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Bariatric surgery patients: Dental considerations

A peer-reviewed article written by Kelly Divito, BSDH, RDH

PUBLICATION DATE: MARCH 2020

EXPIRATION DATE: FEBRUARY 2023

SUPPLEMENT TO ENDEAVOR PUBLICATIONS EARN

3 CE This continuing education (CE) activity was developed by the PennWell dental group, an operating unit of Endeavor Business CREDITS Media, with no commercial support. This course was written for dentists, dental hygienists, and dental assistants, from novice to skilled. Educational methods: This course is a self-instructional journal and web activity. Provider disclosure: Endeavor Business Media neither has a leadership position nor a commercial interest in any products or services discussed or shared in this educational activity, nor with the commercial supporter. No manufacturer or third party had any input in the development of the course content. Requirements for successful completion: To obtain three CE credits for this educational activity, you must pay the required fee, Bariatric surgery patients: review the material, complete the course evaluation, and obtain a score of at least 70%. Dental considerations CE planner disclosure: Laura Winfield, Endeavor Business Media dental group CE coordinator, neither has a leadership nor commercial interest with the products or services discussed in ABSTRACT this educational activity. Ms. Winfield can be reached at lwinfield@ endeavorb2b.com As the rate of obesity climbs in the United States, so does the rate at which Educational disclaimer: Completing a single continuing people have bariatric surgery. The American Society for Metabolic and Bariat- education course does not provide enough information to result ric Surgery (ASMBS) estimates that in 2017 alone, more than 220,000 people in the participant being an expert in the field related to the course 1 topic. It is a combination of many educational courses and clinical had bariatric surgery. Dental clinicians, whether aware of it or not, have likely experience that allows the participant to develop skills and treated patients who have had this type of surgery. There is a stigma with weight- expertise. loss surgery (WLS) that causes some people to keep it private. Unfortunately, Image authenticity statement: The images in this educational activity have not been altered. presurgical patients are not required to have dental clearance, and they are not Scientific integrity statement: Information shared in this CE educated on preventive dental treatment, including how their postsurgical diet course is developed from clinical research and represents the most will affect their oral and dental health. This course highlights clinical findings current information available from evidence-based . and dental considerations that may present in patients who have had bariatric Known benefits and limitations of the data: The information presented in this educational activity is derived from the data surgery. The author collected anecdotal evidence through anonymous online and information contained in reference section. The research surveys completed by postbariatric surgery patients and dental professionals data is extensive and provides a direct benefit to the patient and improvements in oral health. who examine dental experiences from both patient and clinician viewpoints. Registration: The cost of this CE course is $59 for three CE credits. Cancellation and refund policy: Any participant who is not 100% EDUCATIONAL OBJECTIVES satisfied with this course can request a full refund by contacting At the conclusion of this educational activity, participants will be able to: Endeavor Business Media in writing. 1. Define bariatric surgery Endeavor Business Media 2. Describe the different bariatric surgeries Nationally Approved PACE Program Provider for FAGD/MAGD credit. 3. Articulate dental considerations with weight-loss-surgery patients Approval does not imply acceptance by any regulatory authority or AGD 4. Assess pre- and postoperative dental risk factors endorsement. 11/1/2019 to 10/31/2022. 5. Identify clinical signs of vitamin deficiency Provider ID# 320452 6. Gain confidence in speaking to patients about bariatric surgery and dental Endeavor Business Media is designated as an approved PACE program provider by the Academy of considerations General Dentistry (AGD). The formal continuing dental education programs of this program provider are accepted by the AGD for fellowship, mastership, and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2019) to (10/31/2022) Provider ID# 320452.

Endeavor/PennWell Corporation is designated as an approved Provider by the American Academy of Dental Hygiene Inc. # AADHPNW (January 1, 2019–December 31, 2020). Approval does not imply acceptance by a state or provincial Board of Dentistry. Licensee should maintain this document in the event of an audit.

Endeavor Business Media is an ADA CERP–recognized provider

ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at ada. org/goto/cerp. Go online to take this course. DentalAcademyofCE.com QUICK ACCESS CODE 15430 DENTAL ACADEMY OF CONTINUING EDUCATION

