Diet counselling

1. 1
“An ounce of prevention is worth a pound of cure”
- Benjamin Franklin

2. Diet Counselling
- DR. SWARNIMA KHICHI
III Post Graduate

3. Specific Learning Objectives
⋆ To define Diet Counselling
⋆ To understand the rationale of Diet Counselling
⋆ To know how to calculate Dental Diet Health Score
⋆ To know how to communicate in Diet C0unselling
⋆ To know the principles of Diet Counselling
⋆ To understand the Counselling procedure for Caries prevention
3

4. 4
Diet Counselling

5. Diet Counselling
5
It involves giving advice on food selection based on the individual’s reasons for liking it
or not liking certain foods.
Counseling requires information as to why, where, when and what specific foods are
eaten, how frequently and what feelings are experienced.
Minimal requirements for successful diet counselling service include
1. Enrolling active patient involvement in planning, implementing and evaluating the
diet before and after counseling.
2. Insisting on a series of follow up visits to tailor the diet to the patient’s needs and
likes.

6. Rationale for Diet Counselling
6
During pre-eruptive periods of development food exert a nutritional (systemic)effect
on the dentition.
During the post eruptive period when the teeth are fully erupted, foods exert a dietary
(topical) effect.
In patients with erupted teeth dentists find enamel surfaces covered by dental plaque
bacteria that degrade the ingested carbohydrate rich food that adheres to tooth
enamel and forms organic acids producing a carious lesion.
In these instances Dietary Counseling to inhibit the carious process rather than
systemic nutritional counselling for developing a caries resistance is appropriate.

7. Food Choices and Eating Habits that Merit Attention
7
1. Frequency of between meal snacking
2. Physical form and retentiveness of sugar sweetened snacks
3. Amount of sugar added to food or beverages
4. Sequence of intake of foods during meal

8. Diet Prescription Should Incorporate
8
1. Nutritionally balanced varied diet from the high density nutritious basic four food
groups.
2. Eliminate high sugar snacks whenever possible.
3. If sugar containing foods must be included for providing energy needs restrict
them to meal time.
4. Recommend hard cheese and nuts as in between mean snacks.

9. Patient Selection
9
Potential candidate should give high priority to preventive dentistry and should be
able to expend long term efforts to maintain their natural dentition in good health for
a lifetime.
Must demonstrate need for dietary improvement, based on their current food intake
regimen which can be screened with the help ofThe Dental Diet Health Chart.

10. Dental Diet Health Chart
10
It is a simple scoring procedure that can disclose a potential dietary problem that is
likely to adversely affect a patient’s dental health.
It gives points for adequate intake of food from each food groups plus points for
ingesting food especially recommended because they are the best sources of the ten
nutrients essential for achieving and maintaining dental health.
From this sum points are reduced for frequent ingestion of foods that are overtly
sweet i.e. whose sweetness is derived from added refined sugar or concentrated
natural sugars
The difference is the Dental Health Diet Score (DHDS). 60-100 is acceptable. If score
is less than 56 dietary counselling is indicated and recommended

11. Instructions for Calculating the DHDS
11
Step 1
Ascertain the average daily intake.
List everything eaten or drunk on an ordinary weekday including snacks with
⋆ TIME of eating,
⋆ AMOUNT ingested,
⋆ Type of PREPARATION,
⋆ NO OFTEASPOONSOF SUGARADDED

12. 12

13. Instructions for Calculating the DHDS
13
Step 2
Circle foods that are sweetened and with added sugar or are concentrated natural
sweets (honey, raisins, figs).
Classify the uncircled foods or mixed food dishes into one or more of the appropriate
food group blocks.
For each serving place a check mark in the appropriate food group blocks.
Add the number of checks and multiply by the number shown.
Add the points.The Sum is the Food Group Score (96 is the highest score).

14. 14
Food groups RA
S
Portion size considered 1 serving Number
of
servings
Points
Milk( milk and
cheese)
3 8 oz (I c) milk
1
1
2
oz Cheddar cheese
1
1
2
slice American cheese
1
1
2
c cottage cheese
8 oz (1c) yogurt
8 X (Max=24)
8
Meat(meat,
fish, poultry, dry
beans, nuts)
2 2-3 oz lean cooked meat, fish or
poultry
2 eggs
4 tbsp peanut butter
1 c cooked dry beans or lentils
12 X (Max: 24)
12
Fruits and
vegetables
Vitamin A (dark
green and deep
yellow fruits
and vegetables)
1 1
2
c cooked fruit or vegetables
1 medium raw fruit or vegetable
1
2
medium grapefruit or melon
4 oz (
1
2
c ) juice
6 X (Max: 6)
6
Vitamin C (Juice
and Citrus
fruits)
1 (Max: 6)
Other 2 (Max: 12)
6
Bread and
Cereals
(enriched or
whole grain)
4 1 slice bread
3
4
dry cereal
1
2
c cooked cereal, rice, noodles or
macaroni
6 X (Max: 24)
24
Total: 56

