Dental hygienists can help patients improve their oral health by identifying dietary contributors to oral disease by assessing patients for nutrition-related risks and providing dietary counseling.  

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Nutrition counseling has an important place in the dental care setting and can be incorporated into each dental visit, given the clear relationship between dietary factors and dental caries and the association between obesity, diabetes and periodontitis.

 

Nutritional counseling can be defined as: A cooperative mode of interaction between the patient and health care provider aimed at assisting patients in adopting healthy dietary behaviors associated with improved health outcomes. Moreover, it is an important step in determining whether nutritional deficiencies/imbalances exist and assessing the need for necessary referrals.

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Nutritional counseling must incorporate structured elements to increase effectiveness and improve compliance. Specific nutritional recommendations can lead to improvements in patient nutritional status but requires follow-up to provide support and reassess goals.

 

Counseling Objectives
The objectives of the counseling session include the client understanding the individual oral problems and appreciating the need for changing habits; specific alterations in the diet necessary for improved general and oral health; dental caries control; minimal consumption of cariogenic foods, especially between meals; substituting noncariogenic foods into the diet; and improving nutritional adequacy in accordance with recommendations set forth by the USDA. 

Appropriate teaching materials pertinent to the counseling session are the client's radiographs, charting, and food diary; food models and labels; charts of dietary standards and requirements; the MyPyramid poster; a list of snack suggestions and any educational pamphlets illustrating the client's special dietary or oral health needs. 

The ideal environment for performing dental nutritional counseling is free from interruptions and distractions, preferably apart from the clinical treatment room. A non-threatening environment is conducive to learning. The decor should provide pertinent educational posters, pamphlets and food labels and models of portion sizes. 

A warm, friendly, non-threatening atmosphere is crucial in any counseling setting. The technique used in dental nutritional counseling is analogous to interviewing a dental client during the medical and dental history intake, such as establishing eye contact with a professional, nonjudgmental demeanor. The use of open-ended questions elicits more information. An example of such a line of questioning would be "Tell me, what did you have for breakfast today," and then "How was the omelet prepared?" and "What did you put on the toast?" To provide an adequate amount of information, avoid closed-ended questions that provide only "yes" or "no" responses and limit information; for example: "Did you eat lunch today?" Also recommended is to avoid using "why," which elicits defensiveness; for example, "Why do you use butter?" 

It is recommended to use a client-centered approach in the counseling session by guiding clients to develop their own behavioral changes. Having clients make their own suggestions for substitutions and behavior fosters greater compliance. Empowering the client to be involved in making recommendations for change puts the responsibility for change where it can be the most effective, on the clients themselves. During counseling, be sure to keep goals simple, small, realistic and adaptable to the client's lifestyle. Adequately discuss all questions using a conversational tone without lecturing. 

In summarizing the session's purpose and objectives, provide an explanation of the relevance between diet and the client's specific oral findings and caries risk with the emphasis on health promotion and disease prevention. Clarify any confusion of hidden sugars, added sugars and natural sugars. Clarify the moderation of sugar intake, and select substitutions.

Be sure to convey that oral retentiveness of cariogenic foods is related to length of time food debris with fermentable carbohydrate remains on the teeth and exposure to decreased pH. Sticky foods are retained for shorter periods of time and have a shorter oral clearance. Highly retentive fermentable carbohydrates have a delayed rate of oral clearance, thereby increasing exposure of teeth to a decreased pH and higher potential for demineralization. 

Also imperative to clarify is that the sequencing of food consumption within a meal is related to caries incidence. Eating fermentable carbohydrates at the beginning of a meal or between other cariostatic foods such as protein and fat means less cariogenic potential. Protein and fat are not metabolized by bacteria and are recommended to be consumed at the end of a meal. Cheese eaten after sweets or at the end of a meal prevents the decrease in pH and production of acids in the oral cavity. Using water decreases cariogenic activity by rinsing sugars from tooth surfaces. 

Another recommendation would be the use of sugar-free chewing gums, which decrease lactic acid production and increase salivary flow, potentially buffering acids. Chewing a gum with xylitol immediately after each meal reduces the levels of Streptococcus mutans and promotes remineralization. Xylitol is the sugar substitute of choice because it is not fermentable by caries-promoting bacteria. Sorbitol can be fermented by Streptococcus mutans at a very slow rate. 

Insurance Issues
According to Current Dental Terminology (CDT), nutritional counseling is listed under "Other Preventive Services" as code D1310 and receives no compensation when provided in dental practice. It is analogous to the same reimbursement issues as fluoride treatments and sealants for individuals over the age of 14, which are provided at the client's expense.

 

The lack of compensation by insurance companies is not a justification to eliminate dental nutritional counseling from the dental hygiene process of care and increasing a dental client's oral risk for dental disease, oral manifestations of nutritional deficiencies, inadequate dietary intake and knowledge deficit in proper nutrition. It is a preventive intervention as essential as providing oral self-care instructions to ensure behavior modification in the prevention of disease.

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Dietary risk assessment is part of the total oral risk assessment phase in disease prevention and health promotion in the dental hygiene process of care. Dental nutritional counseling can easily be incorporated into behavior modification strategies employed by the dental hygienist.