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Chairside Diet Assessment of Caries Risk

Teresa A. Marshall
J Am Dent Assoc 2009;140;670-674

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Chairside diet assessment of caries risk
Teresa A. Marshall, PhD, RD/LD

ral health care professionals are

O aware of the importance of

dietary habits in relation to
caries risk.1-5 Given chairside
constraints (that is, time or
resources), however, it is easy to lose sight
of diet and instead focus on the immediate
concernthe patients chief complaint. The
Background. A dietary habit assessment should be
an integral component of oral health care. The author
outlines strategies that oral health care professionals
ability to provide diet counseling within can use to assess dietary habits associated with caries
time or resource limitations depends on risk and to develop dietary recommendations.
prioritization of patient needs, an efficient Conclusion. A caries risk assessment tool can be
mode of diet assessment and a comfortable used to identify dietary habits that may contribute to
working knowledge of diet and oral health caries risk.
relationships. In this article, I describe a Practical Implications. The caries risk assess-
caries risk assessment tool and offer strate- ment tool can provide structure for evaluating patients
gies for dietary counseling. dietary habits and food choices and helping oral care
health professionals provide preventive dietary
The Diet Assessment of Caries Risk tool Key Words. Caries; diet.
was developed at The University of Iowa JADA 2009;140(6):670-674.
(Iowa City) to help oral health care profes-
sionals efficiently assess dietary contribu-
tors to caries risk (Table 16,7). The objec-
Dr. Marshall is an assistant professor, Department of Preventive and Community Den-
tives of the Diet Assessment of Caries Risk
tistry, College of Dentistry, N-335 Dental Science Building, University of Iowa, Iowa City,
tool are to identify specific dietary behav- Iowa. 52242-1010, e-mail teresa-marshall@uiowa.edu. Address reprint requests to
iors that affect caries risk and to enable Dr. Marshall.

670 JADA, Vol. 140 http://jada.ada.org June 2009

Copyright 2009 American Dental Association. All rights reserved. Reprinted by permission.

oral health care practi- TABLE 1

tioners to begin conversa- Diet assessment of caries risk.
tions regarding dietary
Having knowledge about Number of < 6/day Low 3-6/day
patients dietary behaviors Meals/Snacks
> 6/day Moderate
that are associated with
Meal/Snack Structure Structured Low Structured meal
caries risk is essential pattern
Unstructured/grazing Moderate
when providing specific,
individualized recommen- Sugared Beverages

dations that may decrease Quantity < 12 ounces/day Low 6-8 ounces of 100 percent
juice or other sugared
caries risk. The caries 12-20 ounces/day Moderate beverage/day; < 12 ounces
process depends on the > 20 ounces/day High of sugared soda pop/day
presence of host and envi- Timing With meals Low With meals
ronmental factors, With snacks Moderate
including exposure to fer- Between meals/snacks High
mentable carbohydrates.

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Frequency 1 exposure/day Low 1 exposure/day
The structure of meals and
2-3 exposures/day Moderate
snacks influences the
4 exposures/day High High
quantity and frequency of
patients exposure to fer- Length of exposure < 15 minutes Low < 15 minutes

mentable carbohydrates 15-30 minutes Moderate

and, subsequently, caries > 30 minutes High
risk.8-11 Key areas to Drinking style Straw Low Straw
include in a dietary assess- Open container Moderate
ment of caries risk are the Swishing within mouth High
number of dietary expo-
* The desired behavior guidelines are based on dietary guidelines and current practice and are presented
sures (meals and snacks), for adolescents and adults. Sources: U.S. Department of Agriculture6 and U.S. Department of Health
the structure of meals and and Human Services and U.S. Department of Agriculture.7
Sugared beverages include 100 percent juice, juice drinks, soda pop, sports drinks, energy drinks, and
snacks and the manner of sugared coffee and tea.
sugared beverage intake.
(Sugared beverages include 100 percent juice,
juice drinks, soda pop, sports drinks, energy Definitions of terms.
drinks, and sugared coffee and tea.) These key
areas, as well as the potential caries risk asso- ANTICIPATORY GUIDANCE
Health promotion guidelines designed to promote health
ciated with probable responses and desired and prevent disease.
behaviors, are outlined in Table 1. The desired
behavior guidelines, which are based on dietary A 24-hour recall is an interviewer-administered dietary
guidelines and current practice, are for adoles- assessment tool designed to gather information about food
and beverage intakes and meal patterns. Open-ended
cents and adults6,7; guidelines for young children prodding questions are asked to facilitate recall of foods
and elderly people differ. and beverages consumed. The 24-hour recall also can be
used to identify food preferences and areas in which the
patient is receptive to change. For example, the interviewers
ANTICIPATORY GUIDANCE questions might follow the following format:
The Diet Assessment of Caries Risk tool is dWhat did you eat or drink first yesterday? Approximately
what time was that? Where were you when you con-
designed to identify diets that place people at sumed it? Did you have anything to eat or drink with the
reported beverage or food?
high risk of developing caries. However, coun-
dWhen did you next eat or drink anything? And what did
seling people with high-caries-risk diets may you consume? About how much did you have? How long
did it take you to consume the beverage or food?
require obtaining additional information The interview can continue with similar prodding questions
regarding their usual dietary intake. Individual until the patient indicates that is all he or she consumed.
Then the interviewer can look for and address potential dis-
foods and beverages are not consumed in isola- crepancies in the patients recall.
tion, and dietary recommendations for oral health dI noticed you reported nothing to drink from noon on. Is
this typical?
can have ripple effects on other aspects of the
dDo you like to eat fruits or vegetables?
diet. Thus, it is helpful for oral health care practi-

