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Dental nutritional counseling techniques for the dental hygienist.



Introduction

Nutrition and oral health have an integral relationship in health status. The integrity of the oral cavity oral cavity
n.
The part of the mouth behind the teeth and gums that is bounded above by the hard and soft palates and below by the tongue and the mucous membrane connecting it with the inner part of the mandible.
 affects dietary intake, which affects nutritional status nutritional status,
n the assessment of the state of nourishment of a patient or subject.
, which in turn presents with oral manifestations of nutritional deficiency in individuals with compromised nutritional status. This interrelationship in·ter·re·late  
tr. & intr.v. in·ter·re·lat·ed, in·ter·re·lat·ing, in·ter·re·lates
To place in or come into mutual relationship.



in
 of nutrition and oral health is the primary reason oral health professionals must be able to recognize dietary inadequacies and provide appropriate intervention and referrals as warranted. Dietary risk assessment is a necessary part of the total oral risk assessment phase in disease prevention and health promotion in the dental hygiene dental hygiene
n.
The practice of keeping the mouth, teeth, and gums clean and healthy to prevent disease. Also called oral hygiene.
 process of care.

Purpose of Dietary Counseling

Nutritional assessment nutritional assessment Oncology The profiling of a Pt's current nutritional status and risk of malnutrition and cancer cachexia. See Cachexia, Malnutrition. , a comprehensive investigation comprising anthropometric an·thro·pom·e·try  
n.
The study of human body measurement for use in anthropological classification and comparison.



an
, physiological and biochemical data to determine baseline nutritional status, is performed by a medical doctor or registered dietitian registered dietitian,
n See dietitian, registered.
. Dietary assessment involves the evaluation of reported information on an individual's dietary intake as compared to dietary standards such as the U.S. Dietary Guidelines dietary guidelines Cardiology A series of dietary recommendations from the Nutrition Committee of the Am Heart Assn, that promote cardiovascular health. See Caloric restriction, food pyramid, French paradox. , MyPyramid Food Guidance System and the Dietary Reference Intakes dietary reference intakes (DRIs),
n.pl a set of nutritional guidelines concerning the intake of vitamins and minerals from food rather than supplements.
. (1) See the "Nutrition" column in the December 2007 issue of Access for a review of nutrition resources.

Dental nutritional counseling is an intervention to prevent dental disease A dental disease is a disease which affects the teeth or gums. Some of the most prevalent types of dental disease include dental caries (also known as tooth decay), and gum disease.  by assessing and analyzing the dental client's health status and educating them about the relationship between diet and oral health and disease. As a change agent and health educator in disease prevention and health promotion, the dental hygienist dental hygienist
n.
A person trained and licensed to provide preventive dental services, such as cleaning the teeth, usually in conjunction with a dentist.
 plays a pivotal role in providing this oral risk assessment to clients in any dental care setting. However, providing nutrition advice and diet counsel in reference to specific medical conditions See carpal tunnel syndrome, computer vision syndrome, dry eyes and deep vein thrombosis. , disease entities or weight loss recommendations is beyond the scope of practice for the dental hygienist. Therefore, referral to a registered dietitian is appropriate practice in accordance with state laws and licensure regulations. (2) A referral system bridging the gap between the two scopes of practice provides the dental hygienist and registered dietitian with a great opportunity for an interdisciplinary approach to health care.

Dental clients of all age groups benefit from receiving diet information in health promotion and dental disease prevention. Individuals at increased risk for nutritional inadequacies and deficiency are the elderly, teenagers and young children; individuals on fad or restrictive diets or who exhibit unusual eating habits; and individuals with lifestyle factors that include living alone, such as bachelors and widowed seniors. Dental clients with conditions affecting dietary intake such as dentures, oral cancer, oral surgery, xerostomia xerostomia /xe·ro·sto·mia/ (zer?o-sto´me-ah) dryness of the mouth due to salivary gland dysfunction.

