Renal Nutrition Forum

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1 Renal Nutrition Forum A Peer Reviewed Publication of the Renal Dietitians Dietetic Practice Group Volume 34 Number 2 In This Issue 1 Feature Article 2 Letter from the Editor 9 Advances in Practice 15 Case Study 22 RPG Stipend Award Report 22 Calendar of Events 25 Board Certified Specialists 26 RPG Stipend Award Report 27 App Review 28 RPG Chair Message 28 Recently Published 29 CRN Chairperson Message 30 Website Highlights 31 RPG Executive Committee Knowledge of and Patient Care Practices Regarding Oral Health Among Dietitians in Nephrology Care Cynthia Pike, MS, RD, LDN, CNSC Renal Dietitian; This study was completed as part of the master s thesis requirement for the Master of Science in Clinical Nutrition Program at Rutgers - School of Health Related Professions cynthia.pike@att.net Diane Rigassio-Radler, PhD, RD Associate Professor, Department of Nutritional Sciences; Director, Institute for Nutrition Interventions; School of Health Related Professions rigassdl@shrp.rutgers.edu James Scott Parrott, PhD Associate Professor; Department of Interdisciplinary Studies; School of Health Related Professions parrotja@shrp.rutgers.edu Laura Byham-Gray, PhD, RD Professor; Director, Master of Science in Clinical Nutrition Program; Department of Nutritional Sciences; Rutgers Biomedical and Health Sciences laura.byham-gray@shrp.rutgers.edu Riva Touger-Decker, PhD, RD, CDN, FADA Professor; Chair, Department of Nutritional Sciences, School of Health Related Professions Director, Division of Nutrition, Rutgers School of Dental Medicine decker@shrp.rutgers.edu This article has been approved for 1.0 CPEU unit. The online CPEU quiz and certificate of completion can be accessed in the Members Only section of the RPG website via the My CPEU link. This CPE offering is available to current RPG members only and the expiration date is April 15, Abstract Background: Oral health screening is part of a nutrition focused physical exam and can identify nutrition-related problems in patients with chronic kidney disease (CKD). Objective: To identify knowledge and frequency of performing select patient care practices related to oral health and disease based on a series of questions among Registered Dietitian (RD) members of the Academy of Nutrition and Dietetics-Renal Practice Group (RPG) or National Kidney Foundation Council on Renal Nutrition (CRN). Design: Descriptive, prospective internetbased survey. Participants/setting: RD members of the RPG/CRN who provide nutrition care to individuals with CKD in an ambulatory/ outpatient setting. invitations were sent to 2614 unduplicated members of the RPG/CRN; 18.8% (n=492) surveys were completed. Statistical analysis performed: Descriptive statistics, Pearson s product-moment correlation and Spearman s rho were conducted; alpha set at p<0.05. Results: The mean total knowledge score for participants was 65.9% (7.9 out of 12 correct). Weak, positive correlations were found between total knowledge score and: years in clinical practice in nephrology care (r=0.122,p=0.008), the reported frequency of evaluating patient s medications for risk of causing xerostomia, (r=0.272,p<0.001) and discussing the relationship between blood sugar control and oral health Continued on page 3. 1

2 Feature Article with patients/clients with diabetes (r=0.169,p<0.001). A moderate, positive correlation was found between total knowledge score and frequency of addressing xerostomia as part of diet/nutrition counseling (r=0.343,p<0.001). Conclusions: In this sample of RDs, those who scored higher on knowledge questions were more likely to report performing select patient care practices related to oral health and disease. Future research should address the impact of education/training regarding oral screening on renal dietetics practice. Key Words: Oral health, chronic kidney disease, nutrition assessment, nutrition focused physical exam. Introduction Nutrition assessment is the first step in the nutrition care process (NCP) (1). Nutrition-focused physical findings are a component of nutrition assessment and can help evaluate an individual s ability to obtain, prepare, ingest, and enjoy food (1,2,3). Nutrition focused physical assessment (NFPA) refers to a combination of information gathered through physical examination, interview, data from the patient s medical record and laboratory data to