Nutritional considerations for patients undergoing maxillofacial surgery – A literature review

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Review Article

Nutritional considerations for patients undergoing maxillofacial surgery e A literature review Shilpa Jain a, Arpit Jain b,*, Umesh Palekar c, Kamal Shigli d, Ajay Pillai e, Ashutosh Dutt Pathak f a

PG Student, Department of Prosthodontics, Crown and Bridge and Implantology, Modern Dental College and Research Centre, Indore, M.P., India b PG Student, Department of Oral Medicine and Radiology, People’s College of Dental Science and Research Centre, Bhopal, M.P., India c Professor and Head, Department of Prosthodontics, Crown and Bridge and Implantology, Modern Dental College and Research Centre, Indore, M.P., India d Professor, Department of Prosthodontics, Crown and Bridge and Implantology, BVP Dental College and Hospital, Sangli, M.H., India e Associate Professor, Department of Oral and Maxillofacial Surgery, People’s Dental Academy, Bhopal, M.P., India f PG Student, Department of Oral and Maxillofacial Surgery, People’s College of Dental Science and Research Centre, Bhopal, M.P., India

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abstract

Article history:

Malnutrition is one of the most common causes of morbidity in patients undergoing

Received 27 February 2013

maxillofacial surgery. In these patients, normal food intake is impaired because of the

Accepted 9 July 2013

disease state and is complicated further by the surgical procedures. Surgery imparts controlled injury and delays wound healing capacity. Consideration should be given to the

Keywords:

nutritional status of these patients in both preoperative and postoperative period so as to

Diet

reduce postoperative complications. It should be imperative upon the part of dental pro-

Nutrition

fessional to identify patients at nutritional risk, perform nutritional screening tests and

Nutritional assessment

provide dietary guidelines. In this paper we have focused on nutritional risk, nutritional

Nutritional risk

assessment, and recommendations for such kind of patients. ª 2013 Indian Journal of Dentistry. All rights reserved.

1.

Introduction

Nutrition is defined as the science of how the body utilizes food to meet requirements for development, growth, repair, and maintenance.1 There are six classes of nutrients found in food: carbohydrates, fats, proteins, vitamins, minerals, and water.2 First three categories are energy producing nutrients;

that is, they provide calories and enable the body to generate energy for carrying on its many functions.2 Although the latter three do not provide energy, they facilitate a variety of activities in the body. In the patient having dental surgery, there are several considerations that impact and rely on nutritional status.2 Malnutrition accounts for one of the major factors contributing to the postsurgical morbidity.3 Firstly, surgery

* Corresponding author. Tel.: þ91 9425474806. E-mail address: [email protected] (A. Jain). 0975-962X/$ e see front matter ª 2013 Indian Journal of Dentistry. All rights reserved. http://dx.doi.org/10.1016/j.ijd.2013.07.014

Please cite this article in press as: Jain S, et al., Nutritional considerations for patients undergoing maxillofacial surgery e A literature review, Indian Journal of Dentistry (2013), http://dx.doi.org/10.1016/j.ijd.2013.07.014

2

i n d i a n j o u r n a l o f d e n t i s t r y x x x ( 2 0 1 3 ) 1 e4

imparts controlled injury and delays or lengthens the process of healing.4 Secondly, the success of the body to heal itself is critically dependent on the extent of the injury and the presence of sufficient and continued nutrition.4 The mouth is the portal for entry of food into the body; thus, disease of the oral and maxillofacial region and/or surgery of these structures may result in impaired food intake both prior to and after surgery.4 The severity and duration of impairment is dependent on the disease state and the surgical intervention required correcting it.4 The dentist must be cognizant of methods to ensure the patient has appropriate nutritional support.

2.

Nutrition and wound healing

Patients undergoing surgical procedures require protein source and energy. Carbohydrates, proteins and fatty acids are chief source of energy.5 The body requires an adequate supply of carbohydrates to prevent protein catabolism and fatty acid metabolism.5 Alternatively, excess glucose or hyperglycemia is not beneficial as it results in decreased leukocyte function, in dehydration and in metabolic acidosis.5 Wound healing requires energy,5 thus nutritional status of patient affects wound healing.5 Although, protein serves as a source of energy, its primary purpose is cellular proliferation and cell repair.5 Prognosis of the maxillofacial surgery depends upon bone healing.5 Protein plays vital role in fracture repair. Patients who are severely malnourished, demonstrate delayed wound healing and impaired wound contraction.5 A malnourished patient has increased susceptibility towards infection. All these conditions lead to prolonged rehabilitative period.5

require artificial nutritional support, the maxillofacial surgery patients should follow food guide that is organized into four major food groups to achieve optimal nutrition. A food group in the food guide includes: - Milk Group: 2 or more cups. - Meat Group: 1 or more servings e fish, poultry, eggs. - VegetableeFruit Group: 4 or more servings: include citrus fruits for vitamin C, green and deep yellow vegetables for vitamin A, other vegetables, fruits and potatoes. - BreadeCereal Group: 4 or more servings of whole grain enriched or restored products.7 There are several modes of support that are commonly used in the ambulatory patients during perioperative period4: clear liquid diet, full liquid diet, pureed diet, mechanical soft diet, and regular diet.4 A clear liquid diet is often used in immediate postoperative period after a parenteral sedation.4 A patient is advised for complete diet after he gains recovery from gastrointestinal intolerance. The diet is low in nutrients.4 A fully liquid diet is more nutritionally complete. The diet is good for patients who cannot chew or swallow foods. A fully liquid diet frequently consists of milk products. But, it should be used with caution in patients with lactose intolerance.4 A pureed or mechanical soft diet is transitional diet. These diets provide patients with increased consistency and food texture. A pureed diet can be administered easily in patients. A soft diet allows more freedom in selecting food items and also is less monotonous than liquid diet. Meats and fruits can be made quite flavored. Meats can be thinned with milk to make broth, while fruits can be used or is added to other foods.8

4.1.