WHAT IS BARIATRIC SURGERY? above the band, and the rest of the stom- professional can prescribe a personalized Obesity has long been a hot topic of dis- ach below the band.1 The band is adjustable preventive treatment plan. cussion among medical professionals. The and reversible and, as such, it is considered Centers for Disease Control and Preven- a restrictive surgery. ACID REFLUX AND EROSION tion (CDC) has released statistics showing Duodenal switch—This is the most Dental professionals know the importance approximately 93 million people are con- complex of bariatric surgeries. It involves the of salivary pH for patients’ dental health. The sidered obese.2 sleeve procedure and then splitting the duo- lower the pH of a substance, the higher the Surgery may be the last resort for obese denum and reconnecting that portion to the acidic content. A pH value of 5.5 or less is people to achieve a healthy weight and life- end of the small intestine.1 When patients considered a dangerous acidic environment style. Bariatric surgery promotes weight loss eat, food will not travel through the length for enamel breakdown, and thus dental car- by changing the digestive system’s anatomy, of the small intestine where most nutrient ies is more likely. which limits the amount of food that can be and caloric absorption takes place. Thus, Bariatric surgery can temporarily restrict eaten and digested.3 Bariatric surgery is a the duodenal switch causes weight loss by or permanently alter the digestive tract by viable therapeutic option for obese patients limiting food intake and preventing caloric removing a portion of the stomach, creating who do not respond to conventional lifestyle absorption. a restrictive pouch for food consumption, or interventions for losing weight.4 Weight- rerouting the intestines, causing portions of loss surgeries involve the stomach and ORAL CONSIDERATIONS the digestive tract to no longer participate digestive tract, and alter certain processes The time to present a preventive plan is in digestion and leading to malabsorption to achieve weight loss. Types of bariatric when a patient mentions that he or she will of the nutrients. surgery include gastric bypass, gastric lap be having weight-loss surgery. It is crucial to Stomach acid and esophageal reflux band, sleeve gastrectomy, and the duode- formulate a comprehensive, patient-specific can become a problem for this population. nal switch.1 plan based on the patient’s caries history, While most patients are placed on antacids Prior to having surgery, patients must status, and initially, compliance may be an issue long- meet certain qualifications. They must be regimen. The dental professional should also term. Acid erodes enamel and can cause obese, with a BMI over 40, or have a BMI of discuss how important nutrition, dietary deterioration of not only teeth, but also of 35 and have comorbidity such as diabetes, supplements, and oral hygiene will become the mucous membranes and esophagus.6 high blood pressure, or sleep apnea, and they in protecting the patient’s dental health and While patients who have gastric bypass are must have failed other weight-loss methods. in the person’s daily life. less likely to experience acid reflux, they are They must attend seminars with a focus on Weight-loss surgery can lead to improved at an increased risk of , which also nutrition, psychological awareness, the sur- health of the patient, but can also pose some causes enamel erosion. gery process, and recovery.5 postoperative health risks, including nutri- The types of foods and beverages con- tional deficiencies, decreased bone mineral sumed, and the frequency and time of TYPES OF BARIATRIC SURGERY density (BMD), and gastroesophageal reflux consumption, are lifestyle factors that are Gastric bypass surgery—Also called disease (GERD) with possible ulceration.4 important in the clinical development of Roux-en-Y gastric bypass, gastric bypass sur- Dental professionals need to be aware of dental erosion.7 Chewable vitamin supple- gery involves making the stomach smaller some special considerations so that patients ments often contain citric, malic, phos- and rerouting the intestines so that food can have optimal oral health after weight- phoric, tartaric, acetic, or carbonic acid. bypasses most of the stomach and the upper loss surgery. Dental concerns following bar- The presence of any of these acids on the part of the small intestine. It is considered a iatric surgery include acid reflux and erosion, nutrition label indicates that the product malabsorptive surgery because it prevents periodontal disease, , caries, and is potentially erosive.8 Dental professionals the body from consuming and absorbing nutritional deficiency contributing to meta- can suggest that patients chew their vita- many calories and nutrients.1 bolic bone diseases. It is imperative to ask mins, and then drink water and swish with Sleeve gastrectomy—Also known as questions and evaluate on a case-by-case water, or chew gum containing xylitol to help sleeve, this is considered a restrictive surgery basis. eliminate acid on their teeth and rebalance because the size of the stomach is reduced Some patients may not disclose that the pH of their .9 by 80%. This also helps prevent overeating by they have had weight-loss surgery. There is Fluoride treatments or MI Paste (GC removing the area of the stomach that pro- a stigma attached to the surgery, and peo- America) combined with optimal home care duces the hunger hormone, ghrelin, which ple may feel vulnerable when they share this decreases the likelihood of tooth destruc- is known to affect patients’ hunger, satiety, information. If a patient has had significant tion from acid erosion. Bariatric surgery and blood sugar control.1 weight loss since his or her last dental visit, patients are advised not to have NSAIDS due Gastric lap band—Often called the it is appropriate to acknowledge this and to their increased risk of stomach ulcers.10,11 band, this involves an inflatable band that ask the patient what caused it. Hopefully, an Pain management medications other than is placed around the upper portion of the open-ended question will lead the patient NSAIDS should be considered to prevent stomach, creating a small stomach pouch to divulge his or her surgery so the dental further medical complications.