determine the optimal nutrition care plan that may or may not have been conducted by the Registered Dietitian (RD) performing the nutrition assessment (4-6). Nutrition focused physical exam (NFPE) refers to the actual conduct of the exam by the RD and includes assessment of nutrition-focused physical findings of the body systems, body composition, vital signs, oral health, and appetite (1,4,5). The purpose of the NFPE is to identify factors that may impact intake, reflect nutrition-related conditions or impact nutritional status (4). The Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists in Nephrology Nutrition (SOP/SOPP) recommends that NFPE include evaluation of oral and perioral structures as well as alterations in taste, smell and dentition (2). The Centers for Medicare and Medicaid Services (CMS) Conditions for Coverage outline nutritional parameters and nutrition-related factors that should be addressed when assessing a patient s nutritional status, including anthropometric data, appetite and oral intake, ability to chew and swallow, medication usage, hydration status, as well as the patient s attitude, motivation and self-management skills (7). The Academy of Nutrition and Dietetics Evidence Analysis Library has similar recommendations for conducting the nutrition assessment in patients diagnosed with chronic kidney disease (CKD) (8). NFPE of the oral cavity includes intra and extra oral screening of the mouth and related structures for non-normal findings and should be included as part of nutrition assessment in patients with CKD (2,9). Oral health screening includes the identification of non-normal findings within or around the oral cavity that may influence dietary intake, reflect possible nutritional deficiencies or swallowing difficulties, and impact nutritional status (1,9). In addition, RDs can identify nutritionrelated oral health problems such as ill-fitting dentures, compromised dentition, or presence of soft tissue lesions and incorporate these findings into their intervention and counseling. RDs should also consider oral manifestations of diseases and medications that may affect the oral cavity (10). Collaboration with and/or referral to oral health care providers when necessary, is an important step in nutrition care planning and reflects inter-professional patient care (4,9,10). The purpose of this study was twofold: 1) to identify knowledge related to oral health and disease based on a score on a series of questions, and 2) to determine current patient care practices regarding oral health and disease among RDs practicing in nephrology care who provide nutrition care to individuals with CKD Stages 3-5 or CKD Stage 5 (on dialysis). The hypotheses tested were that there were no relationships between knowledge based on a summed score for a series of questions related to oral health and disease and: 1. years as an RD in clinical practice, 2. years as an RD in clinical practice in nephrology care, and 3. the frequency of addressing non-normal oral health findings as part of diet/nutrition counseling. The relationships between the total knowledge score and select patient care practices regarding oral health and disease were also explored. Methods Sample The study sample consisted of RDs who were members of either The Academy of Nutrition and Dietetics- Renal Practice Group (RPG) or National Kidney Foundation Council on Renal Nutrition (CRN), work in the ambulatory/outpatient setting with CKD patients Stages 3-5 or CKD Stage 5 (on dialysis) and provide nutrition care to an average of at least one adult CKD Stage 3-5 or CKD Stage 5 (on dialysis) patient per week. Permission to the survey to members was obtained from each organization. invitations were sent to 2614 unduplicated members of the RPG and CRN. Study Design This study was a descriptive, prospective internet -based survey. Survey Monkey was used to distribute the survey and collect completed surveys (11). Institutional Review Board (IRB) approval was obtained through Rutgers Health Sciences IRB - Newark Campus (formerly the University of Medicine and Dentistry of New Jersey - Newark IRB). Members of the RPG and CRN were sent an initial with a brief message to inform them about the study with an option to request a paper copy of the survey or choose to opt-out of the survey at that time. The second contact was an to all members with a brief description of the study, a statement of