Nutrition is a subject many hygienists treat lightly, if at all. If a healthy patient on no medication suddenly develops half a dozen new cavities, we'll probably quiz him about his eating habits and make a few suggestions. If a child arrives for her first dental visit with decayed primary anteriors, we'll certainly have something to say to her mother. But otherwise, we're hygienists, not dieticians - right?
Experts in the field believe we should be more proactive than that. Dr. Carole Palmer, professor of nutrition and preventive dentistry at Tufts University, says, "We're looking at why these things have fallen by the wayside. There was a perception, perhaps, that fluoride had resolved the problem (of caries), but that's far from the truth. A lack of research and funding in nutrition and oral connections has made it difficult to move forward. But nutritional counseling and diet counseling need to be important components of preventive dental care. We can't provide effective care without addressing it. We need ways to close the gap in this area.
"There's always been some concern about nutrition in dentistry, but we do have problems with how time is spent and the number of patients being seen. Reimbursement rears its ugly head. The question is how to integrate appropriate nutritional services as part of a total preventive program."
Kim Otto is a hygienist in Minnesota working on her master's degree in nutrition. None of the eight dentists she has worked for had a program in place for nutritional counseling, and she doesn't believe there will ever be a strong push for it in dentistry.
But that doesn't mean a hygienist can't be proactive, according to Otto. "There are small questions you can ask. A lot of things come to mind. I work with older adults on medication, for instance. Their doctors might not tell them that if they have dry mouth problems, they shouldn't try to solve them with hard candy and gum. It's easy to say, 'Just drink water instead.' If I have an adolescent with decalcification, I ask the pop and brushing questions, and we talk about that. Teens don't realize that a can of Pepsi has 10 teaspoons of sugar, and a can of Mountain Dew has 11. With pregnant women, I remind them about baby bottle decay.
"Nutritional counseling is definitely valid. I'd say it's as important as teaching your patients to floss. Everything you eat has an effect on your teeth in some way, either systemically or directly."
In an ideal world, all patients would have a nutritional profile in their charts. You'd have patients complete a food diary, discuss their eating habits, correlate the findings to both oral health and general health, and make recommendations.
Palmer believes that's how it should work. "A person with diabetes, for instance, wouldn't be treated with just insulin, or just diet, or just exercise," she said. "The same thing is true of dental care. It has to be a multifactorial approach. You can't deal with caries without dealing with diet issues. You also need to be looking at other factors, not just caries - oral infections, periodontitis, heart disease, diabetes, osteoporosis, or immunity. There are a lot of connections being looked at today that need to be translated to patient care."
Palmer is co-author of a new textbook on applied nutrition in dentistry that will provide models for those translations. Diet and Nutrition in Oral Health, due out from Prentice Hall late in 2001, will help dental students and dental hygiene students communicate nutrition concerns to patients.
Another co-author is Connie Mobley, R.D., Ph.D., associate professor of nutrition at the University of Texas Health Science Center. When talking about nutrition and dentistry, Mobley says there are two things on which we should focus.
"One, promote a well-balanced diet to your patients. Use the food pyramid. And two, make your patients aware that the frequency of eating and drinking can increase their risk for caries."
Mobley's perception of nutrition in dentistry is that sugar has unnecessarily been the bad guy. "In the past, the focus in dentistry has been on sugar. What I focus on is how you can promote good general health and, at the same time, good oral health. More than likely, the two are much more closely related than people realize."
Fermentable carbohydrates, Mobley believes, are the real culprits. "Research indicates that some highly processed starches can be as caries-promoting as simple sugar." Pretzels, in other words, can cause a cavity just as easily as a candy bar. Fettuccine Alfredo can be as dangerous to your patient's teeth as butterscotch pie.
Dorothy Ridinger calls it "the refined carbohydrate issue." Ridinger, a hygienist, has a master's degree in food nutrition and teaches nutrition and radiology at Westmoreland Community College in Pennsylvania.
"Everyone knows that candy, pop, and chewing gum cause cavities, but people don't realize that things like potato chips, saltines, and white bread are just simple carbohydrates that break down into glucose. When our students learn nutritional counseling, we focus on carbs. The most important thing is to see that patients know the difference between refined and complex carbohydrates. We want to get it out to the public: Sticky foods cause caries."
But the reality is that carbohydrates are the basis of our American diet. "The easiest snack to grab," Ridinger points out, contains "refined carbs. We tell our patients, 'Be aware of what you eat. Be careful about which snacks you choose.' "
Given that, how can we guide our patients in the right nutritional choices?
"I don't tell people they can't have sugar or fermentable carbohydrates," Mobley says. "I tell them there's a way to eat those things that puts them at lower risk for tooth decay."
Mobley suggests combining a food that's high in protein with a food that's high in fermentable carbohydrates. That way, the protein buffers the effect of the carbohydrate in terms of acid production in the mouth.
"In fact," she states, "milk is considered to be cariostatic. It has protein and calcium, which fosters remineralization. Eat your cookies with milk, and it diminishes the risk of caries from the cookies."