xe·ro·sto·mi·a
n.
, malocclusion Malocclusion Definition

Malocclusion is a problem in the way the upper and lower teeth fit together in biting or chewing. The word malocclusion literally means "bad bite.
 and trauma also benefit from intervention and education on proper diet. Immune-compromising medical conditions, radiation treatment, diabetes, eating disorders eating disorders, in psychology, disorders in eating patterns that comprise four categories: anorexia nervosa, bulimia, rumination disorder, and pica. Anorexia nervosa is characterized by self-starvation to avoid obesity.  and physical disabilities affect oral health and dietary intake. Individuals experiencing such conditions are excellent candidates for dental nutritional counseling to prevent compromised oral health, as well as dietary intervention by a registered dietitian to prevent severely compromised nutritional status. (1,2) Other individuals for whom nutritional counseling and diet education are indicated are clients with polypharmacy producing drug-nutrient interactions, xerostomia, decreased appetite and altered taste sensations, all of which cause a decrease in dietary intake and increase the risk for nutritional deficiency. (1)

Data Collection and Assessment

The indication for dental nutritional counseling is evaluated in the assessment phase of the dental hygiene process of care after the collection of both subjective and objective data. (3,4) Upon completion of thorough evaluation and synthesis of the information from medical and dental histories, extra/intraoral and gingival gingival (jin´jv  examinations, dental and periodontal periodontal /peri·odon·tal/ (per?e-o-don´t'l)
1. pertaining to the periodontal ligament or periodontium.

2. near or around a tooth.


per·i·o·don·tal
adj.
1.
 charting, and radiographs, the client's oral risk assessment is determined. (1)

Changes in the dental chart such as new or recurrent dental and/or root caries caries
 or tooth decay

Localized disease that causes decay and cavities in teeth. It begins at the tooth's surface and may penetrate the dentin and the pulp cavity.
; gingival and periodontal findings such as erythemic gingiva gingiva /gin·gi·va/ (jin´ji-vah) (jin-ji´vah) pl. gin´givae   [L.] the gum; the mucous membrane, with supporting fibrous tissue, covering the tooth-bearing border of the jaw. , tooth loss or loss of lamina LAMINA - A concurrent object-oriented language.

["Experiments with a Knowledge-based System on a Multiprocessor", Third Intl Conf Supercomputing Proc, 1988].
 dura; significant color, sensory or function changes in the oral mucosa The oral mucosa is the mucous membrane epithelium of the mouth. It can be divided into three categories.
  • Masticatory mucosa - keratinized stratified squamous epithelium, found on the dorsum of the tongue, hard palate and attached gingiva.
, tongue and/or salivary glands salivary glands (săl`əvâr'ē), in humans, three pairs of glands that secrete the alkaline digestive fluid, saliva, into the mouth. ; oral lesions indicating nutrient deficiency; polypharmacy; and chewing and swallowing difficulties indicate the need for dietary counseling. (1,2)

An evaluation of the dental client's skin, eyes, mouth and oral soft and hard tissues for significant findings of nutritional deficiencies is a necessary component of a comprehensive oral risk assessment. Clinical signs such as cheilosis, stomatitis Stomatitis Definition

Inflammation of the mucous lining of any of the structures in the mouth, which may involve the cheeks, gums, tongue, lips, and roof or floor of the mouth.
, glossitis glossitis /glos·si·tis/ (glos-i´tis) inflammation of the tongue.

glossitis area´ta exfoliati´va , benign migratory glossitis
 or inflamed, sore tongue are indicative of B complex or iron deficiency iron deficiency A relative or absolute deficiency of iron which may be due to chelation in the GI tract, loss due to acute or chronic hemorrhage or dietary insufficiency Sources Meat, poultry, eggs, vegetables, cereals, especially if fortified with iron; per the . Inflamed, bleeding gingiva and altered taste sensation are indicative of vitamin C vitamin C
 or ascorbic acid

Water-soluble organic compound important in animal metabolism. Most animals produce it in their bodies, but humans, other primates, and guinea pigs need it in the diet to prevent scurvy.
 and vitamin A deficiency Vitamin A Deficiency Definition