confidentiality and consent and a link to participate in the study. Non-responders were sent a follow up two and four weeks after the initial survey invitation. The survey tool questions were adapted with permission from prior studies regarding oral health and disease, and additional questions were developed by the study team (5,12-18). The survey was reviewed by RD experts in nutrition and oral health and RD experts in nephrology care for face and content validity. The survey was then pilot tested with a sample of RDs in nephrology care and modified accordingly. Data Analysis SPSS software, Version 20.0 was used for data analysis. Descriptive statistics were performed on demographic and professional characteristics, knowledge questions and patient care practices. Pearson s product moment correlation was used to explore the relationships between total knowledge score on a series of questions related to oral health and disease, years as an RD in clinical practice and years as an RD in clinical practice in nephrology care. 3

3 Spearman s Rho was used to determine the relationship between total knowledge score on a series of questions related to oral health and disease and select patient care practices. An estimated sample size of 260 RDs was required to achieve statistical power. A priori alpha level of p<0.05 was considered statistically significant. Results The initial with survey link was sent to 2614 RDs through the Survey Monkey website. A total of 656 members of the RPG/ CRN responded to the survey, 93 respondents answered no when asked if they see patients with CKD Stages 3-5 or CKD Stage 5 (on dialysis) in an outpatient/ambulatory setting and therefore did not meet study inclusion criteria. The remaining surveys were reviewed for completeness: those who completed less than 50% of the knowledge questions were excluded from data analyses. A total of 492 surveys were considered usable with a final usable response rate of 18.8%. The mean age of respondents was 47.9 years (median=50.0, range= , SD=12.06, n=444). The majority of respondents were female 97.5% (n=460). The mean numbers of years working as an RD in clinical practice was 20.3 years (median=20.0, range= , SD=1.52, n=468). The mean number of years working as an RD in clinical practice in nephrology care was 12.1 years (median = 10.0, range = , SD=9.33,n=472.). Table 1 summarizes respondent educational characteristics. Table 1: Highest Level of Education Reported by Respondents (N = 475) Highest Level of Education n % of total Bachelors degree % Masters degree % Doctoral degree 5 1.1% Graduate Degree in Relation to RD Credential (n = 209) I completed my degree prior to earning my RD credential I completed my degree at the same time as earning my RD credential I completed my degree after earning my RD credential % % % Note: Graduate includes doctoral and masters degree The advanced/specialist certifications reported by respondents are summarized in Table 2. The most frequently reported certification was the Board Certified Specialist in Renal Nutrition (CSR); of those who responded (n=412), 22.6% reported having the CSR credential (n=93). Table 2: Advanced/Specialist Certifications Held by Respondents CSR Board Certified Specialist in Renal Nutrition (n=412) Yes (n) % % CDE Certified Diabetes Educator (n=392) % CNSC/CNSD Certified Nutrition Support Clinician/Certified Nutrition Support Dietitian (n=385) FADA Fellow of the American Dietetic Association (n=379) CSO Board Certified Specialist in Oncology Nutrition (n= 379) CSG Board Certified Specialist in Gerontological Nutrition (n= 379) CSP Board Certified Specialist in Pediatric Nutrition (n=378) CSSD Board Certified Specialist in Sports Dietetics (n=378) BC-ADM Board Certified Advanced Diabetes Management (n=378) % 4 1.1% 1 0.3% (Percentages reflect the percent of those individual who selected yes for the credential out of those who responded to the question, therefore percentages do not = 100%) The majority of respondents (87.2%, n=416) reported patients with CKD Stage 5 (on dialysis) as their primary patient population. Eighty-eight percent (n=421) of respondents reported that they worked in a dialysis center (Table 3). Among those who worked in a dialysis center, 61.1% (n=256) reported working for a for profit dialysis center/chain (Table 3). Table 3: Dialysis Center Employment Pattern of Respondents (N=477) Work in Dialysis Center Yes Type of Dialysis Center (n=419)* n % of total % For profit dialysis center (chain) % For profit dialysis center (independent) % Not-for-profit dialysis center % Hospital based outpatient dialysis center % Government dialysis center 3 0.7% Other 3 0.7% There were 2 missing responses for Type of Dialysis Center. The knowledge score was calculated by summing the number of correct responses to a series of 12 multiple choice questions regarding NFPE and structure of the oral cavity, cariogenicity, diet, oral hygiene, periodontal disease, xerostomia and oral manifestations of systemic 4