DentalAcademyOfCE.com 3 DENTAL ACADEMY OF CONTINUING EDUCATION

PERIODONTAL DISEASE AND BONE quickly due to this restriction. They may also teeth and local irritation of mucous mem- LOSS frequently sip water with powdered flavor- branes.6 Following surgery, patients are Calcium and vitamin D supplements help ings that contain citric acid, which can be often instructed to consume chewy vita- maintain bariatric patients’ periodontal a contributing factor for caries. Patients are mins numerous times over the course of a health. If bariatric patients are deficient in advised not to drink with meals and not to day as their bodies adjust to tolerate and calcium or vitamin D, the periodontium may consume fluids within 30 minutes before or absorb the nutrients. It would be wise to be compromised by weakened bones and after eating. This is to allow the stomach to mention the cariogenicity of the vitamins to eventual osteoporosis.12 absorb all the nutrition from the food, and patients and encourage them to drink plain Osteoporosis is considered a risk factor so the food will not be pushed through the water after vitamin consumption to increase for periodontal disease since it may influence stomach too quickly. It also prevents over- pH and decrease caries risk. the alveolar bone loss rate in chronic peri- filling and stretching of the stomach. Sip- odontitis, causing tooth loss.12 Patients with ping artificially sweetened acidic drinks, NUTRITIONAL DEFICIENCIES documented periodontal disease prior to dehydration, and eating small portions of Bariatric surgery can permanently change surgery may find their condition has wors- food multiple times a day can increase the the way the body absorbs food. According ened six months postsurgery. Studies by de risk of caries in WLS patients. to Majumder et al, “Nutritional deficien- Carvalho Sales-Peres et al. concluded that Xerostomia in combination with cies are an inherent problem in the post- “P. gingivalis levels increased directly follow- high-acid-containing food consumption can operative period and often require lifelong ing surgery but decreased at the 12-month promote caries due to lack of saliva buff- supplementation.”7 Patients may be on a mark.” 13 The increase exacerbated already ering. Patients suffering from xerostomia nutritionist-guided regimen of vitamins that periodontally compromised dentition would benefit from saliva substitutes, such commonly includes calcium with vitamin and caused measurable bleeding, as mouth rinses or mints; the use of a water D, iron, vitamin B12, and daily multivita- buildup, and increased probing depths in flosser to help eliminate dry, sticky plaque min and mineral tablets.15 Nutrition has a the patients being monitored for the study. along the gumline and in between teeth; systemic effect on the integrity of the oral Interestingly, the authors mention that while and in-office fluoride varnish treatments cavity, including teeth, periodontium, oral weight loss decreased overall body inflam- to strengthen weakened enamel. mucosa, and alveolar bone, making it even mation, it had no effect on decreasing gin- The combination of xerostomia, acid- more important for dental professionals to gival inflammation. containing vitamins, frequent consump- ensure that their bariatric patients are eat- Vitamin deficiencies also have an effect tion of citric acid-containing beverages, and ing nutritionally rich diets and taking their on periodontal health. Data from the inconsistent oral hygiene creates a high risk prescribed vitamin supplements. Nutritional National Health and Nutrition Examina- for caries. Patients may also report halitosis, deficiencies such as iron deficiency anemia tion Survey (NHANES) demonstrates that which can be attributed to ketosis, a high and deficiencies of calcium and vitamins B, women with a low intake of dietary calcium protein/fat diet, or GERD and gastric acids C, and D may have oral presentations in or have more severe periodontal disease and in the mouth. In fact, frequent or excessive around the mouth. Vitamin deficiencies can low levels of vitamin D due to malabsorp- intake of citric acid may cause erosion of present in the mucosa and tongue as color tion or noncompliance, which can lead to “increased gingival inflammation, tooth loss, FIGURE 1: VITAMIN REGIMEN 12 and clinical attachment loss.” It is impera- Symptoms Vitamin/mineral tive that pre- and post-op patients be seen of deficiency regularly by their dental professionals to monitor and manage any changes to their A Xerophthalmia—red, dry eyes periodontal health. Pernicious anemia—pale mucous membranes; —red, smooth surface of B12 tongue with possible burning sensations; Red lesions in mouth; Angular ; CARIES RISK Candidiasis18 Postoperative eating guidelines include restricting portion sizes, chewing foods C Scurvy—bleeding gums, gingivitis19 slowly and completely, eating and drink- ing separately, and avoiding foods that are poorly tolerated.14 Bariatric patients will no D Rickets—bone softening/loss longer be able to gulp large amounts of fluids. Pica—unusual cravings for nonfood items, such as ice, dirt, paint, or starch;20 Swollen/ This is because of the restrictive nature of Iron sore tongue; Burning sensation in tongue/mouth20,21 bariatric surgery. Patients are likely to have only small sips of liquids multiple times dur- ing the day. Patients who have had bariatric Thiamine Beriberi—heart and circulation symptoms18 surgery run the risk of becoming dehydrated