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BOX 2 Without anticipatory dietary guidance, the

patient may return to the dentist having quit but
Anticipatory guidance to support consuming the same quantity of a sports drink or
the dietary recommendation to a diet beverage combined with sugar-laden
decrease Mountain Dew* intake. snacks throughout the day. Anticipatory guidance
should be based on the patients current diet,
DESIRED MODIFICATION acknowledge that the calories provided by the
dLimited Mountain Dew intake, as opposed to the beverages will need to be replaced by calories
current consumption of a 12-pack of Mountain Dew
per day. from food, provide structure for the food calories
RATIONALE FOR MODIFICATION and guide the patient in selecting foods consistent
dProlonged exposure to sugared beverage increases with MyPyramid6 guidelines. An example of an
caries risk.
anticipatory guidance strategy is shown in Box 2.
SUGGESTED STRATEGIES TO ACHIEVE If the six 20-ounce beverages were caffeinated,
dSwitch to diet Mountain Dew.* a patients quitting cold turkey could result in
dGradually decrease Mountain Dew by mixing with him or her experiencing significant caffeine with-
diet Mountain Dew and finally replacing with all diet
Mountain Dew. drawal symptoms and a decrease in the likelihood
of his or her complying with the recommendation

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dReplace Mountain Dew with sugar-free alternative
(that is, tea, water, diet cola).
dLimit Mountain Dew consumption to meals. to quit drinking. Acknowledging the caffeine
dependence, while providing anticipatory guid-
dEnergy intake; Mountain Dew provides 1,900 calories. ance consistent with oral and systemic health,
Without this energy, patient will be hungry. Anticipatory increases the likelihood of the patients being
guidance should emphasize structured meal patterns
and MyPyramid6 food choices to prevent frequent receptive toward recommendations and long-term
intake of foods containing fermentable carbohydrates. compliance. Suggested strategies to use to
dCaffeine intake; patient likely will need caffeine address the caffeine intake include recommending
replacement, because otherwise he or she likely will
treat probable headaches with Mountain Dew; patient a gradual decrease in the consumption of the caf-
will be less likely to attempt behavior change in the
future. feinated beverage, mixing the caffeinated bev-
erage with a decaffeinated beverage (in smaller
* Mountain Dew and diet Mountain Dew are manufactured by
PepsiCo, Purchase, N.Y. amounts until the caffeinated beverage is elimi-
nated) or substituting a sugar-free caffeine source
for the caffeinated beverage.
tioners to have knowledge of patients preferred An example of a 24-hour dietary recall from a
foods, accessibility to foods and current dietary patient with rampant caries and desired diet
habits so they can individualize recommendations modifications is shown in Table 2. Patients can
and provide anticipatory guidance to patients use MyPyramid6 to help them identify alternative
(Box 1). Using the 24-hour dietary recall tool (Box foods and beverages to their original diets and
1), asking the patient questions regarding typical develop dietary habits that support oral and sys-
food groups or both can help oral health care temic health.
practitioners identify the patients dietary frame-
work within which current behaviors exist. Oral COUNSELING STRATEGIES
health care practitioners must consider how diet Although oral health care professionals can iden-
recommendations fit within the patients dietary tify patients food or beverage selections and
framework or whether the framework requires dietary habits that increase their risk of devel-
modification to support or enable oral health care oping caries, patients are responsible for
practitioners recommendations. changing their behaviors. Oral health care profes-
For example, six 20-ounce sugared, carbonated sionals can only provide recommendations; how-
beverages provide approximately 1,500 calories ever, the manner in which those recommenda-
per day. Recommending that the patient who con- tions are provided will improve the patients
sumes this quantity of sugared, carbonated bever- receptivity.12,13 Knowledge of patients under-
ages quit drinking or switch to diet does not standing of diet-disease relationships and motiva-
acknowledge that those beverages provide 50 per- tion to change will help oral health care practi-
cent or more of the patients energy intake and tioners tailor recommendations to each patient.
that the patient will be hungry if he or she quits Providing how-to adviceincluding different
or switches to the diet version of the beverage. strategies to use to achieve the desired outcome