4 Table 4: Results for Percent Correct for Multiple Choice Knowledge Questions (N=492) Question Number Question Stem Correct Incorrect n % n % 1 Normal gingiva is: % % 2 Edentulism is defined as: % % 3 Cariostatic foods are defined as foods or drinks that: % % 4 Which of the following foods is considered cariogenic? % % 5 Which of the following is an appropriate recommendation for prevention of dental caries? % % 6 Xylitol containing gum is considered: % % 7 While performing an intraoral screening, if the RD sees any oral lesions, s/he should also assess: 8 Which of the following is the most frequent oral complaint of individuals with chronic kidney disease? % % % % 9 Which of the following medication classes can cause xerostomia? % % 10 Which of the following is a consequence of xerostomia? % % 11 When compared to individuals without diabetes, those with diabetes and poor glycemic control more often have: % % 12 Periodontal disease is defined as: % % Bold type indicates the highest frequency for each question. Table 5: Reported Frequency of Performing Select Patient Care Practices by Respondents Patient Care Practice Always Most of the Time How often do you address non-normal oral health findings as part of diet/nutrition counseling for patients/clients? (n=475) How often do you evaluate a patient s medications for risk of causing xerostomia? (n=476) How often do you discuss the relationship between blood sugar control and oral health with patients/clients who have diabetes? (n=476) How often do you address xerostomia as part of diet/nutrition counseling for patients/clients?(n=474) When you identify patients with non-normal oral health findings, how often do you refer them to a dentist? (n=475) Bold type represents the most frequent responses for each question. Sometimes Rarely Never n % n % n % n % n % % % % % % % % % % % % % % % % % % % % % % % % % % diseases. Each correct response was given one point. Questions that were left unmarked were considered incorrect. There was no significant difference in the median score for those respondents who answered all 12 of the knowledge questions and those who did not answer 100% of the questions. Therefore, all surveys with 50% or more of the questions answered were included. The mean number of correctly answered questions for all respondents (n=492) was 7.9 out of a possible 12, (median=8, range =1-12, SD=2.10). The mean knowledge score percentage was 65.9% (median=66.7, range= %, SD=17.51). The mean number of correctly answered questions by those respondents who answered all 12 multiple choice knowledge questions (n= 456), was 8.1 out of a possible 12, (median= 8, range =1-12, SD= 1.97). Two percent (n=11) of respondents answered all 12 multiple choice knowledge questions correctly. The response pattern of participants for each question is displayed in Table 4. Respondents were asked to report the frequency of performing five patient care practices regarding oral health and disease (Table 5). The majority did not report regularly performing the select patient care practices. More than one-third reported rarely or never addressing non-normal oral health findings as part of diet/nutrition counseling for 5

