Chairside Diet Assessment of Caries Risk

2009;140;670-674J Am Dent Assoc Teresa A. MarshallChairside Diet Assessment of Caries Risk

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CLINICAL PRACTICE N U T R I T I O N

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

Oral health care professionals areaware of the importance ofdietary habits in relation tocaries risk.1-5 Given chairsideconstraints (that is, time or

resources), however, it is easy to lose sightof diet and instead focus on the immediateconcern—the patient’s chief complaint. Theability to provide diet counseling withintime or resource limitations depends onprioritization of patient needs, an efficientmode of diet assessment and a comfortableworking knowledge of diet and oral healthrelationships. In this article, I describe acaries risk assessment tool and offer strate-gies for dietary counseling.

DIET ASSESSMENT OF CARIES RISK

The Diet Assessment of Caries Risk toolwas developed at The University of Iowa(Iowa City) to help oral health care profes-sionals efficiently assess dietary contribu-tors to caries risk (Table 16,7). The objec-tives of the Diet Assessment of Caries Risktool are to identify specific dietary behav-iors that affect caries risk and to enable

Dr. Marshall is an assistant professor, Department of Preventive and Community Den-tistry, College of Dentistry, N-335 Dental Science Building, University of Iowa, Iowa City,Iowa. 52242-1010, e-mail “[email protected]”. Address reprint requests toDr. Marshall.

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

Background. A dietary habit assessment should bean integral component of oral health care. The authoroutlines strategies that oral health care professionalscan use to assess dietary habits associated with cariesrisk and to develop dietary recommendations.Conclusion. A caries risk assessment tool can beused to identify dietary habits that may contribute tocaries risk.Practical Implications. The caries risk assess-ment tool can provide structure for evaluating patients’dietary habits and food choices and helping oral carehealth professionals provide preventive dietary recommendations.Key Words. Caries; diet.JADA 2009;140(6):670-674.

A B S T R A C T

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

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oral health care practi-tioners to begin conversa-tions regarding dietaryhabits with patients.Having knowledge aboutpatients’ dietary behaviorsthat are associated withcaries risk is essentialwhen providing specific,individualized recommen-dations that may decreasecaries risk. The cariesprocess depends on thepresence of host and envi-ronmental factors,including exposure to fer-mentable carbohydrates.The structure of meals andsnacks influences thequantity and frequency ofpatients’ exposure to fer-mentable carbohydratesand, subsequently, cariesrisk.8-11 Key areas toinclude in a dietary assess-ment of caries risk are thenumber of dietary expo-sures (meals and snacks),the structure of meals andsnacks and the manner ofsugared beverage intake.(Sugared beverages include 100 percent juice,juice drinks, soda pop, sports drinks, energydrinks, and sugared coffee and tea.) These keyareas, as well as the potential caries risk asso-ciated with probable responses and desiredbehaviors, are outlined in Table 1. The desiredbehavior guidelines, which are based on dietaryguidelines and current practice, are for adoles-cents and adults6,7; guidelines for young childrenand elderly people differ.

ANTICIPATORY GUIDANCE

The Diet Assessment of Caries Risk tool isdesigned to identify diets that place people athigh risk of developing caries. However, coun-seling people with high-caries-risk diets mayrequire obtaining additional informationregarding their usual dietary intake. Individualfoods and beverages are not consumed in isola-tion, and dietary recommendations for oral healthcan have ripple effects on other aspects of thediet. Thus, it is helpful for oral health care practi-

TABLE 1

Diet assessment of caries risk.KEY AREA PROBABLE

RESPONSERELATIVE RISK DESIRED BEHAVIOR

GUIDELINES*

Number ofMeals/Snacks

< 6/day Low 3-6/day

> 6/day Moderate

Meal/Snack Structure Structured Low Structured meal pattern

Unstructured/grazing Moderate

Sugared Beverages†

Quantity < 12 ounces/day Low 6-8 ounces of 100 percentjuice or other sugared beverage/day; < 12 ouncesof sugared soda pop/day

12-20 ounces/day Moderate

> 20 ounces/day High

Timing With meals Low With meals

With snacks Moderate

Between meals/snacks High

Frequency 1 exposure/day Low 1 exposure/day

2-3 exposures/day Moderate

≥ 4 exposures/day High High

Length of exposure < 15 minutes Low < 15 minutes

15-30 minutes Moderate

> 30 minutes High

Drinking style Straw Low Straw

Open container Moderate

Swishing within mouth High

* The desired behavior guidelines are based on dietary guidelines and current practice and are presented for adolescents and adults. Sources: U.S. Department of Agriculture6 and U.S. Department of Health 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 sugared coffee and tea.