4 DentalAcademyOfCE.com DENTAL ACADEMY OF CONTINUING EDUCATION

changes. According to Via and Mechanick, interdental brush will help reduce plaque is consistent with the statistics showing “Among all patients who undergo bariatric accumulation. Xylitol products may be help- that more people are having bariatric sur- surgery, high rates of micronutrient defi- ful for dryness and caries prevention. Numer- gery every year. Three percent of respon- ciencies have been observed.”16 Many factors ous clinical trials have shown that chewing dents selected “I’m not sure” as their answer, contribute to nutritional deficiency, “includ- sugar-free gum protects against dental car- perhaps with the realization that patients ing reduced oral intake of food, decreased ies.8 Nutritional counseling should be consid- may not be forthcoming with their health GI absorption, food intolerance, nausea/ ered when caries is likely or present. A caries histories. vomiting, and nonadherence with dietary management by risk assessment (CAMBRA) Dental professionals were questioned on supplements.”17 should be utilized to further identify high- what they currently know about bariatric Encouraging patient compliance with the risk patients.22 Dental professionals should patients and any special considerations they vitamin regimen recommended by their bar- strongly encourage frequent recalls to moni- take when treating WLS patients: iatric surgeon is important in bridging the tor gingival and dental health. A presurgical oral and systemic health link. dental screening should be considered by the What oral hygiene instructions do you bariatric surgical team for a comprehensive give your bariatric surgery patients? PATIENT COMPLIANCE review of the patient’s overall health. This • Electric toothbrush: 79% Post-weight-loss-surgery patients will likely would also allow for baseline dental moni- • String floss: 61% be given a daily vitamin regimen with suf- toring, preventive education, and treatment • Water flosser: 45% ficient supplements to protect their bodies as needed. • Fluoride gels, prescription (e.g., Prevident; from nutrient malabsorption and deficien- Individuals who revert to poor eating hab- Colgate): 39% cies (figure 1). However, dental professionals its compromise the success of the weight- • Prescription mouth rinse (e.g., chlorhexi- should question their patients’ compliance of loss surgery and may develop health risks dine): 3% this regimen by taking a thorough health his- such as diabetes and obesity. Tooth loss, • MI Paste: 13% tory. For example, calcium and vitamin D are bone loss, and burning mouth sensation • Biotene (GlaxoSmithKline) or another crucial for bone support. Patients who have caused by poor nutrition can also compro- dry-mouth rinse: 19% had bariatric surgery are at risk for osteopo- mise overall health. • Proxabrush (Gum/Sunstar): 21% rosis due to the malabsorption of both nutri- As dental professionals, we need to con- • Other: 3% ents. Osteoporosis weakens bone strength tinuously educate ourselves on the connec- and can result in tooth loss. It is imperative tion between the mouth and the rest of the Respondents reported the following that bariatric patients take daily calcium body. If we are not comfortable discuss- conditions as present in bariatric and vitamin D supplements as a precaution. ing a condition/surgery, we may be miss- patients postsurgery: ing information that is vital to our patients’ • Acid reflux/erosion: 42% DENTAL RECOMMENDATIONS oral health. It would be a disservice to our • Caries: 30% Recommendations for bariatric patients patients in this growing WLS population • : 30% might include follow-up questions on their to be undereducated on their dental risks. • Xerostomia: 25% health histories to: • Periodontal disease: 20% • Inquire about which bariatric surgery SURVEY RESULTS • Halitosis: 17% the patient had The author presented two separate anony- • None of these conditions: 38% • Identify noticeable dental concerns or mous online surveys to groups of bariatric The most revealing question asked den- changes, such as or patients as well as dental professionals via tal professionals about their comfort level in gingival bleeding SurveyMonkey. In total, 269 dental profes- discussing bariatric surgery and dental con- • Recommend postsurgery vitamin sionals and 196 bariatric surgery patients siderations. It is clear that this topic needs regimen completed these surveys. Bariatric surgery more attention in our profession: • Assess frequency of eating and drinking patients were questioned on their experi- • Identify use of water flavoring/additives ences with dental care, what their surgical Are you comfortable discussing • Inquire about incidence of vomiting teams instructed them to do postoperatively bariatric surgery and dental • Note any dryness or odor in the mouth for dental care, and what they experienced considerations with patients? A preventive plan may include fluoride following surgery. Of the dental professionals • Yes, I feel I know a lot about this type of gels, MI Paste, or fluoridated mouth rinse who completed the survey, 97% were regis- patient: 18% to help remineralize weakened enamel as tered dental hygienists, with the remaining • Maybe, I know some information but the result of acids from reflux and vitamins. percentage being a combination of certified would like to learn more: 38% Products that neutralize acidic pH are ben- dental assistants and expanded function • Not really, I don’t know enough: 40% eficial in caries management. An electric dental auxiliaries. Eighty-eight percent of • No, I would prefer not to talk about this toothbrush and appropriate interproximal survey takers selected “Yes”; they had treated topic with my patients: 2% aids such as a water flosser, string floss, or a patient who had bariatric surgery. This The author’s investigation with bariatric