5 patients/clients or addressing xerostomia as part of diet/nutrition counseling. Only 25% of respondents reported always or most of the time discussing the relationship between blood sugar control and oral health with patients/clients who have diabetes. The relationships between total knowledge score on a series of questions and select demographics were explored using Pearson s product-moment correlations. No significant relationship was found between total knowledge score and years as an RD in clinical practice. However, there was a weak, positive relationship between total knowledge score and years as an RD in clinical practice in nephrology care (r=0.122, p=0.008), suggesting that as years as an RD in clinical practice in nephrology care increased, there was a small increase in total knowledge score. As shown in Table 6, there were statistically significant positive correlations between total knowledge score and several patient care practices regarding oral health and disease. Only one practice, addressing xerostomia as part of diet/nutrition counseling was of moderate effect, suggesting that the greater knowledge scores were associated with more frequent counseling on this topic. Discussion The primary aims of this study were to identify knowledge related to oral health and disease and frequency of performing select patient care practices related to oral health and disease among RD members of the RPG or CRN. The overall response rate to the survey invitation was 25.1% (n=656) and was similar to the response rate found by others who conducted electronic surveys (5,12). The final number of usable surveys (n=492) exceeded the minimum of 260 responses estimated to achieve statistical power for a small effect size of 0.217, an alpha level of 0.05 at 80% power. Hence, the results may be generalized to the larger U.S. population of RD members of the RPG/CRN. We failed to reject the null hypothesis concerning the relationship between total knowledge score related to oral health and disease and years as an RD in clinical practice as well as the hypothesis that tested the relationship between total knowledge score related to oral health and disease and the frequency of addressing non-normal oral health findings as part of diet/nutrition counseling as there were no statistically significant relationships found. The null hypothesis regarding the relationship between total knowledge score related to oral health and disease and years as an RD in clinical practice in nephrology care was rejected. Statistical analysis using Pearson s product-moment correlation revealed a weak, statistically significant relationship, suggesting that those with more years in clinical practice in nephrology care had slightly higher knowledge scores. The mean total knowledge score for those RDs who participated in this study and answered 50% or more of the multiple choice knowledge questions was approximately 65.9% out of 100%. The content areas that participants answered correctly more often were related to structure/function of the oral cavity. When asked what the RD should assess if s/he sees any oral lesions almost one third of the respondents answered nothing, that is not his/her job which is in direct conflict with the SOP/SOPP and the CMS Conditions for Coverage which both indicate that it is the responsibility of the RD to assess patients for nutrition focused physical findings affecting Table 6: Relationship between Total Knowledge Score and Select Patient Care Practices Patient Care Practice How often do you address nonnormal oral health findings as part of diet/nutrition counseling for patients/ clients? (n=475) How often do you evaluate a patient s medications for risk of causing xerostomia? (n=476) How often do you discuss the relationship between blood sugar control and oral health with patients/ clients who have diabetes? (n=476) How often do you address xerostomia as part of diet/nutrition counseling for patients/clients?(n=474) When you identify patients with non-normal oral health findings, how often do you refer them to a dentist? (n=475) Spearman s rho Significance (2-tailed) <0.001* <0.001* <0.001* * Correlation is significant at p = 0.01 level (2 tailed). the ability to bite, chew and/or swallow (2,7). Although RDs cannot diagnose medical or dental conditions they can identify nutrition related diagnoses, address findings as part of the NCP and refer patients accordingly to oral health care professionals (1,10). The content area that participants answered questions incorrectly most often were questions related to food cariogenicity. Almost 75% of respondents chose the incorrect answer for the definition of cariostatic and approximately 50% incorrectly selected the food considered to be cariogenic from the list of choices. When RDs are counseling patients with poor oral health it is important to give appropriate food choice recommendations that support promoting oral health. When asked about the frequency of addressing non-normal oral health findings as part of their nutrition care plan, only 25% reported