Other cariostatic foods such as cheese and nuts are Ridinger's favorite choices for patients. "They buffer the saliva and decrease acid pH. We also tell patients to follow sugar exposure with celery, carrots, and apples - they work like a broom to sweep away sticky carbohydrates. They can also chew sugarless gum after eating to stimulate salivary flow."
Mobley suggests combining highly processed foods with barely processed ones. Crisp veggies, for example, can be combined with cooked carbohydrates such as noodles or rice.
"If you think about it," she says, "these recommendations fit very nicely with what is described as a well-balanced diet with variety and moderation. A low-caries diet is not much different from what the government proposes as a diet for increased health. Remember what your mother told you - three meals a day and no snacking. The message is very simple, but sometimes patients need to hear it to reinforce what other health care professionals tell them about other chronic diseases. We all can give the same message and be on target. We need to say, 'This is not just good for your heart, or your weight, it's also good for your oral health.' "
Cathy Hester Seckman, RDH, is a frequent contributor who is based in Calcutta, Ohio.
Basic counseling about iced tea
With the support of employers and co-workers, any hygienist can compile full nutritional profiles on patients in the practice. Each patient could keep a five-day food diary, then come in for a nutritional counseling appointment and leave with sound recommendations that integrate with their total health picture. That's in an ideal situation, of course. How many of us see those out here in the real world?
Even in a small office with a tight schedule, though, a hygienist can ease a little basic nutritional counseling into the conversations she has with her patients. If you can ask the simple questions, you'll do some good. It's an extra service we can, and should, offer our patients when we truly have their best interests in mind.
How do patients react? Here's the story of a patient I saw several years ago.
It doesn't happen much in the average general practice, but once in awhile you still see someone with catastrophic decay. The most surprising thing about such problems is that the patient may have no idea as to what caused it. This patient was a young factory worker with 17 gaping, aching cavities.
"Do you have any bad habits that might have caused the problem?" I asked. "Do you chew a lot of gum, drink a lot of soda?"
He shook his head, mystified. "I hardly ever drink pop, and I never chew gum. And I brush my teeth all the time."
"All the time?"
"Yeah, every morning, I never miss. I don't know what the problem is. Are you sure there are 17 cavities?"
"What do you usually drink?" I persisted.
"Iced tea," he said. "That doesn't cause cavities."
"It does if you put sugar in it. Do you?"
He smiled sheepishly. "Oh, yeah. Gotta sweeten it up."
"How often do you drink it?"
"I take a big Thermos to work every day."
"And you spend all day sipping from it, a little at a time?"
At that point I wanted to pound his head against the X-ray machine and knock some sense into him. But, of course, I didn't. Instead, I patiently explained the connections between sugar, bacteria, and time. I suggested adjustments he might make to his diet and home care. Here's more or less what I said during his cleaning:
"You have bacteria in your mouth all the time. It's called plaque - that soft, sticky stuff you can scrape with your fingernail. When you put sugar into your mouth, it combines with plaque to form an acid. The acid attacks your tooth enamel for up to 20 minutes and causes cavities. Imagine what happens when you drink sweetened tea all day. That's like giving your teeth a continuous acid bath. You take a drink - 20 minutes of acid attack. You take another sip - another 20 minutes.
"Maybe you could drink all the iced tea at lunchtime, and brush your teeth afterward. If you can clean your teeth right after eating and drinking, or even swish some water around your mouth, you'll remove a lot of that sugar and prevent the acid attack.
"Drink water the rest of the time, or try using artificial sweetener for your tea. You could even experiment with cutting down on the sugar little by little, until you're drinking the tea straight. And if you can brush after every meal - instead of just in the morning - and floss every day, you'll improve the odds that way too."
He was flabbergasted. "You mean," he said slowly, "that if I'd known all this, I wouldn't have gotten these cavities?"
"Probably not. Taking care of your teeth means more than just brushing them once a day."
"Yeah, I guess," he snorted. "Seventeen freakin' cavities."
About that simple sugar
Even though everyone knows about the sugar in candy, pop, and chewing gum, simple sugars still lurk in places where our patients least expect them. The U.S. Department of Agriculture says the average American consumes 20 teaspoons of added sugar a day. That sugar can be found in an ingredients list as white, brown, raw, or cane sugar; corn syrup; high-fructose corn syrup; honey, molasses, or sorghum syrup; or fruit juice concentrate.
Within your practice, plenty of conscientious sports moms probably let their little soccer players guzzle Gatorade during games. Do they know sugar and high-fructose corn syrup are two of the first three ingredients? Your practice probably also includes some nervous executives who chew antacid tablets several times a day. Do they know some can be sweetened with sugar? Other common items that are thought to be healthy, but may actually contain hidden sugar, include chewable children's vitamins, cough drops, rice cakes, condiments, instant hot cereals, instant breakfast and fruit drinks, and diet supplements.
Teach your patients to read labels. If a form of sugar is one of the first three ingredients, they should investigate an alternative. Teach them to look under carbohydrates in the breakdown chart. If there are 11 grams of sugar in a 20-gram serving, there must be a healthier choice.