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surgery patients showed that bariatric surgi- obesity/post-bariatric-surgery-patients-your-role- 2017;6(3):286-296. https://www.ncbi.nlm.nih.gov/ cal teams recommended different postop- their-long-term-care pubmed/28718091 erative instructions regarding what to eat, 5. Puhl RM, Himmelstein MS, Quinn DM. 17. Stein J, Stier C, Raab H, Weiner R. The nutritional what to drink, and vitamin supplements. Internalizing weight stigma: prevalence and and pharmacological consequences of There was not consistency among bariat- sociodemographic considerations in US adults. obesity surgery. Aliment Pharmacol Ther. ric professionals in their recommendations Obes. 2018;26(1):167-175. 2014;40(6):582-609. to patients. 6. Bingham E, Cohrssen B, Powell CH. Patty’s 18. Allied Health Sciences Section Ad Hoc Nutrition Toxicology, volumes 1-9 (5th ed). John Wiley & Committee, Aills L, Blankenship J, et al. ASMBS CONCLUSION Sons. New York, NY. 2001. Allied Health Nutrition Guidelines for the Surgical When patients have had bariatric surgery, 7. Majumder S, Soriano J, Louie Cruz A, Dasanu Weight Loss Patient. Surg Obes Relat Dis. they have made a body-altering decision to CA. Vitamin B12 deficiency in patients 2008;4(5 Suppl):S73-S108. prolong their lives by potentially alleviat- undergoing bariatric surgery: preventive 19. Sheetal A, Hiremath VK, Patil AG, et al. ing systemic diseases related to or compli- strategies and key recommendations. Surg Malnutrition and its oral outcome—a review. J cated by obesity. How devastating would it Obes Relat Dis. 2013;9(6):1013-9. doi: 10.1016/j. Clin Diagn Res. 2013;7(1):178-180. be, then, to unknowingly compromise their soard.2013.04.017. https://www.ncbi.nlm.nih. 20. National Institutes of Health. National Heart, dental health and their subsequent nutrition gov/pubmed/24091055 Lung, and Blood Institute. Iron deficiency due to lack of a multidisciplinary approach 8. Moynihan PJ. Dietary advice in dental practice. Br anemia. https://www.nhlbi.nih.gov/health-topics/ to include knowledge of dental risks and Dent J. 2002;193:563-568. http://www.nature.com/ iron-deficiency-anemia preventive strategies? articles/4801628 21. Wu YC, Wang YP, Chang JY, et al. Oral Dental professionals need to be aware of 9. Touger-Decker R, van Loveren C. Sugars manifestations and blood profiles in patients the oral-systemic link associated with bar- and dental caries. Am J Clin Nutr. with iron deficiency anemia. J Formos Med iatric surgery. A multidisciplinary approach 2003;78(4):881S-892S. http://ajcn.nutrition.org/ Assoc. 2014;113(2):83-87. between dental professionals and primary content/78/4/881S.full 22. University of California San Francisco. Accessed care physicians, bariatric surgeons, nutri- 10. Scarlata K. The FODMAPs approach—minimize July 1, 2019. CAMBRA. https://dentistry.ucsf.edu/ tionists, and other specialists will address the consumption of fermentable carbs to research/cambra oral-systemic link and keep an open conver- manage functional gut disorder symptoms. sation. Complete blood panel results ordered Today’s Dietitian. 2010;12(8):30. http://www. KELLY DIVITO, BSDH, RDH, graduated from by medical doctors that reveal vitamin defi- todaysdietitian.com/newarchives/072710p30. Ohio State University in 2008 with a bachelor of science in dental hygiene. She is a member of the ciencies would benefit dental teams in pre- shtml American Dental Hygienists’ Association, American 11. de Sousa Prado Geraldo M, Fonseca FLA, de paring dental preventive care. Academy of Oral and Systemic Health, the If current trends continue, more bariat- Fatima Veiga Gouveia MR, Feder D. The use of Organization for Safety, Asepsis and Prevention, and ric patients will be seen each year in the drugs in patients who have undergone bariatric is a founding member of the National Network of dental chair with caries, bone loss, erosion, surgery. Int J Gen Med. 2014;7:219-224. https:// Healthcare Hygienists. She has served as secretary of her local dental hygiene component board in and clinical signs of vitamin deficiency. Fur- www.ncbi.nlm.nih.gov/pmc/articles/PMC4026560/ Northern Virginia. Divito is a board member at large 12. Uwitonze AM, Murererehe J, Ineza MC, et al. ther longitudinal studies are needed to fully of the Ohio State University College of Dentistry understand the pre- and post-op correlations Effects of vitamin D status on oral health. J Dental Alumni Society Board of Governors. She has between bariatric surgery and dental health. Steroid Biochem Mol Biol. 2018;175:190-195. been a professional educator on behalf of Water Pik https://www.sciencedirect.com/science/article/ since 2017. Divito has practiced clinically in general, periodontal, prosthodontic, orthodontic, and public REFERENCES abs/pii/S0960076017300304?via%3Dihub health settings. She is active in the military 1. American Society for Metabolic and 13. de Carvalho Sales-Peres SH, de Moura-Grec community as a volunteer. Her passions include Bariatric Surgery. Estimate of bariatric PG, Yamashita JM, et al. Periodontal status and education, research, philanthropy, and evidence- surgery numbers, 2011-2018. Pubished pathogenic bacteria after gastric bypass: a based practice. Divito lives in Maryland with her June 2018. https://asmbs.org/resources/ cohort study. J Clin Periodontol. 2015;42(6):530- husband and son. She can be reached at [email protected]. estimate-of-bariatric-surgery-numbers 536(7). doi: 10.1111/jcpe.12410 2. Centers for Disease Control and Prevention. 14. Parkes E. Nutritional management of patients Adult obesity facts. Accessed December 3, 2019. after bariatric surgery. Am J Med Sci. 2006; https://www.cdc.gov/obesity/data/adult.html 331(4):207-213. https://www.amjmedsci.com/ 3. The Free Dictionary. Bariatric surgery. https:// article/S0002-9629(15)32808-1/abstract medicaldictionary.thefreedictionary.com/ 15. Rickers L, McSherry C. Bariatric surgery: bariatric+surgery nutritional considerations for patients. Nurs 4. Kreykes A, Choxi H, Rothberg A. Post-bariatric Stand. 2012;26(49):41-48. surgery patients: your role in their long-term 16. Via MA, Mechanick JI. Nutritional and care. J Fam Pract. 2017;66(6):356-363. http:// micronutrient care of bariatric surgery patients: www.mdedge.com/jfponline/article/139105/ current evidence update. Curr Obes Rep.