Vitamin A deficiency exists when the chronic failure to eat sufficient amounts of vitamin A or beta-carotene results in levels of blood-serum vitamin A that are below a defined range.
, respectively. (1,4,5)

There are many nutritional counseling forms in existence that are extremely beneficial and efficient in collecting data on a client's dietary intake. Whether the form is an official document or one created to meet the needs of an individual dental practice Noun 1. dental practice - the practice of dentistry
practice - the exercise of a profession; "the practice of the law"; "I took over his practice when he retired"
 setting, the basic criteria are standard. A dietary assessment form should include the ability to assess diet adequacy of nutrients and food groups, form and frequency of fermentable fermentable,
adj the ability to undergo a chemical reaction in the presence of an enzyme that results in the creation of either acid or alcohol; in the oral cavity, the ability to create acid in plaque.
 carbohydrates, and eating and snacking patterns. The various options available in collecting data on dietary intake include the 24-hour recall, a food diary, or a food frequency checklist.

The 24-hour recall serves as an instrument in collecting data on a client's diet history over the previous 24 hours. The information is obtained through a chairside interview with the client and dental hygienist reviewing, in detail, foods consumed within the previous 24-hour period. The 24-hour recall is quick and easy to administer and provides information in a timely fashion in just one appointment. However, the instrument is limited in scope to include only one day, and not truly representative of a client's normal intake. (4)

A food diary is a total intake analysis of all foods eaten for a three-, five-, or seven-day interval inclusive of inclusive of
prep.
Taking into consideration or account; including.
 at least one weekend day. The food diary is a much more accurate representation of an individual's dietary intake, affording the client with an active role in the dietary assessment and providing the opportunity to make observations for modification. However, it is a time-consuming instrument requiring multiple appointments. The client completes the diary at home and may not be entirely forthcoming and truthful with the dietary information, portion size, or frequency of snacking and consumption of cariogenic cariogenic (kerēōjen´ik),
adj contributing to the advancement of caries. Often used in the context of describing sugary foods.
 foods. (4)

A food frequency checklist represents frequency of consumption of certain foods and indicates how many times per week the individual consumes certain food items such as eggs, fish, chocolate, etc. More information is elicited as compared to the 24-hour recall because it is a daily account of all 7 days of the week. The major disadvantage is that it is limited in scope because it does not fully represent either daily intake or average analysis. (6)

Regardless of which assessment instrument is employed for dietary intervention, it is imperative that the dental hygienist explain the purpose of performing dental nutritional counseling by briefly describing how diet relates to the dental situation presented in the oral findings. This provides a foundation for the nutrition education to follow.

When utilizing the food diary as an assessment technique, the dental hygienist provides the client with a food diary for three, five or seven days (Figure 1) at the initial appointment of dietary assessment. Providing written and oral instructions for use of the food diary facilitates use comprehension, ensuring proper completion of the forms. Instruction for completing the food diary encourages the dental client to provide a more accurate portrayal of eating and snacking behaviors. Therefore, providing suggestions and clarification for listing ethnic and homemade foods, combination dishes such as casseroles or sandwiches, and proper use of household measurements for indicating quantity consumed fosters successful completion of the food diary. Avoid the mention of specific food to prevent biasing the client in their food selection. (4)

When providing instructions, be sure to emphasize the importance of making immediate entries in the diary upon completion of each meal to avoid omissions. Encourage the use of typical days and instruct the client to select consecutive days, and at least one weekend day, uncomplicated by illness, dieting, holidays or other unusual events for a realistic representation of diet and behaviors. Also indicate the need for recording any nutritional supplements Nutritional Supplements Definition

Nutritional supplements include vitamins, minerals, herbs, meal supplements, sports nutrition products, natural food supplements, and other related products used to boost the nutritional content of the diet.
 used and all fluids consumed, including alcoholic beverages

