Caries Process, Prevention and Management: The Diet
Course Number: 713
Course Contents
Dietary Screening for Caries Risk
The objective of dietary counseling in oral health is to reduce caries risk, support soft tissue health (i.e., periodontal tissue), reduce oral cancer risk, and support systemic health.23 Extensive dietary counseling is neither practical from a time perspective nor within an OHCP’s scope of practice. However, dietary screening to identify diet-related caries risks and providing guidance to reduce oral disease should be standard practice for all clinic patients. For practical purposes, dietary guidance to reduce caries risk is consistent with dietary guidance to support soft tissue health and reduce systemic disease.24 When patients present with complex dietary needs, referrals to other health care providers including registered dietitians is appropriate.
The objective of dietary screening is to identify healthy patients who are at risk of oral disease due to their marginal dietary habits. For patients presenting with oral disease, similar screening questions will identify dietary factors contributing to the disease process. Additional discussion to understand dietary behaviors is appropriate to provide dietary recommendations that are doable for individual patients. Dietary recommendations should provide guidance for the patient to achieve ‘better’ dietary behaviors and is a negotiation process with the patient. After all, the patient must be motivated and able to execute the recommendations in their daily life.
Screening components: A dietary screen is designed to identify specific high-risk behaviors and enable anticipatory guidance.22 Contemporary caries research suggest that both high SSB intakes and frequent carbohydrate exposures are significant risk factors for caries. For patients with high SSB intakes, dietary recommendations to lower SSB intakes inherently reduce energy intake. Anticipatory guidance is necessary to provide the patient with strategies to avoid caffeine withdrawal if the SSB contained caffeine as well as provide the patient with better food/beverage choices to replace lost energy. Recommendations for better food choices will complement soft tissue and systemic health. To make such recommendations, the clinician must understand the patient’s food preferences. Finally, as a health care professional screening for weight changes consistent with undiagnosed disease is appropriate. With these considerations in mind, the following screening questions are appropriate:
Meal structure
How many meals and snacks do you eat daily?
How would you describe your eating behaviors? Structured – as in eating at regular times on most days? Or unstructured – eating throughout the day with no regular pattern?
The desired outcome is structured eating events.
Unstructured eating events are associated with caries risk.22
Sugar-sweetened beverages
How much sugar-sweetened beverages do you drink per day? This includes soda-pop, juice drinks, energy drinks, sweetened coffee or tea, sports drinks, etc.
Consistent with WHO and USDGA recommendations, 8 oz is the recommended upper limit of SSB intake.
Greater than 20 oz/day is associated with caries risk.22
How long does it take you to drink your sugar-sweetened beverages?
Consumption limited to less than 30 minutes/day is recommended with consumption preferable at meals and snacks.
Greater than 30 minutes/day is associated with caries risk.22
Sugared candy
How often do you eat sugared candy or medicated lozenges?
The desired outcome is no more than once a day.
Compliance with MyPlate (Figure 12)25
How many food groups (i.e., fruits, vegetables, proteins, grains, dairy) do you eat per day?
The desired outcome is an intake of all food groups consistent with age and sex MyPlate recommendations.25
Recommendations to encourage intakes consistent with MyPlate are appropriate to replace energy from SSBs, support soft tissue health, and support systemic health.
Figure 12. Compliance with MyPlate25
Unintentional weight gain or loss
Have you gained or lost more than 10 pounds during the past six months?
The desired response is no unintended weight change.
An unintentional weight gain or loss of 10 pounds or more over a six-month period is not normal and may be consistent with undiagnosed systemic disease. A referral to the patient’s primary medical provider is appropriate.
Most of us do not consume perfect diets, and many patients have extensive dietary needs. Rather than overwhelming patients with multiple recommendations, the OHCP should engage the patient in the conversation. Clearly communicate the rationale for the desired change to ensure patient understanding. With that knowledge, what is the patient’s priority? What might they be willing to change? What might be the ripple effects of choosing to implement a recommendation? Providing patients with strategies to address the ripple effects will support success in making the desired changes and facilitate improved dietary habits.
Many patients face economic barriers that limit their ability to partake in desired oral hygiene behaviors and select healthier diets. OHCP can screen for both food and water insecurity and make appropriate referrals for patients facing such barriers. Food insecurity is defined as having limited or uncertain access to food due to economic or social circumstances.26 OHCP are in position to screen for food insecurity, and refer patients with food insecurity to their local food banks and social services (Figure 13).27 Water insecurity is defined as having uncertain access to potable water, and has been associated with increased intake of SSBs.28 Although screening tools for water insecurity have not been validated, asking patients if they have running water and if they are comfortable drinking their tap water is appropriate. For patients with limited access and/or who are uncomfortable drinking their tap water, providing guidance to resources for safe drinking water is appropriate.
Figure 13. Food Insecurity Screener Questions27