DIETARY COUNSELING FOR THE PREVENTION AND CONTROL OF DENTAL CARIES

Preeruptive periods of Development (both deciduous and permanent teeth) - foods exert a Nutritional (i.e, systemic) effect on the formation of the dental matrix and its mineralization. Posteruptive period (deciduous or permanent teeth are fully erupted)- foods exert a Dietary (i.e, topical) effect. Dietary counseling- to inhibit the carious process; appropriate in caries-prone patients with erupted teeth whose enamel surfaces are partly covered with dental plaque bacteria. Systemic nutritional counseling- for developing a caries-resistant tooth Some Food Choices and Eating Habits Merit Attention in Dietary Counseling: 1). Frequency of between meal snacking 2). Physical form and retentiveness of sugar-sweetened snacks on and between the teeth 3). Amount of sugar added to food or beverages for sweetening Sugar in liquid form can be as damaging to the teeth as sugar in sticky foods. Starch containing foods- may be more cariogenic than food with a high sugar content because the mixture of bread and sugar is retained around the teeth for longer time than highly sugared foods that are cleared rapidly from the mouth. Length of intimate contact of fermentable carbohydrate with plaque bacteria- determines the cariogenic potential The following are more important than the total amount of sugars consumed according to Shaw - frequency of eating - amount of food retained in the mouth particularly on tooth surfaces - length of time that food residues are retained in critical areas Cheese or peanuts- eating it before or after sugar- containing foods reduces cariogenicity of the latter The following do not produce an acidic plaque pH: Meats, Eggs, some types of nuts some dairy products

Diet counselor should incorporate into the diet prescription : 1. Nutritionally balanced varied diet from the high- density nutritious basic 4 food groups 2. Eliminate high- sugar snacks 3. If sugar- containing foods must be included for providing energy needs, restrict them to mealtime when organic acids formed may undergo neutralization 4. Recommend hard cheeses and nuts as between- meal snacks

DIET COUNSELING - involves giving advice on food selection based on the individual's reasons for liking or not liking certain foods. - it requires obtaining information as to why, where, when and what specific foods are eaten, how frequently, and what feelings are experienced. - an important preventive and supportive service -is both indicated and recommended as a part of a comprehensive preventive dentistry service to patients Minimal requirements for a successful dietary counseling service: 1. Enrolling active patient involvement in planning, implementing, and evaluating the diet before and after counseling 2. Insisting on a series of follow- up

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Patient Selection persons who need counseling must also want information about their potential dental caries problem patient must be willing to improve current undesirable food selections and eating habits Potential candidates for counseling should give high priority to preventive dentistry should be willing to expend long-term effort to maintain their natural dentition in good health for lifetime Dental Health Diet Score - screening device to achieve a demonstrable need for dietary improvement based on current food intake regimen. - a simple scoring procedure that can disclose a potential dietary problem that is likely to adversely affect a patient's dental health. 60- 100- acceptable so dietary counseling is not usually given unless patient requests it 56 or less- dietary counseling is indicated and recommended

DHDS= (adequate intake of foods from each food groups + ingesting recommended foods)frequent ingestion of overtly sweet foods Instructions for Calculating Dental Health Diet Score STEP 1 List all the foods that you eat on one ordinary weekday, including snacks with the time it was eaten (Average Daily Intake)

Lunch (12:00 Noon).

4 oz tomato juice 1 chicken (3 oz) sandwhich on rye bread 1 slice of chocolate cake with fudge icing 1 cup of coffee with 1 tsp of sugar 1 breath mint 1 piece of sugarless gum

P.M. Snack (2:00 P.M.). (3:00 P. M.)