6 DentalAcademyOfCE.com QUICK ACCESS CODE 15430 ONLINE COMPLETION Take this test online for immediate credit. Visit dentalacademyofce.com and sign in. If you have not previously purchased the course, select it from the “Online Courses” listings and complete your purchase. The exam will then be added to your “Archives” page, where a “Take Exam” link will be provided. Click on this link, complete all questions, and submit your answers. An immediate grade report will be generated. If you receive a score of 70% or higher, your verification form will be provided immediately for viewing and printing. View and print forms at any time by visiting the site and returning to your “Archives” page.

QUESTIONS

1. The following are all examples of den- 6. Which of the following is an appropri- 11. Which factor does not contribute to tal risk factors for postoperative bar- ate nutrition question to ask post- nutritional deficiency? iatric surgery patients except: bariatric patients at their dental A. Increased intake of food A. Acid erosion appointments? B. Decreased GI absorption B. Osteoporosis A. What’s your daily intake of calories? C. Food intolerance C. Aphthous ulcers B. Are you exercising regularly? D. Noncompliance with dietary supplements D. Vitamin deficiencies C. Have you been drinking water with additives? 12. Patients who have had gastric bypass 2. Bariatric surgery patients must meet D. How much weight have you lost? are more likely to have acid reflux certain requirements to qualify for disease than those who have had weight-loss surgery. Which of these is 7. Vitamin C deficiency can result in all of the other gastric surgeries. Patients not a requirement? the following except: who have had gastric bypass have a A. BMI over 22 A. Scurvy C. Beriberi decreased risk of vomiting. B. Resting heart rate of 100 bpm or more B. Bleeding gingiva D. Gingivitis A. Both statements are true. C. Type 2 diabetes B. Both statements are false. D. Hypertension 8. Your postbariatric surgery patient pres- C. First statement is true. ents for a dental hygiene appointment. Second statement is false. 3. The duodenal switch bariatric surgery Upon examination you observe a large, D. First statement is false. consists of: swollen tongue, and the patient reports Second statement is true. A. Removing 80% of the stomach occasional burning sensations in her B. Rerouting the digestive tract mouth. You suspect that your patient: 13. Patients who have had weight- C. Preventing absorption of nutrients A. Has insufficient C. Is vitamin B12 loss surgery are advised not to take D. All of the above oral hygiene deficient NSAIDS. NSAIDS cause an increased B. Is iron deficient D. Both B and C likelihood of stomach ulcers. 4. The sleeve gastrectomy is a restric- A. Both statements are true. tive surgery. The gastric band is an 9. A CAMBRA questionnaire should be B. Both statements are false. absorptive surgery. given to all WLS patients due to higher C. The first statement is true. A. Both statements are true. caries risk from nutritional deficien- The second statement is false. B. The first statement is true. cies and frequency of eating. Fluori- D. The first statement is false. The second statement is false. dated mouth rinse, MI paste, and pH The second statement is true. C. The first statement is false. neutralizing products should be con- The second statement is true. sidered during OHI for WLS patients. D. Both statements are false. A. Both statements C. Both statements 14. Pica is a side effect of a thiamine defi- are true. are false. ciency. It involves unusual cravings 5. If bariatric patients have not been con- B. First statement D. First statement for nonfood items such as ice, dirt, sistent with their daily vitamin regi- is true. Second is false. Second paint, or starch. men, they may present with which statement is false. statement is true. A. Both statements are true. of the following clinical signs of iron B. Both statements are false. deficiency? 10. Acid erosion can affect the teeth and C. First statement is true. A. mucous membranes. Erosion can Second statement is false. B. Enlarged tonsils and adenoids cause xerostomia. D. First statement is false. C. Red, swollen tongue A. First statement Second statement is true. D. Blunted interproximal papilla is true. Second C. First statement statement is false. is false. Second 15. A disease associated with vitamin D B. Both statements statement is true. deficiency is: are true. D. Both statements A. Beriberi C. Scurvy are false. B. Rickets D. Spina bifida

