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
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 strate-
gies 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 profes-
sionals efficiently assess dietary contribu-
tors to caries risk (Table 16,7). The objec-
tives of the Diet Assessment of Caries Risk
tool are to identify specific dietary behav-
iors that affect caries risk and to enable
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 assess-
ment 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 Den-
tistry, 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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 CLINICAL PRACTICE N U T R I T I O N

oral health care practi- TABLE 1

tioners to begin conversa- Diet assessment of caries risk.
tions regarding dietary
habits with patients. KEY AREA PROBABLE RELATIVE RISK DESIRED BEHAVIOR
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,
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
risk.8-11 Key areas to Drinking style
include in a dietary assess-
ment of caries risk are the
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
drinks, and sugared coffee and tea.) These key
areas, as well as the potential caries risk asso-
ciated with probable responses and desired
behaviors, are outlined in Table 1. The desired
behavior guidelines, which are based on dietary
guidelines and current practice, are for adoles-
cents and adults6,7; guidelines for young children
and elderly people differ.
ANTICIPATORY GUIDANCE
The Diet Assessment of Caries Risk tool is
designed to identify diets that place people at
high risk of developing caries. However, coun-
seling people with high-caries-risk diets may
require obtaining additional information
regarding their usual dietary intake. Individual
foods and beverages are not consumed in isola-
tion, 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-
> 30 minutes High
Straw Low Straw
Open container Moderate
Swishing within mouth High
BOX 1
Definitions of terms.
ANTICIPATORY GUIDANCE
Health promotion guidelines designed to promote health
and prevent disease.
24-HOUR RECALL
A 24-hour recall is an interviewer-administered dietary
assessment tool designed to gather information about food
and beverage intakes and meal patterns. Open-ended
prodding questions are asked to facilitate recall of foods
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
questions 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 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 dis-
crepancies 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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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.
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 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 frame-
work 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 con-
sumes this quantity of sugared, carbonated bever-
ages quit drinking or switch to diet does not
acknowledge that those beverages provide 50 per-
cent 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.
672 JADA, Vol. 140 http://jada.ada.org June 2009
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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 with-
drawal symptoms and a decrease in the likelihood
of his or her complying with the recommendation
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to quit drinking. Acknowledging the caffeine
dependence, while providing anticipatory guid-
ance 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 caf-
feinated beverage, mixing the caffeinated bev-
erage with a decaffeinated beverage (in smaller
amounts until the caffeinated beverage is elimi-
nated) 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 sys-
temic health.
COUNSELING STRATEGIES
Although oral health care professionals can iden-
tify patients food or beverage selections and
dietary habits that increase their risk of devel-
oping caries, patients are responsible for
changing 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 patients
receptivity.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 adviceincluding different
strategies to use to achieve the desired outcome
 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 CARIES RISK MODIFIED DIET

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
breakfast

Lunch Ham sandwich: Two Work Low Ham and cheese

bread, ham sandwich
Chips
Carrots

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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

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 four
drinks once a week.

and educational resourcesand engaging the
patient in the process are considered more suc-
cessful strategies for ensuring the patients com-
pliance 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. Adminis-
tering 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 exami-
nation 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 out-
lined 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 open-
ended 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 carbo-
hydrate exposures are known to increase the risk
of developing caries, oral health care profes-
sionals do not assess patients dietary habits
owing to resource and time limitations. Assessing

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 CLINICAL PRACTICE N U T R I T I O N

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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