3.

Surgical considerations

The dentist can be confronted with numerous situations that require dietary management. Patients must be first assessed for baseline nutritional status and then assessed for the impact that dental treatment will have on the nutritional status.4 Treatment of head and neck cancer may severely affect the patient’s normal eating pattern.4 The surgical resection of oro-facial structures can impair patient’s dietary intake.4 Chemotherapy/radiotherapy may produce irreversible changes in cancer patients. Oral mucositis occurring during acute treatment phase of chemotherapy or radiotherapy may produce severe pain and may alter the patient’s dietary intake. Altered taste sensation and xerostomia may also be found following the therapy for oral cancer which affects the nutritional intake of the patient.4

4.

Nutritional support

Nutritional support is indicated in patients who cannot have adequate nutrition by diet alone. On the contrary, artificial nutritional support in well-nourished or undernourished patients may either provide no benefit or may increase patient morbidity. Nutritional support for a malnourished patient: - Promotes growth, tissue healing and maturation of collagen.9 - Enhances immunity.10 - Reduces muscle bulk and function.11 - Prevents septicaemia.12

4.2.

Nutritional assessment

All patients should be assessed perioperatively by the dietician and this should be an integral part of multidisciplinary team approach in managing nutritional deficient patients. Following information should be used to assess nutritional status of the patient:

Basic diet

The basic dietary requirement for the surgical patients includes adequate amount of proteins, vitamins and minerals.6 In addition sufficient calorie from carbohydrates and lipids are necessary to provide energy.6 Except for the patients who

- History: preoperative weight, recent weight loss if any, loss of appetite, ability to swallow. Unintentional weight loss of more than 10% body weight within 6 months is considered hazardous. Proper nutritional support is indicated in these patients.13

Please cite this article in press as: Jain S, et al., Nutritional considerations for patients undergoing maxillofacial surgery e A literature review, Indian Journal of Dentistry (2013), http://dx.doi.org/10.1016/j.ijd.2013.07.014

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- Assessment of nutrition should include calorieenitrogen ratio using daily dietary intake.14 - Examination e height/weight ratio, muscle wasting, triceps skinfold thickness, arm circumference and creatinineeheight index should be assessed.15 - Body mass index e calculated as body weight in kilograms divided by height in meter squares.16 - Laboratory tests: diagnostic tests including haematological evaluations provide insight into possible causes of oral or other systemic diseases. Complete blood count should be assessed to aid in determining immune response. Laboratory data provides value for electrolytes, serum proteins, trace elements, glucose, lipids, and organ function.17

4.3.

Nutritional requirements

Gastrointestinal (G.I) tract acts as an important immune organ. Patients suffering from upper gastrointestinal tract cancer suffer from severe proteinecalorie malnutrition. In these patients, enteral nutrition is preferred over parenteral nutrition. Immunonutrition should be considered in critically ill patients and elective surgery patients.18,19

5.1.

3

Patient monitoring

An important part of nutritional support is monitoring the patient. Whether it is enteral or parenteral, a check on patient’s weight, calorieenitrogen ratio, daily dietary intake and fluid balance is necessary. Continuous supervision of patients by dietician from the diagnosis of the disease is essential in limiting weight loss.21

6.

Conclusion

Poor nutrition plays an important role in development of postoperative complications and may increase patient morbidity. Proper nutritional assessment and appropriate preventive measures should be undertaken in the patients undergoing maxillofacial surgery. Nutritional support should be considered in severely malnourished patients. But, the indiscriminate use of nutritional support should be avoided to reduce postoperative complications.

Conflicts of interest Recommendations20

5.

All authors have none to declare.

Level 1  Patients with chronic malnutrition benefit from nutritional support.  Enteral nutrition: - is preferred over parenteral nutrition in patients with functional GI tract. - should be initiated within 18 h of injury in burn patients. - should be initiated within 24 h of admission in critically ill patients.  Immunonutrition should be used in malnourished elective GI surgical patients.  Immunonutrition should involve an initial 5e7 day course with subsequent re-evaluation. Level 2  Patients with severe head injury who did not tolerate gastric feeding within 48 h of injury should receive post-pyloric feeding.  Nutritional assessments should be performed weekly and adequate nutritional support should be provided to meet individual’s needs. Level 3  Incompletely resuscitated patients should not receive direct small bowel feedings due to gastric intolerance.  Intragastric feeding of severe closed head injury patients should be initiated within 12 h of admission.  In severely injured patients, parenteral nutrition should be started within 7 days if patient is unable to tolerate atleast 50% of caloric requirement.

references

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Please cite this article in press as: Jain S, et al., Nutritional considerations for patients undergoing maxillofacial surgery e A literature review, Indian Journal of Dentistry (2013), http://dx.doi.org/10.1016/j.ijd.2013.07.014