BREAKFAST. (Time: ) LUNCH. (Time: ) DINNER (Time: )

A.M Snack ( Time: ) P.M. Snack ( Time: ) Any other Snacks ( Time: )

FIGURE 17-1 Dental Health Diet Score: 24- HOur intake diary STEP 2 -Circle foods that have been sweetened with added sugar -Classify the uncircled foods or mixed food dishes into one or more of the appropriate food groups(Fig 17-2) - place a check mark in appropriate food group block - add number of checks and multiply by 24 each (maximum number of points credit for the milk and meat groups) and 24 each for the fruit- vegetable and bread- cereal groups - add points and the sum is the Food Group Score (96 is the highest score)

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Scoring the Four Food Groups RECOMME Portion Sized NDED Considered One adult Serving servings MILK (milk and cheese) 8 oz (1c) milk 1.5 oz cheddar cheese 1.5 slice American cheese 3 1.5 cottage cheese 8 oz (1c) yogurt MEAT (meat, 2-3 oz lean cooked fish,poultry,dry,beans,nut meat,fish, or poultry s) 2 eggs 4 tbsp peanut butter 2 1 c cooked dry beans or lentils FRUITS AND VEGETABLES Vitamin A: (dark green c cooked fruit or and deep yellow fruits vegetables and vegetables) 1 medium raw fruit or vegetable medium grapefruit 1 or melon 4 oz (1/2c) juice Vitamin C: (juice and citrus fruits) 1 Food Groups Other 2 BREADS AND CEREALS(enriched or whole grain) 4 1 slice bread c dry cereal c cooked cereal,rice,noodles or macaroni

Number of Servings

Points

X 8=

(highest possible score=24)

X 12=

(highest possible score=24)

X 6=

(highest possible score=6)

X 6= X 6=

(highest possible score=6) (highest possible score=12) (highest possible score=24)

X 6=

TOTAL SCORE=

STEP 3 - how many of the foods listed contain one or more of the ten nutrients essential for dental - oral health ? ( fig 17-3) - check one or more eaten on each 8 columns of foods on usual weekday - circle number 7 beside the nutrient that heads this column - only 7 points is given per nutrient regardless of number of foods checked in column (56 is perfect score) - add the circled numbers to obtain the Nutrient Score

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PROTEIN AND NIACIN 7 Cheese Dried beans Dried peas Eggs Fish Meat Milk Nuts poultry

VITAMIN A 7 Apricots Broccoli Butter Cantaloupe Carrots Collards Eggs Greens Liver Margarine Milk Peaches Squash Spinach Sweet potatoes

IRON 7 Beef Broccoli Eggs Green leafy vegetables Liver Oysters Sardines shrimp

FOLIC acid 7 Asparagus Broccoli Cereals Kidney Liver Spinach yeasts

RIBOFLAVIN ( VITAMIN B2)

ASCORBIC ACID (VITAMIN C) 7

CALCIUM AND phosphorus 7

ZINc 7 Beef Liver Lobster Oysters Shrimp (other red meats and shellfish)

Broccoli Broccoli Broccoli Chicken breasts Brussels sprouts Cheese Egs Cantaloupe Eggs Ham Grapefrutgreen Green leafy Liver peppers vegetables Milk Greens Milk Mushrooms Oranges Oranges Pork Raspberries String beans Okra Strawberries spinach tomatoes Add the circle numbers. Total is your NUTRIENT SCORE____

STEP 4 - lists sweets and sugar-sweetened foods and the frequency with which they are consumed in typical day - classify each sweet into liquid, solid and sticky or slowly dissolving category ( fig 17-4) - put check in frequency column for each item (20 mins apart) - add numberof checks; multiply by 5 if sweet is liquid; if solid, multiply by 10; multiply by 15 if slowly dissolving - write products in the Points column and total them - this is Sweet Score

Decay-Promoting Potential Form Liquid Soft drinks,fruit drinks,cocoa,sugar, and honey in beverages, nondairy creamers,ice cream,sherbet,gelatin dessert,flavored yogurt, pudding,custard,popsicles Frequency Points

_____ x 5=

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SOLID AND STICKY Cake,cupcakes,donuts,sweet rolls, pastry,canned fruit in syrup,bananas,cookies, chocolate candy,caramel,toffee,jelly beans,other chewy candy,chewing gum,dried fruit,marshmallows,jelly,jam SLOWLY DISSOLVING Hard candies,breath mints,antacid tablets,cough drops Sweets Evaluation Chart