Main article: Alcoholic beverage
Fermented beverages
  • Beer
  • Ale
  • Barleywine
  • Bitter ale
. Request that meals eaten outside the home be identified with approximate estimations of portion size. Prior to dismissal be sure to emphasize the importance of returning the forms at the follow-up appointment. (4)

Upon receiving the completed food diary at the follow-up visit, review the diary with the client to clarify presented information. Identify any extraordinary influences on appetite such as illness or stress. Discuss food likes and dislikes, food intolerances or allergies. Review the frequency of dining out and alcohol intake. Clarify any special diets being followed in the home secondary to religious, ethnic or weight loss purposes. It is also beneficial to identify which family member is responsible for the cooking and grocery shopping to determine if the client has control over the foods available. (4)

Analysis of Dietary Intake

The primary aspects of the food diary to analyze are nutritional adequacy of each food group and the form and frequency of cariogenic foods. The Web-based nutrition analysis program available at www.mypyramidtracker.gov is an excellent vehicle to analyze the client's three-, five-, or seven-day food diary. The site is very user-friendly and, when the client's food diary has been entered, it provides printed information summarizing nutrition adequacy of dietary intake relative to daily serving sizes from each food group. It identifies deficiencies as well as excesses.

The MyPyramid Food Guidance System Web site (www.mypyramid.gov) provides printed charts as a tool for nutrition education. Charts outlining food intake patterns and calorie levels based on age, gender and activity level help to reinforce proper portion control, adequacy and moderation of discretionary calories,

When time is a factor, the analysis of the 24-hour recall is the better option to employ. Nutritional adequacy of food groups represented in the client's 24-hour intake can also be determined using the MyPyramid Web site according to the client's age, gender and activity level.

Analysis of Cariogenic Foods

The client's dental caries risk is calculated by classifying each fermentable carbohydrate into liquid, solid or slowly dissolving. The score is determined as outlined in the self-explanatory scoring instrument in Figure 2, Scoring Dental Caries Risk.

The first step in the process of determining caries risk is to identify the physical form of fermentable carbohydrates in the diet. The dental hygienist must evaluate the diet for liquids such as sweetened sweet·en  
v. sweet·ened, sweet·en·ing, sweet·ens

v.tr.
1. To make sweet or sweeter by adding sugar, honey, saccharin, or another sweet substance.

2. To make more pleasant or agreeable.
 or unsweetened soft drinks and fruit juices with added sugars. Solids are classified into two categories. The first is soft solid (sticky, retentive re·ten·tive  
adj.
1. Having the quality, power, or capacity of retaining.

2. Having the ability or capacity to retain knowledge or information with ease: a retentive memory.
 solids) such as cakes, cookies, chips, pretzels, jellybeans and chewy chew·y  
adj. chew·i·er, chew·i·est
Needing much chewing: chewy candy.



chewi·ness n.
, sticky candies. The second is hard, slowly dissolving solids such as hard candies, mints and cough drops. (4)

The next step is to determine the frequency of daily meals and snacks inclusive of time and place of eating events. The most effective technique in identifying fermentable carbohydrates in the diet is to circle them in red so they are easily noticed on the food diary or 24-hour recall record. Clients can identify any appropriate or inappropriate practices contributing to their caries risk score. The dental hygienist can corroborate To support or enhance the believability of a fact or assertion by the presentation of additional information that confirms the truthfulness of the item.

The testimony of a witness is corroborated if subsequent evidence, such as a coroner's report or the testimony of other
 the score with clinical findings and oral health conditions prior to dietary counseling . (4)

After analyzing the diet, the client can identify any deficiencies and excesses and make realistic recommendations for behavior modification behavior modification
n.
1. The use of basic learning techniques, such as conditioning, biofeedback, reinforcement, or aversion therapy, to teach simple skills or alter undesirable behavior.