15. Instructions for Calculating the DHDS
15
Step 3
In the Nutrient Evaluation Chart are listed the foods that are good sources of the
nutrients essential for good health in general and dental oral health in particular.
In each of the 8 columns, check the one or more eaten on this usual weekday. If a food
is checked, circle the number 7 beside the nutrient that heads this column.
Regardless of the number of food items checked in each column only 7 points are
given per nutrient.
Add the circled numbers to obtain the Nutrient Score.

16. 16
Proteins and
Niacin 7
Vitamin A 7 Iron 7 FolicAcid
7
Cheese
Dried beans
Dried peas
Eggs
Fish
Meat
Milk
Nuts
Poultry
Apricots
Broccoli
Butter
Carrots
Eggs
Greens
Cantaloupe
Collards
Liver
Margarine Milk
Peaches
Squash
Spinach
Sweet potatoes
Beef
Broccoli
Eggs
Green
leafy
vegetables
Liver
Oysters
Sardines
Shrimp
Asparagus
Broccoli
Cereals
Kidney
Liver
Spinach
Yeasts
Riboflavin 7 Ascorbic
Acid 7
Calcium and
Phosphorus 7
Zinc 7
Broccoli
Chicken
breasts
Eggs
Ham
Liver
Milk
Mushrooms
Pork
Okra
Spinach
Broccoli
Brussel
sprouts
Cantaloupe
Grapefruit
Green
Peppers
Greens
Oranges
Raspberries
Strawberries
Tomatoes
Broccoli
Cheese
Egg
Green leafy
vegetables
Milk
Oranges
String beans
Beef
Lliver
Lobster
Oysters
Shrimp
(other red
meats and
shellfish)
Nutrient Score: 42

17. Instructions for Calculating the DHDS
17
Step 4
List the sweets and sugar sweetened foods and the frequency with which they are
consumed.
Classify each sweet into either the liquid, solid and sticky or slowly dissolving
categories.
Place a check mark in the frequency column for each item as long as they are taken 20
minutes apart.
Add the number of checks. If the sweets are liquid multiply by 5, if solid multiply by 10,
if slowly dissolving multiply by 15.Write the products and total them.This is the Sweet
Score.

18. Sweets Evaluation Chart
18
Form Frequency Points
LIQUID
Soft Drinks, Fruit Drinks,Cocoa, Sugar
And Honey In Beverages, Non Dairy
Creamers, Ice Cream, Sherbet,Gelatin
Dessert, FlavouredYogurt, Pudding,
Custard, Popsickles
5 X 5
SOLIDAND STICKY
Cake, Cupcakes, Donuts, Sweet Rolls,
Pastry, Canned Fruit In Syrup, Bananas,
Cookies, ChocolateCandy, Caramel,
Toffee, Jelly Beans, Other Chewy Candy,
Chewing Gum, Dried Fruit,
Marshmallows, Jellies, Jam
10 X 20
SLOWLY DISSOLVING
Hard Candies, Breath Mints,Antacid
Tablets,Cough Drops
15 X
1. Milk with 1 teaspoon Sugar at 8:00
am
2. Ground nut laddoo and Soan Papdi
at 11.20 am
3. Jehangir at 5:30 pm
Sweet Score: 25

19. Instructions for Calculating the DHDS
19
Step 5
Now put it all together.
Transfer the Food Group Score and the Sweet Score to the totaling of the Scores
Page.
If the 4 food Group Score is barely adequate and/or the Sweet Score is in the “Watch
Out” zone, Nutrition Counseling in indicated.

20. Totaling the Scores
20
Four Food Group Score: 56
72-96 Excellent
64-72 Adequate
56-64 Barely Adequate
56 or less NotAdequate
Sweet Score: 25
5 or less Excellent
10 Good
15 or more WatchOut
If 4 Food Group Score is barely
adequate or not adequate you need
nutritional counselling from a dentist
or a nutritionist.
If Sweet Score is in the “Watch Out”
Zone your dentist will talk about what
improvements to make.