_____ x 10=

_____ x15=

STEP 5 - put it all together ( fig 17-5) - transfer the 4 Food Group Score and Sweet Score to the totaling the Scores page - Nutrition counseling - is indicated when 4 Food Group Score ( barely adequate or not adequate ) and Sweet Score ( watch out zone)

Communication Techniques Communication- basic tool in the practice of preventive dentistry. - It can create motivation for change. - is the giving and receiving of information - involves the knowledge, thoughts, and opinions of counselor and patient

3 Rules in Achieving effective communication with a patient 1. Keeping eye contact with the patient during face- to- face 2. Interviewer's tone of voice, facial expression, and gestures 3. Message must be adapted to the patients needs and level of understanding The following are used to communicate to patient: o interviewing. o teaching o counseling o motivating

INTERVIEWING Purpose - to obtain information and to give help Basic goal in interviewing is to understand 1). The problem 2). Factors that contribute to it 3). Personality of patient

Why should a dental health professional elicit information concerning the food and dietary intake and habits of patients?

1. Dietary interview can serve as valuable diagnostic aid. 2. Knowledge of a peron's daily routine is importsnt for adapting the caries-preventive diet to individual's life 3. Many practical research contributions could be made if data from nutritional assessments could be systematically gathered

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* PHYSICAL SETTING -privacy and a comfortable, relaxed atmosphere are important - private counseling room * DIET INTERVIEWER - Dental hygienist or Nutritionist( for clinical dental nutrition services) * HOW TO INTERVIEW A PATIENT Interviewer should be relaxed and should help the patient to relax and feel comfortable Start with a brief introductory statement about the purpose of the interview Allow patient to talk freely patient must act therefore it is best to start from her or his understanding Cross examination may make the patient defensive Interviewer should unobtrusively direct the interview Do not make decision for the person For a better follow-through, allow patient has learned and with which the patient can cooperate End by recapitulating what the patient has learned and future action that you have agreed on New appointment for reinforcement, answering questions and taking further action

TEACHING AND LEARNING Patient Education is more than simply giving information: it requires the presentation of information with sufficient impact to stimulate action by the learner. Using analogies with everyday experiences may help to explain biological facts in simple language The more the patient is involved in the educational process the greater is the extent of learning. People learn least well by hearing They learn better what they can see They learn best by doing because they are totally involved

Counseling *directive- the role of the patient is passive and the decisions are made by the counselor for the patient. * nondirective- the counselor's role is merely to aid the patient in clarifying and understanding his or her own situation and to provide guidance so the patient can make his/her own final decision.Recommended

Guidelines for counseling 1. Gather information 2. Evaluate and interpret information 3. Develop and implement a plan of action 4. seek active participation of the patient's family 5. Follow up to assess the progress made

MOTIVATION - an incentive for action The following are basic factors that motivate people according to Garn self- preservation recognition love money

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Motivating patients to modify food habits 1. Awareness is reconition that a problem exists but without a inclination to solve it(Hard candies produce acid,which ca cause my teeth to decay.) 2. Interest is a greater degree of awareness but still with no inclination to act.(Maybe I should give up the hard candies: I dont want any more sensitive or painful teeth.) 3. Involvement is a interest and a definite intention to act.( I definitely will give up hard candy.) 4. Action is a trial performance.(I have given up hard candies and chew sugarless gum instead to prevent the dry feeling in my mouth.) 5. Habit is a commitment to perform this action regularly over a sustained.( I havent had a hard candy in six months)

Principles of Diet Management: Application to Caries Prevention - they are simply slight modifications of a normal or adequate diet pattern Normal Diet- one that provides all the nutrients essential for good health by using a variety of foods from the USDA Daily Food Guide Balanced meal- nutrition of human organism is most efficient when there is an interaction of complementary nutrients at the same meal (importance) 4 rules adopted when making dietary modifications: 1. Maintain overall nutritional adequacy by cconforming to the USDA Daily Food Guide 2. Prescribed diet should vary from the normal diet pattern as little as possible 3. Diet should meet the body's requirements for the essential nutrients as generously a the diseased condition can tolerate. 4. Prescribed diet should take into consideration and accommodate the patient's likes and dislikes, food habits, and other environmental factors as long as they don't interfere with the objectives. Step-by-Step Dietary Counseling Procedure for Caries Prevention * Instructions for keeping a food diary * Interviewing and Counseling Visit * Arriving at a Diagnosis NUTRITIONAL MANAGEMENT Diagnosis of the Problem (Managing the causes of Improper Diet) Diet Prescription (Assist the Patient to select an Adequate Noncariogenic Diet) -Allow the patient to write his/her own diet prescription for