672 JADA, Vol. 140 http://jada.ada.org June 2009

Copyright 2009 American Dental Association. All rights reserved. Reprinted by permission.


24-hour dietary recall of a patient* with rampant caries.


Time Food Item Quantity Where Consumed

Breakfast McDonalds One McDonalds Low Cereal with milk

(Oak Brook, Ill.) Orange
bacon, egg and
cheese biscuit
Mountain Dew (Pep- 12 servings, McDonalds High Coffee
siCo, Purchase, N.Y.) consumed
throughout day
beginning with

Lunch Ham sandwich: Two Work Low Ham and cheese

bread, ham sandwich

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Mountain Dew See note in Work High Mountain Dew
Breakfast row

Defined snack Powerade 20 ounces During commute High Propel (PepsiCo)

(The Coca-Cola
Company, Atlanta)

Dinner Subway (Milford, One 12-inch Take out Low Subway meatball
Conn.) meatball sandwich sandwich
sandwich Salad

Mountain Dew See note in Home High Diet Mountain Dew

Breakfast row (PepsiCo)

Between meals Mountain Dew See note in Work, home High Iced tea or diet
Breakfast row Mountain Dew

1. Patient likes fruits and vegetables and is willing to drink milk on cereal.
2. Patient quantified his Mountain Dew intake as about a 12-pack per day.
3. Patient reported swishing, but not holding, Mountain Dew in his mouth.
4. Although the patient accepted diet Mountain Dew, he was unwilling to give up all of his Mountain Dew at this time. We negoti-
ated limiting Mountain Dew to lunch only with a water rinse after consumption.
5. Patient denied regular intake of candy, baked goods and snack foods.

* The patient was a 25-year-old man who was 5 feet, 10 inches tall and weighed 276 pounds. Reported alcohol intake included three to four
drinks once a week.

and educational resourcesand engaging the The questions asked to assess the topics out-
patient in the process are considered more suc- lined in the Diet Assessment of Caries Risk tool
cessful strategies for ensuring the patients com- should be tailored to the age and culture of the
pliance than are telling the patient what to do or patient and to the oral health care professionals
to quit.12,13 style. However, all questions should be open-
Oral health care practitioners should include ended and nonjudgmental so as to minimize the
an assessment of diet-related caries risk factors patients guilt and encourage honest responses.
in the patients initial health history. Adminis- Receiving accurate information from the patient
tering this assessment before performing the oral is essential for negotiating dietary changes that
examination will not interrupt the flow of the oral support oral and systemic health.
examination and can improve patients perception
of dietary questions and honesty of response. In CONCLUSIONS
contrast, if the oral health care practitioner has a Although marginal dietary habits that increase
wide-eyed look after performing the oral exami- the quantity and frequency of fermentable carbo-
nation and asks the patient vague questions hydrate exposures are known to increase the risk
about dietary habits, a patients defenses may be of developing caries, oral health care profes-
raised and he or she may minimize reporting sionals do not assess patients dietary habits
actual behaviors. owing to resource and time limitations. Assessing

JADA, Vol. 140 http://jada.ada.org June 2009 673

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dietary habits is an essential component of pre-

ventive oral health care and targeting specific
high-risk behaviors will help oral health care
practitioners provide preventive dietary recom-
mendations to patients.
Disclosure. Dr. Marshall did not report any disclosures.

Nutrition is published in collaboration with the Nutrition Research

Group of the International Association for Dental Research.

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674 JADA, Vol. 140 http://jada.ada.org June 2009

Copyright 2009 American Dental Association. All rights reserved. Reprinted by permission.