BOX 1

Definitions of terms.

ANTICIPATORY GUIDANCEHealth promotion guidelines designed to promote healthand prevent disease.

24-HOUR RECALLA 24-hour recall is an interviewer-administered dietaryassessment tool designed to gather information about foodand beverage intakes and meal patterns. Open-ended prodding questions are asked to facilitate recall of foodsand beverages consumed. The 24-hour recall also can beused to identify food preferences and areas in which thepatient is receptive to change. For example, the interviewer’squestions might follow the following format: dWhat did you eat or drink first yesterday? Approximately

what time was that? Where were you when you con-sumed it? Did you have anything to eat or drink with thereported beverage or food?

dWhen did you next eat or drink anything? And what didyou consume? About how much did you have? How longdid it take you to consume the beverage or food?

The interview can continue with similar prodding questionsuntil the patient indicates that is all he or she consumed.Then the interviewer can look for and address potential dis-crepancies in the patient’s recall.dI noticed you reported nothing to drink from noon on. Is

this typical? dDo you like to eat fruits or vegetables?


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tioners to have knowledge of patients’ preferredfoods, accessibility to foods and current dietaryhabits so they can individualize recommendationsand provide anticipatory guidance to patients(Box 1). Using the 24-hour dietary recall tool (Box1), asking the patient questions regarding typicalfood groups or both can help oral health carepractitioners identify the patient’s dietary frame-work within which current behaviors exist. Oralhealth care practitioners must consider how dietrecommendations fit within the patient’s dietaryframework or whether the framework requiresmodification to support or enable oral health carepractitioners’ recommendations.

For example, six 20-ounce sugared, carbonatedbeverages provide approximately 1,500 caloriesper day. Recommending that the patient who con-sumes this quantity of sugared, carbonated bever-ages “quit drinking” or “switch to diet” does notacknowledge that those beverages provide 50 per-cent or more of the patient’s energy intake andthat the patient will be hungry if he or she quitsor switches to the diet version of the beverage.

Without anticipatory dietary guidance, thepatient may return to the dentist having quit butconsuming the same quantity of a sports drink ora diet beverage combined with sugar-ladensnacks throughout the day. Anticipatory guidanceshould be based on the patient’s current diet,acknowledge that the calories provided by thebeverages will need to be replaced by caloriesfrom food, provide structure for the food caloriesand guide the patient in selecting foods consistentwith MyPyramid6 guidelines. An example of ananticipatory guidance strategy is shown in Box 2.

If the six 20-ounce beverages were caffeinated,a patient’s quitting “cold turkey” could result inhim or her experiencing significant caffeine with-drawal symptoms and a decrease in the likelihoodof his or her complying with the recommendationto quit drinking. Acknowledging the caffeinedependence, while providing anticipatory guid-ance consistent with oral and systemic health,increases the likelihood of the patient’s beingreceptive toward recommendations and long-termcompliance. Suggested strategies to use toaddress the caffeine intake include recommendinga gradual decrease in the consumption of the caf-feinated beverage, mixing the caffeinated bev-erage with a decaffeinated beverage (in smalleramounts until the caffeinated beverage is elimi-nated) or substituting a sugar-free caffeine sourcefor the caffeinated beverage.

An example of a 24-hour dietary recall from apatient with rampant caries and desired dietmodifications is shown in Table 2. Patients canuse MyPyramid6 to help them identify alternativefoods and beverages to their original diets anddevelop dietary habits that support oral and sys-temic health.

COUNSELING STRATEGIES

Although oral health care professionals can iden-tify patients’ food or beverage selections anddietary habits that increase their risk of devel-oping caries, patients are responsible forchanging their behaviors. Oral health care profes-sionals can only provide recommendations; how-ever, the manner in which those recommenda-tions are provided will improve the patient’sreceptivity.12,13 Knowledge of patients’ under-standing of diet-disease relationships and motiva-tion to change will help oral health care practi-tioners tailor recommendations to each patient.Providing how-to advice—including differentstrategies to use to achieve the desired outcome



BOX 2

Anticipatory guidance to supportthe dietary recommendation todecrease Mountain Dew* intake.

DESIRED MODIFICATIONdLimited Mountain Dew intake, as opposed to the

current consumption of a 12-pack of Mountain Dew per day.

