Chairside Diet Assessment of Caries Risk

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

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CLINICAL PRACTICE

N U T R I T I O N

Teresa A. Marshall, PhD, RD/LD

ral health care professionals are

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
ability to provide diet counseling within
time or resource limitations depends on
prioritization of patient needs, an efficient
mode of diet assessment and a comfortable
working knowledge of diet and oral health
relationships. In this article, I describe a
caries risk assessment tool and offer strategies for dietary counseling.

DIET ASSESSMENT OF CARIES RISK

The Diet Assessment of Caries Risk tool

was developed at The University of Iowa
(Iowa City) to help oral health care professionals efficiently assess dietary contributors to caries risk (Table 16,7). The objectives of the Diet Assessment of Caries Risk
tool are to identify specific dietary behaviors that affect caries risk and to enable
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ABSTRACT
Background. A dietary habit assessment should be
an integral component of oral health care. The author
outlines strategies that oral health care professionals
can use to assess dietary habits associated with caries
risk and to develop dietary recommendations.
Conclusion. A caries risk assessment tool can be
used to identify dietary habits that may contribute to
caries risk.
Practical Implications. The caries risk assessment tool can provide structure for evaluating patients
dietary habits and food choices and helping oral care
health professionals provide preventive dietary
recommendations.
Key Words. Caries; diet.
JADA 2009;140(6):670-674.

Dr. Marshall is an assistant professor, Department of Preventive and Community Dentistry, College of Dentistry, N-335 Dental Science Building, University of Iowa, Iowa City,
Iowa. 52242-1010, e-mail teresa-marshall@uiowa.edu. Address reprint requests to
Dr. Marshall.

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Chairside diet assessment of caries risk

CLINICAL PRACTICE

N U T R I T I O N

ANTICIPATORY GUIDANCE

The Diet Assessment of Caries Risk tool is

designed to identify diets that place people at
high risk of developing caries. However, counseling people with high-caries-risk diets may
require obtaining additional information
regarding their usual dietary intake. Individual
foods and beverages are not consumed in isolation, and dietary recommendations for oral health
can have ripple effects on other aspects of the
diet. Thus, it is helpful for oral health care practi-

used to identify food preferences and areas in which the

patient is receptive to change. For example, the interviewers
questions might follow the following format:
dWhat did you eat or drink first yesterday? Approximately
what time was that? Where were you when you consumed it? Did you have anything to eat or drink with the
reported beverage or food?
dWhen did you next eat or drink anything? And what did
you consume? About how much did you have? How long
did it take you to consume the beverage or food?
The interview can continue with similar prodding questions
until the patient indicates that is all he or she consumed.
Then the interviewer can look for and address potential discrepancies in the patients 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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TABLE 1
oral health care practitioners to begin conversaDiet assessment of caries risk.
tions regarding dietary
KEY AREA
PROBABLE
RELATIVE RISK
DESIRED BEHAVIOR
habits with patients.
RESPONSE
GUIDELINES*
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,
Sugared Beverages
individualized recommenQuantity
< 12 ounces/day
Low
6-8 ounces of 100 percent
dations that may decrease
juice or other sugared
12-20 ounces/day
Moderate
caries risk. The caries
beverage/day; < 12 ounces
of sugared soda pop/day
process depends on the
> 20 ounces/day
High
presence of host and enviTiming
With meals
Low
With meals
ronmental factors,
With snacks
Moderate
including exposure to ferBetween meals/snacks
High
mentable carbohydrates.
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
Length of exposure
< 15 minutes
Low
< 15 minutes
patients exposure to fer15-30 minutes
Moderate
mentable carbohydrates
and, subsequently, caries
> 30 minutes
High
risk.8-11 Key areas to
Drinking style
Straw
Low
Straw
include in a dietary assessOpen 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
and Human Services and U.S. Department of Agriculture.7
the structure of meals and
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.
BOX 1
(Sugared beverages include 100 percent juice,
juice drinks, soda pop, sports drinks, energy
Definitions of terms.
drinks, and sugared coffee and tea.) These key
ANTICIPATORY GUIDANCE
areas, as well as the potential caries risk assoHealth promotion guidelines designed to promote health
ciated with probable responses and desired
and prevent disease.
behaviors, are outlined in Table 1. The desired
24-HOUR RECALL
behavior guidelines, which are based on dietary
A 24-hour recall is an interviewer-administered dietary
assessment tool designed to gather information about food
guidelines and current practice, are for adolesand 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 beverages consumed. The 24-hour recall also can be
and elderly people differ.

CLINICAL PRACTICE

N U T R I T I O N

BOX 2

Anticipatory guidance to support

the dietary recommendation to
decrease Mountain Dew* intake.
DESIRED MODIFICATION

dLimited Mountain Dew intake, as opposed to the

current consumption of a 12-pack of Mountain Dew

per day.
RATIONALE FOR MODIFICATION

dProlonged exposure to sugared beverage increases

caries risk.

CONFOUNDERS TO ACHIEVING DESIRED MODIFICATION

dEnergy intake; Mountain Dew provides 1,900 calories.