21. Communication
21
Communication is a basic tool in preventive dentistry because it can create motivation
to change.
It is the giving and receiving of information; it involves the knowledge, thoughts and
opinions of the counselor and patient.
Diet Counselling is an important preventive and supportive service because faulty diet
and inadequate nutrition can be a major etiological factors in dental oral health
problem.
It also helps in preventing future oro-dental problems related to dietary factors
contributing to lasting beneficial effects.

22. Communication
22
3 rules for achieving effective communication with patient are
1. Keeping eye contact with the patient
2. Verbal and non verbal communication (tone of voice, facial expressions, gestures)
3. Personalization of message (according to patient’s needs and understanding)

23. Communication
23
Methods used for Communication are
Interviewing
Teaching and
Learning
Counselling Motivating

24. Interviewing
24
Basic Goal of interviewing is to understand
1. The problem
2. The factors that contribute to it
3. The personality of the patient

25. Interviewing
25
Purposes
1. Dietary interview can serve as a valuable diagnostic aid
2. Knowledge of a person’s daily routine is important for adapting the caries
preventive diet to an individual’s lifestyle
3. Data for research

26. Interviewing
26
Physical Setting
Interviewing in a Private Counselling room without distractions and interruptions will
enable the patient to talk more freely
Avoid interviewing on chairside in the dental operatory because it may engender fear
and withdrawal.

27. Interviewing
27
The Diet Interviewer
Either a dentist or a dental hygienist who have
1. Skill
2. Time
3. Background knowledge of the science of nutrition, oral medicine and oral
pathology

28. Interviewing
28
How to Interview a Patient
Interviewer should relax and help the patient be relaxed and comfortable.
Ask questions that will encourage the patient’s expression of feelings about his/her
current dental condition.This helps the interviewer to understand the patient’s
personality and language skills.
Listen before speaking because she/he may reveal answers of questions without being
asked. And may help in understanding his level of understanding the cause for his/her
problem.
Questions that require reflection or extended answers are preferred than yes/no
questions.

29. Interviewing
29
How to Interview a Patient
Interviewer should unobtrusively direct the interview and gain the patient’s
confidence before investigating underlying basic factors of the specific dental
problem.
Do not make decisions for the patient. Allow patient to make choices based on what
he has learnt.
While closing the interview recapitulate what the patient has learnt and the future
action that has been agreed on.
Schedule a new appointment for reinforcement and taking further actions.

30. Teaching and Learning
30
Patient education is more than simply giving information: it requires the presentation
of information with sufficient impact to stimulate action by the learner.
Teaching aids that can be used are
1. Booklets on nutrition and dental health
2. Pamphlets
3. VisualAids
4. Blackboard with Chalk

31. Teaching and Learning
31
Information should be presented in small increments.
If not understood information should be repeated.
Next level should not be attempted until previous level is fully understood.
Use analogies from everyday experience.
It is better if the patient participates in evaluating his/her diet and writes his/her own
diet prescription with guidance from the counselor.

32. Counselling
32
There are two approaches to counselling
Directive
• Role of patient is passive
• Decisions are made by the counsellor
Non-directive
• Counsellor’s role is only to aid the patient in clarifying
and understanding his/her situation and to provide
guidance so that the patient can decide the type of
action
• This method is recommended

33. Counselling
33
Guidelines for counselling
The prerequisite for successful nutrition counselling is a realistic and honest statement
that the patient, not the counselor, bears the responsibility for making changes in the
food selections and eating habits.

34. Counselling
34
The Guidelines are
1. Gather information
•Personal identifying
data
•Likes and dislikes
•Patients perception
as to the cause of
the problem
2. Evaluate and
Interpret Information
•Relative adequacy of
diet
•Eating habits
•Indirect
environmental or
systemic factors
contributing to
dietary problem
3. Develop and
Implement a plan of
Action
•Consisting primarily
of gradual and
qualitative change in
diet using
acceptable food
exchange
4. Seek Active
Participation from
Patient’s family
•Include them in the
counselling session
5. Follow Up to asses
the progress made
•Clarify problems
encountered in
following diet
prescription
•Reinforce and
encourage making
and maintain
changes
•Set up visits for
periodic check ups

35. Motivation
35
Motivation stimulates or is an incentive for action.
Counsellor’s positive attitude and conviction as to the necessity and effectiveness of
nutrition counselling can stimulate the patient to initiate an improved dietary pattern.
According to GARN, the basic factors that motivate people are
Self
Preservation
Recognition Love Money