2. See behavior therapy.
. The dental hygienist should provide guidance in identifying foods in the diary that require changing. It is also important to provide dietary guidance in finding acceptable substitutions for the cariogenic foods. To enhance compliance, help clients create their own meal plans for one day. (4)

Counseling Objectives

The objectives of the counseling session include the client understanding the individual oral problems and appreciating the need for changing habits; specific alterations in the diet necessary for improved general and oral health; dental caries control; minimal consumption of cariogenic foods, especially between meals; substituting noncariogenic foods into the diet; and improving nutritional adequacy in accordance with recommendations set forth by the USDA USDA,
n.pr See United States Department of Agriculture.
. (4)

Appropriate teaching materials pertinent to the counseling session are the client's radiographs, charting, and food diary; food models and labels; charts of dietary standards and requirements; the MyPyramid poster; a list of snack suggestions and any educational pamphlets illustrating the client's special dietary or oral health needs. (4)

The ideal environment for performing dental nutritional counseling is free from interruptions and distractions, preferably apart from the clinical treatment room. A non-threatening environment is conducive to learning. The decor should provide pertinent educational posters, pamphlets and food labels and models of portion sizes. (4)

A warm, friendly, non-threatening atmosphere is crucial in any counseling setting. The technique used in dental nutritional counseling is analogous to interviewing a dental client during the medical and dental history intake, such as establishing eye contact with a professional, nonjudgmental non·judg·men·tal  
adj.
Refraining from judgment, especially one based on personal ethical standards.

Adj. 1. nonjudgmental
 demeanor. The use of open-ended questions elicits more information. An example of such a line of questioning Noun 1. line of questioning - an ordering of questions so as to develop a particular argument
line of inquiry

line of reasoning, logical argument, argumentation, argument, line - a course of reasoning aimed at demonstrating a truth or falsehood; the
 would be "Tell me, what did you have for breakfast today," and then "How was the omelet prepared?" and "What did you put on the toast?" To provide an adequate amount of information, avoid closed-ended questions that provide only "yes" or "no" responses and limit information; for example: "Did you eat lunch today?" Also recommended is to avoid using "why," which elicits defensiveness; for example, "Why do you use butter?" (4)

It is recommended to use a client-centered approach in the counseling session by guiding clients to develop their own behavioral changes. Having clients make their own suggestions for substitutions and behavior fosters greater compliance. Empowering the client to be involved in making recommendations for change puts the responsibility for change where it can be the most effective, on the clients themselves. During counseling, be sure to keep goals simple, small, realistic and adaptable to the client's lifestyle. Adequately discuss all questions using a conversational tone without lecturing. (4,6)

In summarizing the session's purpose and objectives, provide an explanation of the relevance between diet and the client's specific oral findings and caries risk with the emphasis on health promotion and disease prevention. Clarify any confusion of hidden sugars, added sugars and natural sugars. Clarify the moderation of sugar intake, and select substitutions.

Be sure to convey that oral retentiveness re·ten·tive  
adj.
1. Having the quality, power, or capacity of retaining.

2. Having the ability or capacity to retain knowledge or information with ease: a retentive memory.
 of cariogenic foods is related to length of time food debris with fermentable carbohydrate remains on the teeth and exposure to decreased pH. Sticky foods are retained for shorter periods of time and have a shorter oral clearance. Highly retentive fermentable carbohydrates have a delayed rate of oral clearance, thereby increasing exposure of teeth to a decreased pH and higher potential for demineralization demineralization /de·min·er·al·iza·tion/ (de-min?er-al-i-za´shun) excessive elimination of mineral or organic salts from tissues of the body.

de·min·er·al·i·za·tion
n.
. (7-9)

Also imperative to clarify is that the sequencing of food consumption within a meal is related to caries incidence. Eating fermentable carbohydrates at the beginning of a meal or between other cariostatic foods such as protein and fat means less cariogenic potential. Protein and fat are not metabolized by bacteria and are recommended to be consumed at the end of a meal. Cheese eaten after sweets or at the end of a meal prevents the decrease in pH and production of acids in the oral cavity. Using water decreases cariogenic activity by rinsing sugars from tooth surfaces. (9-12)

