Caries-Prone Patients: Prevention, Assessment, and Interventions, 3rd Edition __________________________
NUTRITIONAL QUESTIONNAIRE AND FOOD LOG This form is intended to gain information about habits that may promote tooth decay. When answering the following questions, please choose the answer that fits best and provide as much information as possible. Feel free to provide any additional information you feel is important. Please bring this completed form to your appointment on _________________________ . 1. What are your favorite drinks and how often do you consume them? ________________________________________ ______________________________________________________________________________________________ 2. How often do you eat fast food? Daily 2–3 times a week Less than once a week 3. How often do you skip meals? Daily 2–3 times a week Less than once a week 4. Do you chew gum? Yes No If yes, how often? Daily 2–3 times a week Less than once a week If yes, what kind? _________________________________________________________________________________ 5. Do you consume antacids, breath mints, or hard candies regularly? Yes No If yes, how often? Daily 2–3 times a week Less than once a week Do you make an effort to choose sugar-free antacids, breath mints, or hard candies? Yes No 6. Please list your favorite snacks and how often you eat these items. ___________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 7. Do you buy food or drinks from vending machines? Yes No 8. Is your drinking water fluoridated? Yes No Don’t know Use the following chart to record your food and drink intake for three days. Meals and snacks should be recorded. Choose days that you are eating normally (not dieting) and include at least one weekday and one weekend day. If possible, record the carbohydrate and sugar content of foods eaten. Time Food Eaten Grain Fruit Vegetable Protein Dairy Fat Sugar _______ __________________ ________ _________ __________ _________ _______ _______ _______ _______ __________________ ________ _________ __________ _________ _______ _______ _______ _______ __________________ ________ _________ __________ _________ _______ _______ _______ _______ __________________ ________ _________ __________ _________ _______ _______ _______ _______ __________________ ________ _________ __________ _________ _______ _______ _______ _______ __________________ ________ _________ __________ _________ _______ _______ _______ _______ __________________ ________ _________ __________ _________ _______ _______ _______ _______ __________________ ________ _________ __________ _________ _______ _______ _______
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Table 1
The patient education pamphlet “Sip All Day, Get Decay!” produced by the Minnesota Dental Association (available at http://www.sipallday.org) states that the average 12-ounce can of soda has 10 teaspoons of sugar and a pH just over 3. The low pH of soft drinks results from the ingredient phosphoric acid. Sodas also contain carbonic acid, and many contain citric acid. Therefore, even diet sodas are detrimental to oral health due to their acidic pH levels.
Patients who sip soda throughout the day cause their oral pH to plunge due to the acidity of the soda and the acid formed from oral bacteria metabolizing the sugars with this extended exposure a source of an increased risk for the development of dental caries [28]. Sports drinks and fruit juices also tend to be acidic and contain high amounts of sugar [29; 30]. The use of these products should be limited. Milk and water remain the best drink options for healthy teeth. The development of flavored, unsweetened water gives patients another drink option that is not detrimental to their teeth.
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