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Part 6: Nutrition: More than just the basic four!

Jan. 1, 2002

by Tammy L. Carullo, RDH, PC, PS

Avoiding clinical complacency means so much more than keeping current with the latest technologies, cutting-edge instrumentation techniques, and reviewing or learning updated information in continuing education classes. Today's dental hygienist needs to reach for the stars and offer innovative services to patients. Nutri-tional counseling is a unique program that benefits patients and keeps you from teetering on the edge of a complacency rut.

In addition to being a beneficial treatment option for preventive patients, nutritional counseling can be a very lucrative and viable addition to your purview. Teaching patients proper nutrition and guiding them to an improved quality of life is only part of this option.

The most important component of patient education is the links between oral health and systemic disease, as well as how nutrition plays an integral part in both. The U.S. Surgeon General's report linked the state of this country's oral health to systemic diseases such as diabetes, heart disease, stroke, lung disease, and even certain types of cancer. Dental professionals have, I hope, been paying much closer attention to these critical factors, performing at a higher preventive level.

Unfortunately, a recent poll suggests that the number of dental practices performing services such as nutritional counseling are dwindling. Such counseling is offered at only 4 percent of offices. Periodontal therapy, fluoride treatments, and sealants still rank highly as preventive treatments for dental patients. However, we have been overlooking one very critical component of the equation between oral health and systemic health — nutrition!

If the body is deficient in essential nutrients, vitamins, minerals, amino acids, and enzymes — not only necessary to sustain life but to dramatically improve the quality of life — disease processes will surface and the body's ability to fight infection is severely weakened. A diet poor in these essentials will weaken the immune system, making the host more susceptible to infection and disease in various forms, including periodontal disease. Yes, you read it right — periodontal disease.

There is a correlation that exists between the body's inability to combat infection and nutrition. A diabetic patient, for example, not only has to very closely watch his or her nutritional intake, but, due to the increased sugar content within the crevicular fluid and a depressed ability to heal, the patient is more susceptible to periodontal infection.

For years, dental professionals made the connection between the mouth and the heart with the relationship to the bacteremia issue. However, recent studies have shown that the very plaques that exist in the oral cavity can produce similar effects within the walls of arteries themselves, leading to a higher incidence of high cholesterol, heart disease, and stroke.

Now that we know some of the reasons why patients need to be consuming the proper nutrients, how do we get started? First, we need to begin with a baseline of information. Whatever the treatment or care you deliver, this should always be the foundation on which you build any treatment plan. Laying the groundwork for nutritional counseling begins with a comprehensive review of the patient's medical history.

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Six steps to nutritional counseling
Medical history. Find out everything you can about the nutritional supplements a patient may be taking; history of any dieting, including the use or abuse of any diet drugs; and any history of systemic problems, including medication prescribed by the physician. This is one step you do not want to coast through. Knowing the warning signs to specific diseases such as diabetes can prevent a potentially serious situation.

Nutritional analysis. Have your patient keep a food and activity journal for one full week. This will clearly show you any trouble spots that may exist with eating patterns and fitness level.

Individualization. As in any area of dental treatment and care, individualization is important. One patient may be experiencing a high level of dental caries, yet professes to have excellent home care. Upon your analysis, you discover that the patient is on a low-fat, high-carbohydrate diet.

She thinks she is a healthy eater. After all, we have been taught for years that "fat makes you fat" and fat is an unhealthy part of the average American diet. Generally, patients who are on this type of regimen fail to make the connection that "fat-free" often means "sugar-loaded." Simple carbs such as pretzels could very well be the culprit.

So carefully examine the analysis to determine the appropriate recommendations for that individual patient.

Patient education. One of the most frustrating aspects of dental hygiene, including nutritional counseling, is patient compliance. We can teach them everything we know about good oral hygiene and proper nutrition, but we cannot force them to follow through — the "you can lead a horse to water, but you can't make him drink" mentality.

While we may not be able to go home with each of our patients and make certain that each follows through with our instructions, one aspect is far more beneficial than any "over-the-shoulder" presence — patient education. What and how we teach our patients could be the difference between success and failure or, more appropriately, compliance vs. noncompliance.

Patient education needs to be motivational and inspirational. A patient who is less than enthusiastic about what you are saying is more likely to allow frustration to take over and quit trying. But if you inspire greatness, greatness will result.

Implementation. Now that each painstakingly placed brick is a permanent part of your foundation, you are ready to implement counseling. Implementation starts by presenting your patient's nutritional intake for a given day, complete with a multitude of options.

This appointment generally takes approximately one hour. Allow plenty of time for questions. I think this is probably the most overlooked aspect of implementation of any procedure. Patients are going to have questions. Nutritional counseling is a very personal issue, and patients will undoubtedly have more questions than usual. Give them enough time to look over the plan and ask about all concerns or doubts.

Follow-up. Once the plan is underway, you need to monitor the success of your patients through a three-month follow-up schedule. Remember that nutritional counseling for the dental patient is not about weight, so there will not be any "weigh-ins." The subsequent counseling sessions keep the patient on the road to true nutritional success.

Nutritional counseling plays an important role in both the oral and systemic health of our patients. Besides a benefit to patients, it can be a very lucrative business venture as well. Still, practices are reluctant to include this service simply because of the time-management issue and the uncertainty that it will yield any positive acceptance.

The first obstacle to overcome is to establish a need to provide the service within your practice by getting feedback from the patients themselves. Simply begin by advertising the new service in your reception/welcome area with a sign or poster that states:

"We are now providing nutritional counseling services to our patients. Please ask your dentist or hygienist for details."

This idea has been implemented in practices across the country with astounding results. These dental practices have been overwhelmed with the response from their patients. You have to keep in mind that patients are continually looking for leadership, especially within the nutrition/diet industry.

In the absence of leadership, they will listen to anyone who steps up to the plate, including people who do not offer factual or knowledgeable nutritional advice. Dental professionals have a unique opportunity to provide the healthiest nutritional plan to patients. The diet industry is now a multibillion dollar industry riddled with misinformation, lies, and false hope.

For more information on how to implement a nutritional counseling program, drop me a line at [email protected].

Tammy L. Carullo, RDH, PC, PS, is CEO of Practice by Design, Inc. She is a practice-management consultant and continuing-education instructor. She may be contacted by e-mail at [email protected] or phone (717) 867-5325. For more information about her company, visit

Common herbals that can contribute to periodontal breakdown

  • Black Cohosh
  • Echinacea
  • Red Raspberry Leaves
  • Evening Primrose Oil
  • Ginko Biloba
  • Ginseng
  • St. John's Wort
  • Kava Kava