_____________________________________ Caries-Prone Patients: Prevention, Assessment, and Intervention
There are several caries risk assessment tools available [4; 84]. Practitioners need to find a tool that allows them to evaluate the variety of factors associated with caries risk as they begin to discuss how diet and nutrition affect the patient’s risk for caries. Caries risk assessments categorize patients into one of three categories. A patient at low caries risk exhibits no caries risk factors and a dental history of no incipient or active caries lesions in the past three years. Patients at moderate risk for caries include those that had either one or two incipient or active caries lesions in the past three years or no caries history in the past three years but at least one caries risk factor. High caries risk is the determination given to patients who have developed three or more caries lesions (incipient or active) in the past three years, have low fluoride contact, present with multiple caries risk factors, or have severe xerostomia [85]. Separate caries risk assessment forms for patients ages 0 to 6 years and for patients older than 6 years can be found on the ADA website at http://www.ada.org/en/member-center/ oral-health-topics/caries. Use of these forms will facilitate and standardize the dental team’s caries risk assessment. In addition, the use of risk assessment forms can help uncover the role of poor nutrition as a risk factor and allow the topic of nutrition to be more effectively woven into the risk reduc- tion discussion. NUTRITIONAL COUNSELING All patients stand to benefit from nutritional counseling. Once a caries risk level has been established, all patients should be counseled on how their diet affects their teeth, their caries risk, and their general oral health. Personalized oral hygiene instruc- tions should be established for each patient. Those patients identified as being at moderate to high risk for caries may need to have nutritional counseling and preventive measures not just discussed but also incorporated into their treatment plans. Dental caries is a preventable disease. However, a high inci- dence of caries in early childhood is the single strongest predic- tor of the development of carious lesions into adolescence and adulthood [86]. For patients at low to low-moderate risk for dental caries, nutritional counseling may be performed at the dental cleaning, or recare, appointment. Questions regarding diet, such as those listed later in this section, may be asked on the medical history form or directly of the patient by the dental professional. For these patients, the goal of nutritional counseling is education designed to maintain their low caries risk level. THE NUTRITIONAL COUNSELING APPOINTMENT Patients with a moderate- to high-risk level of caries may ben- efit from a separate nutritional counseling appointment. The appointment length is individualized based on the patient’s dental knowledge, dietary habits, and motivation level. During this appointment, the dental professional and patient have
an opportunity to evaluate the patient’s current diet, discuss preventive treatments, and set goals to improve the diet and reduce caries incidence. To gain information concerning dietary habits, the dental professional may have patients complete a diet questionnaire and food log [87]. An example of a dietary questionnaire and food log was previously shown in Table 1 . Alternatively, the dental professional may choose to interview patients concern- ing dietary habits, using questions such as: • What are your favorite snacks? • On a typical school or workday, what do you eat for lunch? • What is your favorite soft drink or fruit juice, and how often do you drink it? • How long does it take you to finish a can of soda or a glass of juice? • How often do you brush your teeth? How often do you floss? Follow-up to the nutritional counseling appointment should take place in order to encourage the patient’s goals and rein- force habit changes. This follow-up may consist of a phone call to check in with the patient, or it may be a short appoint- ment a few weeks after the counseling appointment. The patient’s progress can be reevaluated at subsequent dental appointments. Establishing and routinely reassessing a patient’s caries risk level allows the dental professional to provide proactive care and recommend preventive measures to minimize the patient’s risk of dental decay. Occasionally, a patient may benefit from a referral to a dieti- cian, nutritionist, or primary care physician. This is especially true if a condition such as acid reflux, an eating disorder, or chemical dependency is suspected or confirmed. SETTING GOALS The dental professional should be practical when recommend- ing changes to a patient’s diet. Asking patients to forfeit their favorite foods in exchange for increased brushing and flossing will rarely improve patient compliance. It is important to note, however, that relatively minor changes in nutrition and habits can lower a patient’s caries risk. By evaluating each patient’s individual incentives and motivation level, dental profession- als can help patients set goals that are realistic and achievable. Some examples of these goals are: • Limiting soda drinks to mealtimes • Exchanging sugared gum or candies for sugar-free or xylitol-sweetened varieties • Replacing soda with flavored water • Including sweet foods with meals, when the sugar content will be diluted
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