that they always or most of the time address non-normal oral health findings as part of diet/nutrition counseling. These practices are inconsistent with the SOP/SOPP which considers NFPE an important component of nutrition assessment and recommends RDs in nephrology care evaluate patient s dietary intake, appropriateness of food and fluid intake and factors that affect intake (2). RDs should identify nutrition related oral health findings and incorporate them into the assessment, intervention/counseling and monitoring for patients (1,2,10). Patients on dialysis have poorer oral health than their healthier counterparts not on dialysis (19-22). Since malnutrition is often a concern in patients on dialysis, all issues that can affect intake and impact overall nutritional status including oral health should be addressed. 6

6 Xerostomia is a common complaint in patients with CKD. The causes of hyposalivation are multifactorial and include side effects of medications, fluid restriction, and poor glucose control in patients with diabetes (23-30). Many patients with CKD take antihypertensive medications as well as other medications such as antidepressants, analgesics, and diuretics that can contribute to feelings of xerostomia and hyposalivation (23,24,27-29). Although 67% of respondents were able to correctly identify that antihypertensive medications can cause xerostomia, over 60% of respondents reported that they rarely or never evaluate patient s medications for risk of causing xerostomia. The SOP/SOPP recommends that RDs in nephrology nutrition evaluate all medications and dietary supplements for their impact on nutritional status (2). In addition, although the majority of respondents correctly answered that xerostomia is a frequent complaint by patients with CKD, more than one third of respondents reported rarely or never addressing xerostomia as part of diet/nutrition counseling. Xerostomia is associated with difficulty chewing and swallowing, oral soft tissue diseases and caries, and can result in increased fluid intake causing undesirable increases in interdialytic weight gains (IDWGs) (23-25,33). It is important that RDs in nephrology care consider all factors that contribute to the complaint of xerostomia and incorporate them into the assessment and counseling of patients/clients. Patients with diabetes are at greater risk for periodontal disease than those without diabetes, particularly among those who have poor glucose control (25,34). Those with poor glycemic control may complain of xerostomia and experience reduced saliva production more often than individuals in good glycemic control (25,35,36). Although the majority of respondents correctly identified that patients with poorly controlled diabetes often have lower salivary flow, the majority of respondents did not report regularly discussing the role of blood sugar control and oral health with patients/clients who have diabetes. The SOP/SOPP for RDs in nephrology nutrition recommends that RDs address co-morbid conditions such as diabetes and glycemic control as part of the nutrition assessment and intervention (2). The CMS Interpretive Guidelines for dialysis centers also specify that assessment of glycemic control is among the parameters that can be addressed as part of the assessment of nutritional status by the RD and that appropriate counseling should be incorporated into patient care to achieve and sustain nutritional status (7). The SOP/SOPP and the Position of the Academy of Nutrition and Dietetics on Oral Health and Nutrition both state that RDs should refer to and/or collaborate with health care professionals yet when asked how often the respondent refers patients with non-normal oral health findings to a dentist over 25% reported rarely or never doing so (2,10). RDs in nephrology care are expected to have an inter-professional focus, practice beyond entry level, and collaborate with other health care professionals (2). Limitations and Strengths This study was an internet-based survey distributed through SurveyMonkey via . Undeliverable s were a limitation due to invalid or outdated RPG or CRN member contact information. Some potential participants had previously opted out of SurveyMonkey and others opted out of the survey once the invitation was sent. The survey was created for this study and was reviewed by experts and pilot tested for face and content validity, but was not tested