DentalAcademyOfCE.com 7 QUICK ACCESS CODE 15430 ONLINE COMPLETION Take this test online for immediate credit. Visit dentalacademyofce.com and sign in. If you have not previously purchased the course, select it from the “Online Courses” listings and complete your purchase. The exam will then be added to your “Archives” page, where a “Take Exam” link will be provided. Click on this link, complete all questions, and submit your answers. An immediate grade report will be generated. If you receive a score of 70% or higher, your verification form will be provided immediately for viewing and printing. View and print forms at any time by visiting the site and returning to your “Archives” page.

QUESTIONS

16. Post-WLS patients are at risk for dehy- 21. Acid erosion can be caused by: 26. According to the CDC, bariatric sur- dration due to: A. GERD gery promotes weight loss by chang- A. Inability to drink large quantities of fluids B. Prolonged consumption of acidic beverages ing the digestive system’s anatomy and B. Inability to drink beverages with meals C. Frequent vomiting limiting the amount of food that can C. Frequent vomiting D. All of the above be eaten and digested. In 2017 alone, D. All of the above more than 220,000 people had WLS. 22. Data from NHANES demonstrates A. Both statements C. Both statements 17. There are universal protocols that that women with a low intake of are true. are false. all bariatric surgeons give their dietary calcium have: B. First statement D. First statement patients. All patients receive the same A. More severe periodontal disease is true. Second is false. Second recommendations. B. Low levels of vitamin D due to malabsorp- statement is false. statement is true. A. Both statements are true. tion or noncompliance B. First statement is true. C. Increased gingival inflammation, tooth loss, 27. Nutrition has a systemic effect on: Second statement is false. and clinical attachment loss A. Teeth C. and C. Both statements are false. D. All of the above B. Periodontium alveolar bone D. First statement is false. D. All of the above Second statement is true. 23. Osteoporosis weakens bone strength and can result in tooth loss. A lack of 28. Which of the following can cause 18. Bariatric patients are advised not to vitamin D and calcium can compro- bone softening and tooth loss? drink with meals and not to consume mise the periodontium. A. Osteoporosis C. Both a and b fluids within 30 minutes before or A. Both statements are true. B. Vitamin D D. Neither a nor b after eating. This prevents overfilling B. First statement is true. deficiency and stretching of the stomach. Second statement is false. A. Both statements are true. C. Both statements are false. 29. A presurgical dental screening should B. First statement is true. D. First statement is false. be considered by the bariatric surgi- Second statement is false. Second statement is true. cal team for a comprehensive review C. Both statements are false. of the patient’s overall health. This D. First statement is false. 24. Prior to having surgery, patients must would also allow for baseline den- Second statement is true. meet certain qualifications. They tal monitoring, preventive education, must be obese, with a BMI over 40 or and treatment as needed. 19. Gastric lap band involves an inflatable have a BMI of 35 and have comorbid- A. Both statements C. Both statements band that is placed around the upper ity such as diabetes, high blood pres- are true. are false. portion of the stomach creating a small sure, or sleep apnea, and/or have B. First statement D. First statement stomach pouch above the band, and the failed other weight-loss methods. is true. Second is false. Second rest of the stomach below the band. Gas- A. Both statements are true. statement is false. statement is true. tric lap band is a reversible procedure. B. First statement is true. A. Both statements are true. Second statement is false. 30. There are numerous longitudinal B. First statement is true. C. Both statements are false. studies completed on WLS patients Second statement is false. D. First statement is false. and their dental risks. According to C. Both statements are false. Second statement is true. the informal survey shared in this D. First statement is false. paper, dental professionals feel com- Second statement is true. 25. All are examples of malabsorptive fortable discussing dental consider- WLS except: ations of WLS patients clinically. 20. Which pH represents an acidic envi- a. Duodenal switch A. Both statements C. Both statements ronment in the oral cavity? b. Gastric bypass are true. are false. A. 5.5 C. 7.5 c. Sleeve gastrectomy B. First statement D. First statement B. 6.5 D. 8.5 d. None of the above is true. Second is false. Second statement is false. statement is true.