Another recommendation would be the use of sugar-free chewing gums, which decrease lactic acid lactic acid, CH3CHOHCO2H, a colorless liquid organic acid. It is miscible with water or ethanol. Lactic acid is a fermentation product of lactose (milk sugar); it is present in sour milk, koumiss, leban, yogurt, and cottage cheese.  production and increase salivary flow salivary flow,
n the amount of saliva naturally produced by the salivary glands. Saliva production is increased by the presence of food or irritating substances, such as vomit, in the oral cavity.
, potentially buffering acids. Chewing a gum with xylitol xylitol /xy·li·tol/ (zi´li-tol) a five-carbon sugar alcohol derived from xylose and as sweet as sucrose; used as a noncariogenic sweetener and also as a sugar substitute in diabetic diets.  immediately after each meal reduces the levels of Streptococcus mutans Streptococcus mu·tans
n.
A species of Streptococcus associated with the production of dental caries.
 and promotes remineralization remineralization /re·min·er·al·i·za·tion/ (re-min?er-al-i-za´shun) restoration of mineral elements, as of calcium salts to bone.

re·min·er·al·i·za·tion
n.
. Xylitol is the sugar substitute of choice because it is not fermentable by caries-promoting bacteria. Sorbitol sorbitol /sor·bi·tol/ (sor´bi-tol) a six-carbon sugar alcohol from a variety of fruits, found in lens deposits in diabetes mellitus.  can be fermented by Streptococcus mutans at a very slow rate. (13,14)

Insurance Issues

According to Current Dental Terminology (CDT CDT
abbr.
Central Daylight Time


CDT Central Daylight Time

CDT n abbr (US) (= Central Daylight Time) → hora de verano del centro;
(BRIT
), nutritional counseling is listed under "Other Preventive Services" as code D1310 and receives no compensation when provided in dental practice. It is analogous to the same reimbursement issues as fluoride treatments and sealants for individuals over the age of 14, which are provided at the client's expense. (2) The lack of compensation by insurance companies is not a justification to eliminate dental nutritional counseling from the dental hygiene process of care and increasing a dental client's oral risk for dental disease, oral manifestations of nutritional deficiencies, inadequate dietary intake and knowledge deficit in proper nutrition proper nutrition,
n in Tibetan medicine, a therapeutic concept that begins with a digestive formulation because it is believed that a medical condition is primarily the result of a nutritional dysfunction or disturbance in the process of delivering nutrients.
. It is a preventive intervention as essential as providing oral self-care instructions to ensure behavior modification in the prevention of disease.

Summary

As stated earlier, dietary risk assessment is part of the total oral risk assessment phase in disease prevention and health promotion in the dental hygiene process of care. Dental nutritional counseling can easily be incorporated into behavior modification strategies employed by the dental hygienist.

In client-centered dental nutritional counseling, it is crucial to offer guidance in making small changes that the client has suggested. Ensure the substitution of foods that are a realistic change and will foster lifelong behavior modification and compliance. Clients should make one to two small realistic goals per session and work methodically on a few at a time. Recare visits offer the perfect opportunity to re-evaluate and assess compliance and offer further guidance in fostering behavior modification in the prevention of further dental caries, problems with dietary intake and oral manifestations of nutritional deficiencies.

References

(1.) Palmer CA. Diet and nutrition in oral health, 2nd ed. Upper Saddle River, N.J.: Prentice Hall; 2007.

(2.) Sroda R. Nutrition for a healthy mouth. Baltimore: Uppincott, Williams & Wilkins; 2006.

(3.) Mueller-Joseph L, Petersen M. Dental hygiene process of care. diagnosis and care planning. Albany, N.Y.: Delmar Publishers; 1995.

(4.) Wilkins EM. Clinical practice of the dental hygienist, 9th ed. Philadelphia: Lippincott, Williams, and Wilkins; 2005.

(5.) Wardlaw GM, Hampl JS, DiSilvestro RA. Perspectives in nutrition, 7th ed. New York New York, state, United States
New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of
: McGraw-Hill; 2007.

