practices or other protocols specific to the medical condition of the patient/client.


In an otherwise healthy patient/client without severe nutritional disorder there is no contraindication to the Procedures. But the Procedures may be postponed pending medical advice if the patient/client has

  1. One or more comorbidities of nutritional disorder.
  2. One or more complications of nutritional disorders.
  3. Recently changed medications, under medical advice or otherwise.
  4. Recently experienced changes in his/her medical condition.


Dental hygienists are required to initiate emergency protocols as required by the College of Dental Hygienists of Ontario’s Standards of Practice, and as appropriate for the condition of the patient/client.

First-aid provisions and responses as required for current certification in first aid.


Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2)

For a patient/client with a history of nutritional disorder, the dental hygienist should specifically record

  1. A summary of the medical and medications history.
  2. Any advice received from the physician/primary care provider relative to the patient/client’s condition.
  3. The decision made by the dental hygienist, with reasons.
  4. Compliance with the precautions required.
  5. All Procedure(s) used.
  6. Any advice given to the patient/client.


The patient/client is urged to alert any healthcare professional who proposes any intervention or test that he or she has a history of nutritional disorders.

As appropriate, discuss 

  1. The importance of a good diet in the maintenance of oral health, with particular reference to
    1. reducing consumption and, especially, frequency of intake of food and drink containing sugar 
    2. limiting to meals and avoiding as snacks food and drink containing sugar
    3. consuming snacks food and drinks that are free from sugar
    4. avoiding frequent consumption of acidic drinks. 
  2. The need for regular oral health examinations and preventive oral healthcare. 
  3. Home oral hygiene including information about choice of toothpaste, tooth-brushing devices, dental flossing, mouth rinses and saliva control, with particular reference to the timing of tooth-brushing relative to meals. 
  4. Medication side effects such as dry mouth, and recommend treatment.
  5. Scheduling and duration of appointments for patients/clients who are debilitated.
  6. Comfort level while reclining, and stress and anxiety related to the Procedures.
  7. Mouth ulcers and other conditions of the mouth relating to nutritional disorders, comorbidities, medications or diet.
  8. Pain management.



  1. Promotion of health through oral hygiene for persons who have nutritional disorders.
  2. Reduction of the adverse effects, such as undernutrition in the institutionalised elderly, by
    1. monitoring for indications of nutritional disorders in persons undergoing oral healthcare
    2. generally increasing the comfort level of persons in the course of dental hygiene interventions 
    3. using appropriate techniques of communication
    4. providing advice on scheduling and duration of appointments .
  3. Reduction of risk of oral health needs being unmet.


  1. Failing to identify and seek advice for dental erosion.
  2. Performing the Procedures at an inappropriate time, such as 
    1. when the patient/client is weakened by nutritional disorder which requires medical attention
    2. in the presence of complications or comorbidities for which prior medical advice is required
    3. in the presence of acute oral infection without prior medical advice.
  3. Disturbing the normal dietary and medications routine of a person with nutritional disorder.
  4. Inappropriate management of pain or medication.








College of Dental Hygienists of Ontario, regulatory body
Greyhead Associates, medical information service specialists


College of Dental Hygienists of Ontario


College of Dental Hygienists of Ontario, Practice Advisors


Dr Gordon Atherley
O StJ , MB ChB, DIH, MD, MFCM (Royal College of Physicians, UK), FFOM (Royal College of Physicians, UK), FACOM (American College of Occupational Medicine), LLD (hc), FRSA

Dr Kevin Glasgow

Lisa Taylor

Kyle Fraser
RDH, BComm, BEd, MEd


The College of Dental Hygienists of Ontario gratefully acknowledges the Template of Guideline Attributes, on which this advisory is modelled, of The National Guideline Clearinghouse™ (NGC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.

Denise Lalande
Final layout and proofreading

© 2010, 2020 College of Dental Hygienists of Ontario


1 Persons includes young persons and children.
2 In adults, BMI is scaled according to the following categories: underweight = < 18.5; normal weight = 18.5 to 24.9; overweight = 25 to 29.9; and obesity = 30 or greater.  In children, BMI is compared against percentiles for children of the same sex and age: underweight = < 5th percentile; normal weight = 5th to 84th percentiles; overweight = 85th to 94th percentiles; and obesity = 95th percentile or above.