8 DentalAcademyOfCE.com PUBLICATION DATE: MARCH 2020 ANSWER SHEET

EXPIRATION DATE: FEBRUARY 2023 Bariatric surgery patients: Dental considerations

Name: Title: Specialty:

Address: Email: AGD member ID (if applies):

City: State: ZIP: Country:

Telephone: Primary ( ) Office ( ) License renewal date:

Requirements for obtaining CE credits by mail/fax: 1) Read entire course. 2) Complete info above. 3) Complete test by marking one answer per question. 4) Complete course evaluation. 5) Complete credit card info or write check payable to Endeavor Business Media. 6) Mail/fax this page to DACE. A score of 70% is required for CE credit. For questions, call (800) 633-1681. Course may also be completed at dentalacademyofce.com. Mail/fax completed answer sheet to: EDUCATIONAL OBJECTIVES Endeavor Business Media Attn: Dental division 1. Define bariatric surgery 7666 E. 61st St. Suite 230, Tulsa, OK 74133 2. Describe the different bariatric surgeries Fax: (918) 831-9804 3. Articulate dental considerations with weight-loss-surgery patients 4. Assess pre- and postoperative dental risk factors  Payment of $59 is enclosed. 5. Identify clinical signs of vitamin deficiency Make check payable to Endeavor Business Media 6. Gain confidence in speaking to patients about bariatric surgery and dental considerations If paying by credit card, please complete the COURSE EVALUATION following: MC Visa AmEx Discover 1. Were the individual course objectives met? Acct. number: ______

Objective #1: Yes No Objective #2: Yes No Exp. date: ______CVC #: ______

Objective #3: Yes No Objective #4: Yes No Billing address: ______

Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. ______

2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 Charges on your statement will show up as PennWell / Endeavor. 3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0

4. How would you rate the objectives and educational methods? 5 4 3 2 1 0 1. 16. 5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0 2. 17. 6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0 3. 18. 7. Was the overall administration of the course effective? 5 4 3 2 1 0 4. 19.

8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0 5. 20.

9. Please rate the usefulness of the supplemental webliography. 5 4 3 2 1 0 6. 21. 7. 22. 10. Do you feel that the references were adequate? Yes No 8. 23. 11. Would you participate in a similar program on a different topic? Yes No 9. 24. 12. If any of the continuing education questions were unclear or ambiguous, please list them. 10. 25. ______11. 26. 13. Was there any subject matter you found confusing? Please describe. ______12. 27. 13. 28. 14. How long did it take you to complete this course? ______14. 29.

15. What additional continuing dental education topics would you like to see? 15. 30. ______AGD code: 150, 750

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS. INSTRUCTIONS PROVIDER INFORMATION EDUCATIONAL DISCLAIMER All questions have only one answer. Grading of this examination is done manually. Participants Endeavor is an ADA CERP–recognized Provider. ADA CERP is a service of the American Dental Completing a single CE course should not provide enough information to give participants the will receive confirmation of passing by receipt of a verification form. Verification of Participation Association to assist dental professionals in identifying quality providers of continuing dental feeling that they are experts in the field related to the course topic. It is a combination of many forms will be mailed within two weeks after taking an examination. education. ADA CERP neither approves nor endorses individual courses or instructors, nor does educational courses and clinical experience that allows the participant to develop skills and it imply acceptance of credit hours by boards of dentistry. Concerns about a CE provider may be expertise. COURSE EVALUATION AND FEEDBACK directed to the provider or to ADA CERP at ada.org/gotocerp/. We encourage participant feedback. Complete the survey above and e-mail feedback to Aileen CANCELLATION AND REFUND POLICY Gunter ([email protected]) and Laura Winfield ([email protected]). Endeavor is designated as an approved PACE program provider by the Academy of General Any participant who is not 100% satisfied with this course can request a full refund by contacting Dentistry. The formal continuing dental education programs of this program provider are Endeavor in writing. COURSE CREDITS AND COST accepted by the AGD for fellowship, mastership, and membership maintenance credit. Approval All participants scoring at least 70% on the examination will receive a verification form for three does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The IMAGE AUTHENTICITY CE credits. The formal CE program of this sponsor is accepted by the AGD for fellowship and current term of approval extends from 11/1/2019 to 10/31/2022. Provider ID# 320452. The images provided and included in this course have not been altered. mastership credit. Please contact Endeavor for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. RECORD KEEPING © 2019 by the Academy of Dental Therapeutics and Stomatology, a division of Endeavor Business Endeavor maintains records of your successful completion of any exam for a minimum of six years. Media Please contact our offices for a copy of your CE credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt.

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