for reliability. The multiple choice knowledge questions are not intended to reflect a comprehensive knowledge of oral health and disease. The questions regarding the reported frequency of performing patient care practice were based off of a Likert-type scale response and may not accurately represent individual practices. Response bias is possibly a limitation as participants voluntarily accessed and completed the survey. The large initial sample size of member contacts from both the RPG and CRN add strength to the results of the study. Using SurveyMonkey allowed for ease of distribution, tracking and sending follow up s to non-responders. SurveyMonkey only allows submission from s that are on the invitation list ensuring that only those from the original sample population could complete the survey. The survey link could be accessed at any time and the survey took only minutes to complete. Accurate transfer of data to SPSS was feasible with SurveyMonkey and decreased the potential for human error in transcription of data. Conclusion The results of this study suggest that although more than 50% of the respondents answered knowledge questions correctly, most RDs in renal clinical nutrition practice do not report integrating oral NFPA practices into patient care. All of the practices that correlated positively with knowledge score were related to counseling and educating patients about NFPA outcomes and not actual performance of a nutrition focused physical exam. RDs in nephrology care are encouraged to evaluate their current level of knowledge and practices regarding oral health components of NFPE. The patient care practices explored in this study are consistent with the SOP/SOPP for RDs in nephrology nutrition and CMS Conditions for Coverage, hence RDs should conduct NFPE components that include the oral cavity as part of nutrition care. Future research should focus on exploring practice patterns and barriers to performing skills, addressing knowledge deficits related to oral health and CKD and evaluating if additional education and training impacts practice. References 1. Academy of Nutrition and Dietetics. International Dietetics and Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process. encpt 2014 edition. Academy of Nutrition and Dietetics; Kent P, McCarthy M, Burrows J, et al. Academy of Nutrition and Dietetics and National Kidney Foundation: Revised 2014 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Nephrology Nutrition. J Acad Nutr Diet. 2014;114(9): DiBenedetto Barba P, Brommage D. Nutrition Assessment in Chronic Kidney Disease. In: Byham-Gray LD, Stover J, Wiesen K, ed. A Clinical Guide to Nutrition Care in Kidney Disease 2ed. Chicago, IL: Academy of Nutrition and Dietetics; Touger-Decker R. Physical Assessment Skills for Dietetics Practice: The Past, the Present, and Recommendations for the future. Top Clin Nutr. 2006; 21(3): Stankorb S, Rigassio Radler D, Khan H, Touger-Decker R. Nutrition focused physical examination practices of registered dietitians. Top Clin Nutr. 2010;25:

7 6. Fuhrman PM. Nutrition Focused Physical Assessment. In: Charney P, Malone AM ed. ADA Pocket Guide to Nutrition Assessment. 2nd ed. Chicago, IL. American Dietetic Association. 2009: Conditions for Coverage for End-Stage Renal Disease Facilities. Final Rule. Department of Health and Human Services; Centers for Medicare & Medicaid Services; Available at: cms.gov/regulations-and-guidance/legislation/cfcsandcops/ downloads/esrdfinalrule0415.pdf July 21, Nutrition Guideline List Chronic Kidney Disease Executive Summary of Recommendation. Academy of Nutrition and Dietetics Evidence Analysis Library. Available at: library.com/topic.cfm?cat=3929. Accessed July 21, Rigassio-Radler D, Touger-Decker R. Nutrition Screening in Oral Health. Top Clin Nutr. 2005;20(3): Position of the Academy of Nutrition and Dietetics: Oral Health and Nutrition. J Acad Nutr Diet. 2013;113(5): SurveyMonkey. Available at: Accessed December 16, Munson L. Nutrition Focused Physical Examination Practices of RD Members of the Renal Practice Group and/or the Council on Renal Nutrition. UMDNJ-SHRP Masters in Clinical Nutrition. May 13, Thesis. 13. Bastos JA, Vilela EM, Henrique MN, et al. Assessment of knowledge toward periodontal disease among a sample of nephrologists and nurses who work with chronic kidney disease not yet on dialysis. J Bras Nefrol. 