*Diet quality * Nutrient balance * Cariogenic potential Compare the New Diet with the Old Compare the total exposure of sweets in the two diets. B. Compare the adequacy of new and lold diets

CONCLUSIONS

1. The dietary guidance advocated here can improve general as well as dental health. Page 7 of 9

2. Personalized dietary counseling added to other caries-preventive measures should reduce carie recurrence significantly. 3. The daily ingestion of a balanced and varied selection of foods from the 4 food group, avoidance of sweets that are retained next to tooth enamel, and discontinuance of betweenmeal snacking are the basic elementsin achieving diet that produces few caries. 4. To realize maximum patient acceptance and cooperation with the diet prescription, determine and manage the reasons for the original diet, and suit the new diet to the patient's daily routine and lifestyle. 5. The objectivity, personalization of the diet, and the time spent in counseling are rewarded both financially and by the satisfaction of performing a useful health care and preventive dentistry service. SUMMARY GUIDELINES, DITARY COUNSELING FOR CARIES PREVENTION AND CONTROL Before Counseling I. Explain to the patient the reason for counseling. For example : "usually we deal with the effects of dental decay by restorative procedures. We would also like to find the cause in order to prevent cavities rather than to treat them in future; this is a compex disease in which diet plays one of the important roles. We would like to rule out diet as a factor in your tooth decay problem." II. Dental Health Diet Score: below 56 indicates a need for diet counseling. III. Food Intake. Obtain a representative food intake pattern by asking the patient to keep a 5-day diary (preferably including a weekend) The Counseling Visit IV. Reasons for Diet. To develop rapport with the patient, ask him or her to describe a typical days activities. A. This description provides clues to the reasons for food selection B. The description makes possible personalization of the diet, which will maximize patient cooperation. V. Education about the role of diet in the development and prevention of dental caries A. Caries: explain the interaction of teeth, plaque, sugar Plaque bacteria + sugar = acid Tooth+ acid= decay B. Ask patient, " Which is easiest for you to control - sugar, teeth, or bacteria?" VI. Cariogenic potential of the diet ( if applicable) A. Have the patient circle in red all foods listed in the food diary, that are sweetened with sugar. B. Stress the difference in cariogenic potential between retained and nonretained sweets. C. Explain the importance of frequency of eating as an important factor in cariogenicity. 1. State that the reaction of bacterial enzymes ( in the plaque ) on sugar is to change it to acid within 20 SECONDS. The acid continues to form for about 20 MINUTES. 2. Multiply: number of sugar exposures multiplied by 20 minutes equals to minutes of acid production ( convert to hours) a. When the sugar is eaten ( with or between meals) b. Form ( solid or liquid) VII. Adequacy of diet listed in food dairy A. Explain the importance of an adequate diet. B. Have patient transpose individual combinations of foods and dishes into appropriate food groups.

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C. Determine the adequacy of the diet by comparing the patient's intake with the amounts recommended ( place OK or minus in the Difference column; the patient can see the several causes of tooth decay and inadequacies of his or her diet) . VIII. Diagnosis of theproblem. Determine with patient any possible nutritional or dietary implication in oral problem. IX. Diet Prescription A. Allow the patient to write his or her own diet prescription for 1. Diet quality 2. Nutrient balance 3. Cariogenic potential X. Compare old and new diets A. Compare the total exposure of sweets in the two diets. B. Compare the adequacy of new and old diets XI. Summary Allow the patient to summarize the decisions for changes and the reasons for them XII. Follow- up Two or 3 weeks later, ask patient tomcomplete a new 5- day food diary compare it with the original; clarify misunderstandings.

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