Dental nutritional counseling techniques for the dental hygienist.
Nutrition and oral health have an integral relationship in health status. The integrity of the oral cavity affects dietary intake, which affects nutritional status, which in turn presents with oral manifestations of nutritional deficiency in individuals with compromised nutritional status. This interrelationship 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 process of care.
Purpose of Dietary Counseling
Nutritional assessment, a comprehensive investigation comprising anthropometric, physiological and biochemical data to determine baseline nutritional status, is performed by a medical doctor or registered dietitian. 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, MyPyramid Food Guidance System and the Dietary Reference Intakes. (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 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 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, 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, malocclusion and trauma also benefit from intervention and education on proper diet. Immune-compromising medical conditions, radiation treatment, diabetes, eating disorders 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 examinations, dental and periodontal 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; gingival and periodontal findings such as erythemic gingiva, tooth loss or loss of lamina dura; significant color, sensory or function changes in the oral mucosa, tongue and/or salivary glands; 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, glossitis or inflamed, sore tongue are indicative of B complex or iron deficiency. Inflamed, bleeding gingiva and altered taste sensation are indicative of vitamin C and vitamin A deficiency, 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 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 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 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 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 used and all fluids consumed, including alcoholic beverages. 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 or unsweetened soft drinks and fruit juices with added sugars. Solids are classified into two categories. The first is soft solid (sticky, retentive solids) such as cakes, cookies, chips, pretzels, jellybeans and chewy, 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 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. 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)
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. (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 demeanor. The use of open-ended questions elicits more information. An example of such a line of questioning 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 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. (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 production and increase salivary flow, potentially buffering acids. Chewing a gum with xylitol immediately after each meal reduces the levels of Streptococcus mutans and promotes remineralization. Xylitol is the sugar substitute of choice because it is not fermentable by caries-promoting bacteria. Sorbitol can be fermented by Streptococcus mutans at a very slow rate. (13,14)
According to Current Dental Terminology (CDT), 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. It is a preventive intervention as essential as providing oral self-care instructions to ensure behavior modification in the prevention of disease.
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.
(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: 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 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 food items on enamel and dentin demineralization and on plaque pH in situ, J Dent Res 1994; 73: 652.
(10.) Linke HAB, 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 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, 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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