2011;33(4): Wooten KT, Lee J, Jared H, Boggess K, Wilder RS. Nurse Practitioner s and certified nurse midwives knowledge, opinions and practice behaviors regarding periodontal disease and adverse pregnancy outcomes. J Dent Hyg. 2011;85(2): Lopes MH, Southerland JH, Buse JB, Malone RM, Wilder RS. Diabetes educators knowledge, opinions and behaviors regarding periodontal disease and diabetes. J Dent Hyg. 2012;86(2): Quijano A, Shah AJ, Schwarcz AI, Lalla E, Ostfeld RJ. Knowledge and orientations of internal medicine trainees toward periodontal disease. J Periodontol. 2010;81(3): Owens JB, Wilder RS, Southerland JH, Buse JB, Malone RM. North Carolina internists and endocrinologists knowledge, opinions, and behaviors regarding periodontal disease and diabetes: need and opportunity for interprofessional education. J Dent Education. 2011; 75(3): Brody RA, Trostler N, Rigassio-Radler D, Rachman-Elbaum S, Touger-Decker R. Impact of an Oral Health Assessment Training Program for Israeli Registered Dietitians on Knowledge of Nutrition Focused Physical Assessment of the Head, Neck and Oral Cavity. University of Medicine and Dentistry of New Jersey. Unpublished Thesis Akar H, Akar GC, Carrero JJ, Stenvinkel P, Lindholm B. Systemic consequences of poor oral health in chronic kidney disease patients. Clin J Am Soc Nephrol. 2011;6(1) Thorman R, Neovius M, Hylander B. Clinical findings in oral health during progression of chronic kidney disease to end-stage renal disease in a Swedish population. Scand J Urol Nephrol. 2009;43(2) Borawski J, Wilczynska-Borawska M, Stokowska W, Mysliwiec M. The periodontal status of pre-dialysis chronic kidney disease and maintenance dialysis patients. Neprol Dial Transplant. 2007;22 (2): Naugle K, Darby ML, Bauman DB, Lineberger LT, Powers R. The oral health status on individuals on renal dialysis. Ann Periodontol. 1998;3(1): Bossola M, Tazza L. Xerostomia in patients on chronic hemodialysis. Nature Rev Neprol. 2012; 8: Bots CP, Brand HS, Veeman EC, et al. Interdialytic weight gain in patients on hemodialysis is associated with dry mouth and thirst. Kidney Int. 2004;66(4): Chuang SF, Sung JM, Kuo SC, Huang JJ, Lee SY. Oral and dental manifestations in diabetic and nondiabetic uremic patients receiving hemodialysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;99(6): Baytaktar G, Kurtulus I, Kazancloglu, Bayramgurler I, Cintan S, Bural C, Bozfakioglu S. Oral health and inflammation in patients with end-stage renal failure. Perit Dial Int. 2009;29(4) Scully C. Salivary Glands and Saliva Number 10. Drug effects on Salivary glands: dry mouth. Oral Diseases. 2003;9: Navazesh M, Brightman VJ, Pogoda JM. Relationship of medical status, medications and salivary flow rates in adults of different ages. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996;81(2) Nonzee V, Manopatanakul S, Khovidhunkit SO. Xerostomia, hyposalivation and oral microbiota in patients using antihypertensive medications. J Med Assoc Thai. 2012:95(1): Sung JM, Kuo SC, Guo HR, Chuang SF, Lee SY, Huang JJ. The role of oral dryness in interdialytic weight gain by diabetic and non-diabetic haemodialysis patients. Nephrol Dial Transplant. 2006; 21: Proctor R, Kumar N, Stein A, Moles D, Porter S. Oral and dental aspects of chronic renal failure. J of Dent Res. 2005;84: Bots CP, Brand HS, Veeman EC, et al. Acute effects of hemodialysis on salivary flow rate and composition. Clin Nephrol. 2007;67(1): Guzeldemir E, Toygar HU, Tasdelen B, Torun D. Oral health-related quality of life and periodontal health status in patients undergoing hemodialysis. J Am Dent Assoc. 2009;140(10): Rajhans NS, Kohad RM, Chaudhari VG, Mhaske NH. A clnical study of the relationship between diabetes mellitus and periodontal disease. J Indian Soc Periodontol. 2011;15(4): Dodds MWJ, Yeh C-K, Johnson DA. Salivary alterations in type 2 (noninsulin dependent) diabetes mellitus and hypertension. Community Dent Oral Epidemiol. 2000; 28: Eltas A, Tozoglu U, Keles M, Canakci V. Assessment of oral health in peritoneal diálisis patients with and without diabetes. Perit Dial Int. 2012;32(1) Share Your Results If you are doing a small study or quality initiative in your facility, please consider sharing your results for potential publication in the Renal Nutrition Forum. Early trials, even if not clinically significant, are important steps to learn and build upon for future research. Contact: Managing Editor Stacey Phillips, MS, RD rpgforumeditor@gmail.com 8