Ch. 16 Nutrition

Effective Counseling Tips

1. Be nonjudgmental of current eating habits, likes, and dislikes. 2. Let the patient know you are listening by engaging in good eye contact and nodding your head. Provide feedback as to what you understood them to say. 3. Use open body language-no crossed arms, looking down, tapping pencils, swinging legs, or looking around. 4. Offer encouragement. 5. Sandwich criticism between two positive statements. 6. Avoid finger pointing. 7. Turn off or turn down the radio and block out external noises.

Creating Trust

1. Show that your interests are the same 2. Demonstrate concern for others 3. Deliver on your promises 4. Be consistent and honest 5. Communicate frequently, clearly, and openly

Understanding barriers

Before counseling the patient, it is best to consider their lifestyle and determine if there are any barriers to eating well. Sometimes poor food choices are made for reasons other than lack of education. Be sure to inquire about daily eating patterns and ask open-ended questions. *Many times, job schedules dictate odd hours of eating. *Income plays a huge role. *Single parents make choices whether they take their child to the doctor or buy food for the family for a week. *Students in professional programs attend school from 9-5 and try to work and study the remainder of the day. *CONVENIENCE can be the single most important factor in choosing foods for busy families. *The patient may prefer the taste of sweet or fast food to more wholesomely prepared food.

Collecting diet information

If it is determined that a patient can benefit from nutritional counseling and gives consent to participate, the next step is to gather information about eating habits from a diet diary. There are several types: 1. 24 hour recall 2. 3 day food record 3. 7 day food diary 4. Computerized diet assessment

Computerized diet assessment

More general that dental related but is good for analyzing the nutrient content of food. There are several online programs that are helpful if a particular nutrient deficiency is suspected. A good starting place is MyPlate; patients can customize a diet based on age, height, weight, and activity level.

Nutritional counseling as part of patient treatment

Nutritional Code D1310 is listed under Preventive Services. Unfortunately, there is NO third party compensation for this procedure. It falls into the same black hole as fluoride treatments/sealants for patients older than 14 years of age. The clinician may want to provide nutritional counseling during an appointment scheduled for another compensated procedure. Do not confuse an insurance company's lack of compensation for lack of imoortance. Preventive nutritional counseling is just as important during dental treatment as is reinforcing good home care.

Counseling Techniques: The Direct Approach

The direct approach is when your are the dictator and the patient plays a passive role. This is the MOST INEFFECTIVE METHOD because it is human nature to put up a defense when being told what to do.

Questions to ask for 24 hour recall

1. Do you drink either regular or diet soda/sweet tea? 2. Do you regularly drink fruit juice or sports drinks? 3. Do you suck on breath mints or hard candy? 4. Do you snack during the day? If so, how often? 5. Are the snacks usually sweet or sticky in nature? 6. Do you snack when you watch TV, play video games, and study? 7. Do you eat a lot of citrus fruits or drink citrus juices? 8. How many times a day do you brush and floss?

3 and 7 day diet diaries

Are for a more in-depth study and should include at least one day of the weekend. This would require the patient to keep track of the food consumed on a daily basis. Forms should be explained and given to the patient to complete at home and returned at the end of the week. After analyzing the content, appoint the patient for a one-on-one counseling session where deficiences can be explained and suggestions for improvements made.

Who Benefits from counseling

Elderly: Are at high risk for dental caries because of salivary gland hypofunction and increased consumption of simple sugars. Buying food on a fixed income and preparing meals for one person are also complicating factors. Many are on multiple medications, which cause xerostomia and need to learn how to bring more saliva into the mouth. Teenagers: Peer pressure for females to be thin or males to be muscular can create unusual eating habits. Convenience and fast foods are staples in the teen diet, and a balance in food choices may be lacking. Fast food, snacks from vending machines, and skipping regular meals are predominant in this group. Single/Independent: People responsible only for themselves may spend little time on meal planning and preparation. Convenience takes high priority. When asked, they will say that it is not worth the effort to cook for just one. Adults who diet: Specialty diets should raise concerns. The grapefruit diet causes enamel erosion, and the Atkins diet eliminates all carbohydrates, including the healthy fiber-rich carbohydrates that are part of a balanced diet. Explaining the benefit of MyPlate creates better awareness of the connection between a balanced diet and oral health. Patients with change in dental health: New or recurrent caries can be a result of poor snack or meal choices. An increase in soda consumption and developing a new habit of sucking on hard candy can be devastating to enamel. A new diagnosis of periodontal disease is the perfect opportunity to explain how a nutrient poor diet can exacerbate oral infection. Infants/toddlers/school aged children: Prevention of dental caries is of HIGH importance in this group. Always counsel in the presence of whoever does the grocery shopping and meal preparation. Giving examples of healthy snacks vs cariogenic is a must. Educating about cariostatic can benefit EVERYONE in the household.