Without this energy, patient will be hungry. Anticipatory

guidance should emphasize structured meal patterns
and MyPyramid6 food choices to prevent frequent
intake of foods containing fermentable carbohydrates.
dCaffeine intake; patient likely will need caffeine
replacement, because otherwise he or she likely will
treat probable headaches with Mountain Dew; patient
will be less likely to attempt behavior change in the
future.
* Mountain Dew and diet Mountain Dew are manufactured by
PepsiCo, Purchase, N.Y.

tioners to have knowledge of patients preferred

foods, accessibility to foods and current dietary
habits so they can individualize recommendations
and provide anticipatory guidance to patients
(Box 1). Using the 24-hour dietary recall tool (Box
1), asking the patient questions regarding typical
food groups or both can help oral health care
practitioners identify the patients dietary framework within which current behaviors exist. Oral
health care practitioners must consider how diet
recommendations fit within the patients dietary
framework or whether the framework requires
modification to support or enable oral health care
practitioners recommendations.
For example, six 20-ounce sugared, carbonated
beverages provide approximately 1,500 calories
per day. Recommending that the patient who consumes this quantity of sugared, carbonated beverages quit drinking or switch to diet does not
acknowledge that those beverages provide 50 percent or more of the patients energy intake and
that the patient will be hungry if he or she quits
or switches to the diet version of the beverage.
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COUNSELING STRATEGIES

Although oral health care professionals can identify patients food or beverage selections and
dietary habits that increase their risk of developing caries, patients are responsible for
changing their behaviors. Oral health care professionals can only provide recommendations; however, the manner in which those recommendations are provided will improve the patients
receptivity.12,13 Knowledge of patients understanding of diet-disease relationships and motivation to change will help oral health care practitioners tailor recommendations to each patient.
Providing how-to adviceincluding different
strategies to use to achieve the desired outcome

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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.

Without anticipatory dietary guidance, the

patient may return to the dentist having quit but
consuming the same quantity of a sports drink or
a diet beverage combined with sugar-laden
snacks throughout the day. Anticipatory guidance
should be based on the patients current diet,
acknowledge that the calories provided by the
beverages will need to be replaced by calories
from food, provide structure for the food calories
and guide the patient in selecting foods consistent
with MyPyramid6 guidelines. An example of an
anticipatory guidance strategy is shown in Box 2.
If the six 20-ounce beverages were caffeinated,
a patients quitting cold turkey could result in
him or her experiencing significant caffeine withdrawal symptoms and a decrease in the likelihood
of his or her complying with the recommendation
to quit drinking. Acknowledging the caffeine
dependence, while providing anticipatory guidance consistent with oral and systemic health,
increases the likelihood of the patients being
receptive toward recommendations and long-term
compliance. Suggested strategies to use to
address the caffeine intake include recommending
a gradual decrease in the consumption of the caffeinated beverage, mixing the caffeinated beverage with a decaffeinated beverage (in smaller
amounts until the caffeinated beverage is eliminated) or substituting a sugar-free caffeine source
for the caffeinated beverage.
An example of a 24-hour dietary recall from a
patient with rampant caries and desired diet
modifications is shown in Table 2. Patients can
use MyPyramid6 to help them identify alternative
foods and beverages to their original diets and
develop dietary habits that support oral and systemic health.

CLINICAL PRACTICE

N U T R I T I O N

TABLE 2

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

24-HOUR RECALL
Time
Breakfast

CARIES RISK
Food Item

Quantity

MODIFIED DIET

Where Consumed

One

McDonalds

Low

Cereal with milk

Orange

Mountain Dew (PepsiCo, Purchase, N.Y.)

12 servings,
consumed
throughout day
beginning with
breakfast

McDonalds

High

Coffee

Ham sandwich:
bread, ham

Two

Work

Low

Ham and cheese

sandwich
Chips
Carrots

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.) meatball
sandwich

One 12-inch
sandwich

Take out

Low

Subway meatball
sandwich
Salad

Mountain Dew

See note in
Breakfast row

Home

High

Diet Mountain Dew

(PepsiCo)

Mountain Dew

See note in
Breakfast row

Work, home

High

Iced tea or diet

Mountain Dew

Lunch

Between meals

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 negotiated 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

patient in the process are considered more successful strategies for ensuring the patients compliance than are telling the patient what to do or
to quit.12,13
Oral health care practitioners should include
an assessment of diet-related caries risk factors
in the patients initial health history. Administering this assessment before performing the oral
examination will not interrupt the flow of the oral
examination and can improve patients perception
of dietary questions and honesty of response. In
contrast, if the oral health care practitioner has a
wide-eyed look after performing the oral examination and asks the patient vague questions
about dietary habits, a patients defenses may be
raised and he or she may minimize reporting
actual behaviors.

The questions asked to assess the topics outlined in the Diet Assessment of Caries Risk tool
should be tailored to the age and culture of the
patient and to the oral health care professionals
style. However, all questions should be openended and nonjudgmental so as to minimize the
patients guilt and encourage honest responses.
Receiving accurate information from the patient
is essential for negotiating dietary changes that
support oral and systemic health.
CONCLUSIONS

Although marginal dietary habits that increase

the quantity and frequency of fermentable carbohydrate exposures are known to increase the risk
of developing caries, oral health care professionals do not assess patients dietary habits
owing to resource and time limitations. Assessing
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McDonalds
(Oak Brook, Ill.)
bacon, egg and
cheese biscuit

CLINICAL PRACTICE

N U T R I T I O N

dietary habits is an essential component of preventive oral health care and targeting specific
high-risk behaviors will help oral health care
practitioners provide preventive dietary recommendations 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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