RATIONALE FOR MODIFICATIONdProlonged exposure to sugared beverage increases

caries risk.

SUGGESTED STRATEGIES TO ACHIEVE DESIRED MODIFICATION

dSwitch to diet Mountain Dew.*dGradually decrease Mountain Dew by mixing with

diet Mountain Dew and finally replacing with all diet Mountain Dew.

dReplace Mountain Dew with sugar-free alternative (that is, tea, water, diet cola).

dLimit Mountain Dew consumption to meals.

CONFOUNDERS TO ACHIEVING DESIRED MODIFICATIONdEnergy intake; Mountain Dew provides 1,900 calories.

Without this energy, patient will be hungry. Anticipatoryguidance should emphasize structured meal patternsand MyPyramid6 food choices to prevent frequentintake of foods containing fermentable carbohydrates.

dCaffeine intake; patient likely will need caffeinereplacement, because otherwise he or she likely willtreat probable headaches with Mountain Dew; patientwill be less likely to attempt behavior change in thefuture.

* Mountain Dew and diet Mountain Dew are manufactured byPepsiCo, Purchase, N.Y.


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and educational resources—and engaging thepatient in the process are considered more suc-cessful strategies for ensuring the patient’s com-pliance than are telling the patient what to do orto quit.12,13

Oral health care practitioners should includean assessment of diet-related caries risk factorsin the patient’s initial health history. Adminis-tering this assessment before performing the oralexamination will not interrupt the flow of the oralexamination and can improve patients’ perceptionof dietary questions and honesty of response. Incontrast, if the oral health care practitioner has awide-eyed look after performing the oral exami-nation and asks the patient vague questionsabout dietary habits, a patient’s defenses may beraised and he or she may minimize reportingactual behaviors.

The questions asked to assess the topics out-lined in the Diet Assessment of Caries Risk toolshould be tailored to the age and culture of thepatient and to the oral health care professional’sstyle. However, all questions should be open-ended and nonjudgmental so as to minimize thepatient’s guilt and encourage honest responses.Receiving accurate information from the patientis essential for negotiating dietary changes thatsupport oral and systemic health.

CONCLUSIONS

Although marginal dietary habits that increasethe quantity and frequency of fermentable carbo-hydrate exposures are known to increase the riskof developing caries, oral health care profes-sionals do not assess patients’ dietary habitsowing to resource and time limitations. Assessing

TABLE 2

24-hour dietary recall of a patient* with rampant caries.24-HOUR RECALL CARIES RISK MODIFIED DIET

Time Food Item Quantity Where Consumed

Breakfast McDonald’s (Oak Brook, Ill.)bacon, egg andcheese biscuit

One McDonald’s Low Cereal with milkOrange

Mountain Dew (Pep-siCo, Purchase, N.Y.)

12 servings, consumedthroughout daybeginning withbreakfast

McDonald’s High Coffee

Lunch Ham sandwich:bread, ham

Two Work Low Ham and cheesesandwich ChipsCarrots

Mountain Dew See note in “Breakfast” row

Work High Mountain Dew

Defined snack Powerade (The Coca-Cola Company, Atlanta)

20 ounces During commute High Propel (PepsiCo)

Dinner Subway (Milford,Conn.) meatballsandwich

One 12-inch sandwich

Take out Low Subway meatballsandwich Salad

Mountain Dew See note in “Breakfast” row

Home High Diet Mountain Dew(PepsiCo)

Between meals Mountain Dew See note in “Breakfast” row

Work, home High Iced tea or dietMountain Dew

Notes: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 fourdrinks once a week.


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dietary habits is an essential component of pre-ventive oral health care and targeting specifichigh-risk behaviors will help oral health carepractitioners provide preventive dietary recom-mendations to patients. ■

Disclosure. Dr. Marshall did not report any disclosures.

Nutrition is published in collaboration with the Nutrition ResearchGroup of the International Association for Dental Research.

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dren. Dent Clin North Am 2005;49(4):725-737, v.5. Fontana M, Zero DT. Assessing patients’ caries risk. JADA 2006;

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ment of Agriculture. Dietary Guidelines for Americans 2005. “www.health.gov/dietaryguidelines/dga2005/document/default.htm”. AccessedAug. 14, 2008.

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12. Pignone MP, Ammerman A, Fernandez L, et al. Counseling topromote a healthy diet in adults: a summary of the evidence for theU.S. Preventive Services Task Force. Am J Prev Med. 2003;24(1):75-92.

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