36. Motivation
36
If clinicians can help patient understand that a healthy mouth and teeth and a nice
looking smile can help them achieve one or more of these goals patients will be
inclined to adopt a diet that promotes oral health
Stages in changing dietary pattern are
•Recognition that the
problem exists
without an inclination
to solve it
Awareness
•Greater degree of
awareness but still
with no inclination to
act
Interest •Interest and a definite
intention to act
Involvement
•Trial Performance
Action •Commitment to
perform this action
regularly over a
sustained period of
time
Habit

37. Motivation
37
Illustration of giving up hard candy to prevent dental decay
•Hard candies produce
acid, which can cause
my teeth to decay
Awareness
•Maybe I should give up
the hard candies. I don’t
want any more sensitive
or painful teeth
Interest •I definitely will give up
hard candy
Involvement
•I have given up hard
candies and chew
sugarless gum instead
to prevent the dry
feeling in my mouth
Action •I haven’t had a hard
candy in 6 months
Habit

38. Principles of Diet Management: Application to Caries
Prevention
38
Rules to be follow during dietary modification
1. Maintain overall nutritional adequacy.
2. Prescribed diet should vary from normal diet pattern as littles as possible.
3. The diet should meet the body’s requirements for essential nutrients.
4. The prescribed diet should take into consideration and accommodate the patient’s
likes and dislikes, food habits and other environmental factors as long as they do
ot interfere with objectives.

39. Principles of Diet Management: Application to Caries
Prevention
39
4. Ideally it is best to wean the patient from the taste of sweets. Next best is to
restrict the consumption of sugar containing foods to meals.The complete
elimination of sticky, concentrated sweets especially in between meals is a
requirement.
5. Recommend the liberal use of firm detergent foods such as raw fruits and raw
vegetables so that there will be some oral clearance of food debris and stimulation
of salivary flow.
6. Recommend drinking and cooking with fluoridated water or the ingestion of
fluoride supplements if the patient lives in non fluoridated area from birth to 13
years of age; recommend the use of fluoride dentifrice and mouth rinse.

40. Counselling Procedure For Caries Prevention
40

41. Instructions for Keeping a Food Diary
41
1. Keep a running 5 day food intake Diary
2. Diary kept for 5 consecutive days including a weekend or holiday
3. Stress the importance of detail
4. Patient asked not to make any changes in usual dietary pattern
5. Do not discuss mechanism of caries production or the role that food can play

42. 42

43. The Interviewing and Counselling Visit
43
1. The visit is scheduled for at least 5 days after the food diary is given
2. This visit be devoted exclusively to interview and counselling because
a. A useful diet counselling takes 45-60 minutes
b. Reserving this visit solely for diet counselling gives the session the identification and
importance it deserves
c. A fee for the time spent and the counselling rendered in less likely to be questioned
3. It should not include other dental procedures

44. Arriving at diagnosis
44
1. Chief Complaint and
Presenting Illness
• Gives good picture of the
rapidity of caries process
• Occurrence of half a dozen or
more new caries lesions after
all dental work in the last 6
months maybe indicative of
rampant caries
• Nutrition Counselling and
Behaviour Modification may
be advised
2. Personal and Social History
• May provide clues to the
reason the patient prefers a
particular diet.
• Accomplished by ascertaining
the patient’s daily routine,
interests and lifestyle
• Patient may include
environmental factors(
economic, cultural, religious,
stress and anxiety) that
influence food selection and
habits
• Information concerning the
dental health status of the
parents or siblings or special
diets for other members of
the family is elicited at the
same time.
3. Medical History
• Physiological stresses, spurt
growths, diabetes, allergies,
GIT problems can influence
nutritional status

45. 4. Diet History and Evaluation
45
The patient’s 5-day food diary is analyzed for
1. Adequacy of intake of foods from food groups
2. The amount and type of foods sweetened with sugar and the frequency of eating
them
The patient is asked to do the following

46. Step 1
46
⋆ Circle in red all the foods recorded in the 5 day food diary that are sweetened with
sugar .
⋆ Patient is usually surprised at the number of circled foods
⋆ Explain causes and process of dental decay and that certain foods especially
sugars and certain eating habits can contribute and initiate carious lesions.
Bacteria + Sugar = Acid
Acid +Tooth =Demineralization =beginning of tooth decay

47. Step 2
47
⋆ The patient is asked to classify and tally the foods circled in red in the diary
according to their physical nature and how frequently they were eaten.
⋆ The total number of check marks is multiplied by 20.
⋆ The factor 20 represents the number of minutes the plaque pH remain at a tooth
demineralization potential when sweets come into contact with dental plaque.
⋆ This will enable the patient to recognize the problem and will want to solve them.