Clues to look for in the information obtained during data collection

Include: 1. New or recurrent caries 2. Tooth loss 3. Skin lesions 4. Atrophied lingual papillae 5. Burning tongue 6. Pale or gray mucosa 7. Angular cheilitis 8. Greasy scaly skin around nose 9. Inadequately functioning salivary glands 10. Difficulty chewing or swallowing 11. Ill-fitting dentures 12. Sores under appliances 13. Loss of lamina dura 14. Polypharmacy (multiple medications) 15. Erythemic marginal and attached gingiva 16. Report of dietary change without physician supervision If any of the above are found, the next step would be to EXPLAIN THE NEED FOR NUTRITIONAL COUNSELING to the patient. Give a reason for wanting to participate. Explain the relationship between positive assessment findings to their diet. Initiate an open dialogue about food and snack selection. Once patients realize the connection between their diet and oral concern, their willingness for further investigation usually leads to informed consent. Telling a patient to change will not result in the desired effect.

24 hour recall

The 24 hr recall works best if desiring a QUICK inquiry of a patient's eating habits. Ask the patient to list all the foods consumed in a 24 hr time period, including serving size and time of day consumed. Ask if it is a typical sample, and if not ask what would make it typical. This can be accomplished while waiting for the dentist to give an examination, or after the dental charting. Use a highlighter to emphasize all sugar laden foods eaten during meals or snacks. A second different colored highlighter can be used to indicate foods high in saturated or trans fats.

Introduction

The AND recommends collaboration between dietetic and dental professionals to promote overall health and disease prevention/intervention. State laws restrict the source of nutritional advice for general medical conditions to be the domain of a registered dietitian or a registered dietician nutritionist (RD or RDN). [ANYONE can self-designate as a nutritionist, which does not require a certain level of education or regulated credentials] The purpose of dental nutritional counseling is to prevent or minimize dental disease and should be the goal in discussing food and diet changes with patients. Becoming involved in a patient's weight loss or recommending a diet for a SPECIFIC MEDICAL CONDITION is BEYOND THE SCOPE OF PRACTICE and is better left to their doctor or dietician. Most patients fail to recognize the relationship that nutritional status and eating habits have with their dental health.

Nutritional counseling procedures:

The need for dental nutritional counseling is evaluated during the data collection phase of treatment. Procedures included in the data collection phase are as follows: 1. Medical/dental history 2. Vital signs 3. Intraoral/extraoral examination 4. Gingival examination 5. Periodontal Screening and Recording (PSR)/periodontal chart 6. Dental chart 7. Radiographs 8. Nutritional counseling

Setting the Stage

Use both artificial and real examples of serving sizes, incorporating favorite foods that were documented on the diet diary. Be sure to display radiographs, oral photos, and oral education visual aids to help personalize and emphasize your counseling session. It is best to counsel your patient in a place that does not invoke anxious feelings. Sitting at a table or counter is better than sitting in the treatment chair. Seat patients at eye level and provide a surface where you can spread out their counseling forms and write if necessary. Examples of visuals: Laminated redireference card Food props that indicate appropriate serving sizes Empty boxes and bottles of favorite foods for reading labels Stuffed animal people to engage children Colorful Pyramid Guides to capture and keep attention focused. Patient radiographs and completed dental and periodontal charting Oral hygiene aids for plaque removal

Counseling Techniques: The Nondirect Approach

With the nondirect approach, the PATIENT is in control and the clinician's role is that of facilitator. This is also referred to as the PATIENT-CENTERED TECHNIQUE.It demonstrates respect for what the patient already knows about his or her diet and nutrition and allows for the patient's input and personal preferences. Change is more apt to happen via this method.