(6.) Rosal MC, Ebbeling CB, Lofgren I, et al. Facilitating dietary change: the patient-centered counseling model, J Am Diet Assoc 2001; 101: 332-41.

(7.) Kashket B, Van Houte J, Lopez LR, Stocks S. Lack of correlation between food retention on the human dentition dentition, kind, number, and arrangement of the teeth of humans and other animals. During the course of evolution, teeth were derived from bony body scales similar to the placoid scales on the skin of modern sharks.  and consumer perception of food stickiness. J Dent Res 1991; 70: 1314.

(8.) Kashket S, Zhang J, Van Houte J: Accumulation of fermentable sugars and metabolic acids in food particles that become entrapped on the dentition, J Dent Res 1996; 75: 1885.

(9.) Lingstrom P, Birkhed D, Ruben J, Arends J. Effects of frequent consumption of starchy starch·y  
adj. starch·i·er, starch·i·est
1.
a. Containing starch.

b. Stiffened with starch.

2. Of or resembling starch.

3.
 food items on enamel and dentin dentin /den·tin/ (den´tin) the chief substance of the teeth, surrounding the tooth pulp and covered by enamel on the crown and by cementum on the roots.den´tinal

adventitious dentin  secondary d.
 demineralization and on plaque pH in situ In place. When something is "in situ," it is in its original location. , J Dent Res 1994; 73: 652.

(10.) Linke HAB HAB

See: House Air Waybill
, Birkenfeld LH. Clearance and metabolism of starch foods in the oral cavity. Ann Nutr Metab 1999; 43: 131.

(11.) Boyd LD, Dwyer JT. Guidelines for nutrition screening, assessment, and intervention in the dental office. J Dent Hyg 1998; 72 (4): 31-43.

(12.) Linke HAB, Riba HK. Oral clearance and acid production of dairy products during interaction with sweet foods. Ann Nutr Metab 2001; 45: 202-208.

(13.) Hayes C: The effect of non-cariogenic sweeteners on the prevention of dental caries: a review of the evidence. J Dent Educ 2001; 65: 1106.

(14.) Hildebrandt GH, Sparks BS. Maintaining mutans streptococci Streptococcus (plural, streptococci)
A genus of spherical-shaped anaerobic bacteria occurring in pairs or chains. Sydenham's chorea is considered a complication of a streptococcal throat infection.
 suppression with xylitol chewing gum, J Am Dent Assoc 2000; 131: 909.

Recommended Resources for Examples of Dental Caries Scoring

Darby ML, Walsh MM. Dental hygiene theory and practice, 2nd ed. St. Louis: Saunders, Elsevier Science; 2003: Chapter 28.

Nizel AE, Papas AS. Nutrition in clinical dentistry, 3rd ed. Philadelphia: W.B. Saunders Company; 1989: Chapter 17.

Wilkins EM. Clinical practice of the dental hygienist, 9th ed. Philadelphia: Lippincott, Williams, and Wilkins; 2005: Chapter 32.

Luisa Nappo-Dattoma, RDH RDH
abbr.
Registered Dental Hygienist


RDH,
n an abbreviation for registered dental hygienist.
, RD, EdD, is a full-time assistant professor at Farmingdale State College in Farmingdale, N.Y.
Figure 1. Sample of a completed one-day diary for a 24-hour recall.

FOOD DIARY

Name: Amanda Banks

Age 29   Gender F   Height 5' 6"   Weight 150#   BMI 24.2

                               Quantity
            Type of foods/     (i.e., cup, oz.,   Preparation
Time        beverage           tbsp., tsp.)       technique

BREAKFAST

7 am        Pancakes           2 medium           Frozen; heated
            Maple syrup        2 tbsp.            in microwave
            Coffee; milk;      6 oz; 2 oz;
            sugar              2 tsp.
SNACK

10 am       Chocolate donut    1                  Donut shop
            Coffee; milk;      16 oz.; 4 oz.;
            sugar              2 packets

LUNCH

2 pm        Pepperoni pizza    2 slices           Pizzeria
            Lemonade           12 fluid oz.
                               bottle
SNACK

3 pm        Breath mints       2
4 pm        Chips              2 oz. bag          Vending
            Cola               12 oz. bottle      Machine

DINNER

8 pm        Double burger      1                  Fast Food
            with cheese
            Fries              Large
            Cola               16 oz

SNACK

11 pm       Chocolate chip     4                  Home
            cookies
            Chocolate milk     8 oz.