48. Step 2
48

49. Step 3
49
⋆ The adequacy of the diet in terms of desirable number of servings of each food
groups in readily determined by classifying each food or mixture of foods into the
four food groups.
⋆ The amount of food considered an average serving in credited by one stroke in
the appropriate block.
⋆ The average daily intake is calculated by dividing the number of strokes for 5 days
by 5 and recording the result in average column.

50. Step 3
50
⋆ Actual average intake is then compared with the suggested daily intake
depending on the individual’s age and size.
⋆ If the average intake is equal to more write OK.
⋆ If average intake is less than suggested the amount is recorded as a minus
quantity in the difference column.

51. 51

52. 52
5. Clinical and Oral
Examination
• Suggestive of
malnutrition, nutritional
anaemia, cheilosis,
stomatitis, mouth
breathing
6. Diagnosis
• It should indicate
• The relative amount
of dental caries
• Produced by faulty
food habits that are
caused by
• Lack of knowledge,
psychological, social,
economic or systemic
problems

53. Nutritional Management
53
Managing
Cause of
Improper diet
Assisting
patient to select
an adequate
non Cariogenic
Diet
Compare new
diet with the old
Reinforcement
by follow up Re-
evaluation

54. Managing the Cause of Improper Diet
54
Some of the most common reasons for eating excessive sweets are
⋆ Eating sweets is an accepted household dietary practice of the family
⋆ Sweets are a compensation for psychological stress
⋆ Sweets are used as breath sweeteners after smoking
⋆ Sweets moisten a dry mouth or soothe throat irritation
Deal with basic cause first either by treating, advising or referring to a specialist.

55. Assisting patient to Select an Adequate Non Cariogenic
Diet
55
Step 1
• Commend the Patient
Step 2
• Allow the Patient to Suggest Improvement and write his or her own diet
prescription
Step 3
• Allow the patient to delete from the diet plaque forming, sugar
sweetened foods
Step 4
• Allow the Patient to select Non-plaque promoting Snack Substitutes
Step 5
• Allow the patient to select Menus

56. 56

57. 57

58. 58

59. Comparing the New Diet with the Old
59
⋆ Encourage the patient to evaluate the adequacy of the new, self prescribed diet
and also note in it the number, form and frequency of concentrates sweets and
sugar rich foods.
⋆ The patient usually compares the new and old diet with a sense of satisfaction
that the substitution were so easily made.
⋆ The patient is pleasantly surprised and grateful to the counsellor that an easily
acceptable and non cariogenic diet was so easy to design.

60. Reinforcement by Follow-up and Re-evaluation
60
⋆ Schedule follow up visit 2 weeks later.
⋆ The patient is asked to complete a second 5 day food diary in the same manner as
before.
⋆ Evaluate the new food diary and compare the results with the original plan.
⋆ Discuss misinterpretations, misunderstandings and problems that have arisen
during this period.
⋆ Menu changes are recommended if necessary.

61. Reinforcement by Follow-up and Re-evaluation
61
⋆ Continuing reinforcement of dietary advice is just as important as continuing
review of toothbrushing and flossing practices.
⋆ Self help preventive measures should be discussed at each dental visit.
⋆ Repetition, clarification and encouragement are keys to success in long term
maintenance of the new, acceptable, less cariogenic and more nutritious diet.

62. Conclusion
62
⋆ Further research is needed to provide more risk-oriented recommendations,
particularly regarding the development of a valid and reliable chairside tool for
clinicians to assess a patient’s caries risk.
⋆ Current paradigms emphasize the importance of maintaining a healthy and stable
oral plaque biofilm for long-term disease control.
⋆ One way to do this is to limit or exclude refined sugars from the diet;
however, within the constraints of present-day consumer culture, behavioural
dietary changes are difficult to achieve and sustain.
⋆ But at an individual level Diet Counselling can go a long in establishing a stable
oral plaque biofilm.

63. Conclusion
63
⋆ It ought to be stressed, however, that a thorough analysis of the need, cost
benefits, and risk-benefits of all these preventive measures and more against
dental caries in various societies and subgroups has to be performed before using
them as public preventive measures

64. References
64
⋆ Nathe CN. Dental Sealants. In: Harris NO, GG Franklin, Nathe CN, eds. Primary
Preventive Dentistry. 8th Ed. USA: Pearson;2014
⋆ Nizel AE, Pappas AS. Nutrition in Clinical Dentistry. 3rd Ed. USA
⋆ Hiremath SS.Textbook of Public Health dentistry. 3rd Ed. India
⋆ Watt PRG et al. Ending the neglect of global oral health: time for radical action.
The Lancet. 2019;394:10194:261-272

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