Recommendations for Poor Oral Hygiene and Diet

The first step is to thoroughly assess the medical, dental, and social history to determine the risk factors associated with the extensive decay. As indicated by the question, the dental hygienist has uncovered poor oral hygiene and diet as the risk factors. To tackle the concern with the patient’s food choices, a complete assessment of nutritional intake will reveal the components of the patient’s dietary intake and behaviors that may be causing the problem. The patient should fill out a food record for 1 day to 7 days. There are many food records available online, as well as apps designed to record food intake. The more days requested, the stronger the assessment will be. As all carbohydrates have the potential to be cariogenic, identify all carbohydrates consumed on one day and review with the patient. Involve the patient in the process and have her identify all carbohydrates on the remaining days. Including the patient as much as possible gives her more ownership of the problem and enhances compliance. Continue with a discussion on the process of decay related to carbohydrate intake, the reduction of pH to 5.5 or below in the oral cavity, and the subsequent demineralization of enamel. The discussion can lead back to the patient’s food diary to show examples of meals, snacks, or eating behaviors that lend to an acidic environment in the oral cavity. Consider the form of the food (eg, sticky carbohydrates are more cariogenic than liquid carbohydrates), frequency of intake (eg, the carbohydrate is consumed at once or over a period of time), or sequence in a meal (eg, the carbohydrate consumed at the end of a meal may be more cariogenic than one consumed with a meal). It is also important to discern meals or snacks that contain carbohydrates, but do not cause a reduction of pH below 5.5 due to anti-cariogenic, cariostatic, or noncariogenic properties of food. For example, a meal consisting of:

• Unsweetened tea
• Cottage cheese with peaches
• Baked chicken breast
• Green beans
• Sweetened applesauce
• Roll with butter

The highlighted foods represent the significant sources of carbohydrates. However the phosphorus, calcium, protein, and/or fat in the cottage cheese, chicken, and the butter may provide a buffering effect and help neutralize the pH of the oral cavity.1 Asking the patient a series of questions to find what she is willing to change can lead to behavior change. Establishing small, realistic, and measurable goals is the cornerstone of nutrition counseling. While a goal of “I will eat less sugar” is not measurable or practical, a goal of “I will switch my sweetened applesauce for unsweetened applesauce” or “I will drink one less regular soda and substitute with cold water three times a week” is measurable and practical. Motivational interviewing is one technique that is a patient-centered conversation in which the dental hygienist supports and strengthens the positive behavior changes the patient wishes to pursue.2 The conversation can also include the patient’s goal for oral health. It may not be caries or plaque reduction, but whiter teeth. A carefully chosen toothpaste to meet the goal of the dental hygienist and satisfy the patient’s goal may prove to be helpful. A toothpaste containing stabilized stannous fluoride will not only reduce caries, but the bactericidal and bacteriostatic nature will aid in the reduction of plaque biofilm and oral malodor, among other benefits. A higher Relative Dentin Abrasion value, but not higher than 250 as recommended by the American Dental Association, is also beneficial at removing more plaque biofilm and stain.3 Finally, recommendation of a power toothbrush will prove to be beneficial as the research clearly points to the increased reduction of plaque biofilm over a manual brush.4 Behavior change is difficult and takes time and patience. The value of recare appointments is to reveal the behavior changes the patient accomplished or choose not to incorporate. Continue to reinforce the positive achievements and advance to implement other, more difficult suggestions.  

1. Stegeman CA, Davis JR. The Dental Hygienist’s Guide to Nutritional Care. 5th ed. New York: Elsevier; 2019:351–364.
2. Arnett M, Gwozdek A. Motivational interviewing for dental hygienists. Dimensions of Dental Hygiene. 2017;15(5):54-57.
3. Dörfer CE. Abrasivity of dentifrices from a clinical perspective. J Clin Dent. 2010;21(Suppl):S4.
4. Yaacob M, Worthington HV, Deacon SA, et.al. Powered versus manual toothbrushing for oral health. Cochrane Database Syst Rev. 2014;(6):CD002281.