Department of Public Health Dentistry, Faculty of Dental Sciences, MS Ramaiah University of Applied Sciences, Bengaluru-560054, India

^*Corresponding author: Amra S, Department of Public Health Dentistry, Faculty of Dental Sciences, MS Ramaiah University of Applied Sciences, Bengaluru-560054, India; Phone: +91 9731723236; E-mail: dramra.sultana@gmail.com

Article Information: Submission: 28/04/2022; Accepted: 03/06/2022; Published: 08/06/2022

Copyright: © 2022 Amra S, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Dental caries is a diet-related disease that continues to be a problem for certain dental patients. Frequent consumption of fermentable carbohydrates that have low oral clearance rates increases the risk for caries. This report emphasises on the significance of diet counseling in prevention of dental caries.

A 21-year-old female patient reported to the clinic with a chief complaint of brownish discoloration on the posterior region. On eliciting detailed case history it was found that patient had adequate oral hygiene practices, however, the patient had a habit of snacking and not rinsing her teeth immediately afterward. Detailed dietary analysis revealed on patients habit of ‘in-between’ consumption of sugary foods. Hence the intervention was aimed at reduction of in-between consumption and replacement with alternate diet. Multiple oral health education sessions, positive reinforcement and allowing the patient to decide the alternate by explaining her food pyramid followed by convincing the patient to change her pattern of diet were the measures taken. All these measures resulted in changing the eating habit of the patient.

Hence it is important to understand the risk of patient to develop dental caries and to plan tailor made interventions for a caries preventive regimen.

Dental caries; Diet; Diet counseling; Diet chart; Sugars; Cariogram

Many chronic health problems are associated with increased consumption of free sugars. The term free sugars refers to monosaccharides and disaccharides that are naturally present in honey, syrups, and fruit juices, as well as also added by manufacturers or consumers to food and beverage [1]. According to the WHO, free sugars should make up less than 5% of one’s daily total energy intake, to reduce one’s risk of obesity and dental decay. This recommendation is based on the recognition that dental caries has cumulative health effects, affecting both children and adults. Even a small reduction in the risk of dental caries in childhood is significant in later life since dental caries is the consequence of lifelong exposure to a dietary risk factor [2].

Despite dental caries is highly preventable disease, but increased intake of free sugars considers as major risk factors for chronic disease among population [3]. Age wise prevalence was 62% in patients above 18 years and 52% among 3-18 years of age in India [4]. Dental caries occur when bacteria metabolize sugar, which produces organic acids, leading to the demineralization of the hard tooth structure [5]. Dental caries is a multifactorial disease and one of its factors is behaviour related diet. With this background, it seems logical that dental practitioners should conduct risk assessment based on the primary findings. This will enable planning interventions specific to risk identification ranging from diet counselling to complex treatment.

A 21-year-old female patient reported to the Comprehensive Oral Health Care Unit with a chief complaint of brownish discoloration on posterior region since 1 year with no history of pain and sensitivity and any other related signs. Patient had past dental history of restorations and oral prophylaxis which was done 1 year ago. The patient confirmed adequate oral hygiene practices. However, the 24 hour diet chart revealed that she ate sugary snacks during and after the college times and taking dinner without brushing or rinsing her teeth immediately afterward.

On Intra-oral examination, it was found that following teeth had been restored with glass ionomer cement: teeth numbers 47, 37, 17 and 26 in addition, teeth numbers 46, 48,and 36 had deep pit and fissures. Since we were looking at more sensitive index, ICDAS was used because it had continuum to caries pathway from sound tooth to distinct cavitation [6]. Considering patients caries status, we planned to conduct a risk assessment using cariogram including one week diet chart. Caries risk assessment was done and data was collected as suggested by Bratthall [7].

Patient data was obtained for all the parameters enlisted in the cariogram and it revealed that patient had 44% actual chance to avoid new cavities and contribution of planned diet was 22% (Figure 1).

Patient was asked to submit the diet chart for 7 days including time, frequency and consistency of food that she ate. The detailed analysis of the 7 days diet chart revealed the in-between sugar snacking and the frequency of consumption was 4-5 times per day and consistency of food was predominately retentive and the average sugar-score for a week was 37.14, hence intervention was to reduce in-between consumption.

The cariogram output suggested that the diet with respect to its content of fermentable carbohydrates is a problem - a reduced intake of such products would be an advantage. Hence intervention was planned for diet counseling and for preventive regime. Rationale for diet counseling was the frequency of cariogenic diet, consistency, and in-between consumption.

It included familiarizing patient with balance diet, food pyramid, and the beneficial effects of all the foods in the pyramid and importance of balanced diet. Patient was also informed about oral health including types of dentition, simple oral diseases and emphasizing dental caries. Patient was also explained about the role of cariogenic diet in causing dental caries, stages of dental caries andremineralization and demineralization using Stephen’s curve [5]. However comprehension was maintained and technical terms were not used.

It started with reinforcing first session contents and diet chart analysis of the patient. And patient herself was able to appreciate the frequency, consistency and in-between snacking behaviour being responsible for dental caries. The second session ended up with requesting the patient to submit alternate replacements for the snacks she was consuming.

The patient came up with alternate diet with suggestion of nuts and fruits. Basically patient was into the behaviour of consuming quick snacks to overcome the stress.

Considering the patient suggestion, it was reinforced the importance of planned diet and beneficial effects of these foods and the patient was motivated to adhere to this plan. Following which patient was asked to maintain diet chart for subsequent second and third week. Timely Whatsapp messages were sent to the patient reinforcing the beneficial effect and exactly at those timings were in the habit of consuming sugary snacks.

Similarly, second and third week diet chart was submitted by the patient. The analysis indicated that, there were not many changes in the diet chart in the second week whereas in the third week diet chart showed drastic improvement. Sugar score was calculated based on the form, frequency and consistency of sugar intake by classifying each sugarintake into liquid, solid and sticky or slowly dissolving using Nizel and Papas 24 hour diet method [5]. Table 1 shows pre and post intervention of diet chart and Table 2 shows the average and composite score for sugar consumption for each week. The average sugar score calculated for fourth week was 5.7. Along with this patient was also instructed to rinse her mouth each time after consumption of food.

Fourth week risk assessment revealed that patient had 82% actual chance to avoid new cavities and contribution of diet was 1% (Figure 2).

It was very clear that consistency, frequency and in-between snacking habit played a major role in causing dental caries [8]. This relationship between dietary habits and dental caries was proven by Vipeholm study [8]. Tailor made interventions, active patient participation in planning diet, motivation and reinforcement for patient compliance to treatment regimen contributes to effectiveness of interventions demonstrated as decreased total diet score and change in diet pattern [9]. Rather than considering the total score, from the diet chart, detailed analysis of diet chart is more beneficial. It gave us better idea about the in-between meal consumption, frequency of snacking and quality of food which facilitated in patient education about diet and dental caries and also planning interventions. The change in diet pattern was evident after 4 weeks which was backed with 3 face to face sessions and frequent reinforcement messages. However, the sustainability of the changed behaviour is yet to be studied.

Also, patient had the background of science therefore using the language such as balanced diet, food guide, and pyramid helped us to maintain the comprehension level. Understanding literacy level of patient is very important for patient compliance and successful dietary intervention. Hence this method appears to be promising in bringing about changes in individual level, however for future direction we would recommend to develop a diet chart which can be scored for type of food, frequency and time which can enhance sensitivity and contribute to evidence. This particular case report has shown promising results with diet counseling as an intervention, however more number of cases in the future is recommended.