Figure 2. One example of a scoring measurement form for caries risk
related to dietary intake of cariogenic foods. Adapted with
permission from Carole A Palmer, EdD, RD, Division of Nutrition and
Oral Health Promotion, Department of Public Health and Community
Service, Tufts University School of Dental Medicine.

SCORING DENTAL CARIES RISK
(Caries-Promoting Potential)

                                               Frequency
                                               (place a check
Food Items      Reference Foods                for each
(from 24-hour   Considered                     exposure to
recall)         Cariogenic                     cariogenic food)

1               Liquid
2               Soft drinks, fruit drinks,     --
3               cocoa, sugar and honey in      --
4               beverages, nondairy            --
                creamers, ice cream,           --
                sherbet, flavored or frozen
                yogurt, pudding, custard,
                Popsicle, jelly

1               Solid & Sticky
2               Cakes, cupcakes, doughnuts,    --
3               sweet rolls, potato chips,     --
4               pretzels, pastry, canned       --
5               fruit in syrup, bananas,       --
6               cookies, chocolate candy,
                caramel, toffee, jelly
                beans, other chewy candy,
                chewing gum, dried fruit,
                marsh- mallows, jelly, jam

1               Slowly Dissolving
2               Hard candies, breath mints,    --
3               antacid tablets, cough drops   --
                                               --

                                                          Total
                                                          Points
                                               Weighted   Each
                                               Score      Category
Food Items      Reference Foods
(from 24-hour   Considered
recall)         Cariogenic

1               Liquid
2               Soft drinks, fruit drinks,     X 1        --
3               cocoa, sugar and honey in
4               beverages, nondairy
                creamers, ice cream,
                sherbet, flavored or frozen
                yogurt, pudding, custard,
                Popsicle, jelly

1               Solid & Sticky
2               Cakes, cupcakes, doughnuts,    X 2        --
3               sweet rolls, potato chips,
4               pretzels, pastry, canned
5               fruit in syrup, bananas,
6               cookies, chocolate candy,
                caramel, toffee, jelly
                beans, other chewy candy,
                chewing gum, dried fruit,
                marsh- mallows, jelly, jam

1               Slowly Dissolving
2               Hard candies, breath mints,    X 3        --
3               antacid tablets, cough drops

                                               TOTAL SCORE --

Key for Scoring Caries Risk:

* Classify each sweet into liquid, solid and sticky, or slowly
dissolving. (Use reference food list)

* For each time a sweet was eaten, either at a meal or between
meals (at least 20 minutes apart) place a check in the
frequency column.

* In each category tally the number of sweets eaten and multiply
by the weighted score. Record the category points in the respective
column.

* Tally all the category points to determine the total score.

Risk Score:
(Risk for
dental caries)            Recommendations to lower caries risk:

0-1     Low Risk          1. Reduce the frequency of between-meal
                          sweets

2-4                       2. Don't sip constantly on sweetened
                          beverages

5-7     Moderate Risk     3. Avoid using slowly dissolving items like
                          hard candy, cough drops etc.

8-9                       4. Eat more non-decay promoting foods
                          such as: (low fat cheese, raw vegetables,
                          crunchy fruits, nuts, popcorn, bottle
                          water & diet sodas)

>9      High Risk         5. Use water or milk instead
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Title Annotation:nutrition
Author:Nappo-Dattoma, Luisa
Publication:Access
Geographic Code:1USA
Date:Mar 1, 2008
Words:3783
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