Santa Monica College Impact of Oral Health and Nutrition Information Essay

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Diet Trends

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DECEMBER 2019 • VOL 33, N0 10
Trendy Diets and
Oral Health
President’s Message
Dental Hygienist Liaisons’
Nutritional Interventions
Incorporating Chairside Blood
Glucose Testing As a Vital Sign
in Patient Risk Assessment
Infographic: ADHA and CDC
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New Poll: Adding Dental
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utrition is inseparable from oral health.
What we eat affects our ability to eat.
Nutrition information is a vital aspect
of the oral and systemic health education we provide our patients. Taking a nutritional
history is part of the assessment step of the dental
hygiene process of care.1
ADHA’s Prevention and Wellness policies include the following.2

The American Dental Hygienists’ Association supports nutritional guidelines and programs that promote total health and
encourages media advertising and public education that promote
healthy eating habits and wellness. (Nutrition 13-94/29-74)

The American Dental Hygienists’ Association advocates arrangements between school districts and vendors to promote the consumption of healthy foods and beverages. (Nutrition 1-12/14-01)

The American Dental Hygienists’ Association encourages health
professionals to advocate for legislation, policies, programs, and
research to foster reduced consumption of artificially and sugar
sweetened beverages (SSBs); to provide education on reducing
consumption of artificially and SSBs to all children and their
caregivers; and to identify children at risk for obesity or who are
obese and provide a referral to a primary care health professional,
nutritionist or registered dietitian. (Sugar Sweetened Beverages
In September, the Robert Wood Johnson released a consensus
statement, “Healthy Beverage Consumption in Early Childhood:
Recommendations from Key National Health and Nutrition Organizations.” The statement contains recommendations for selecting
the best beverages for children at different ages, emphasizing the
preferability of milk and water over juice, especially with added sugar.
The statement is available online at
ADHA is currently at the table for discussions of the 2020-2025
Dietary Guidelines for Americans, having provided testimony to the
Dietary Guidelines Advisory Committee of the U.S Department of
Agriculture (USDA) and U.S. Department of Health and Human
Services (DHHS) in July. We advocated for a policy change to raise
the visibility of a daily oral care routine within the dietary guidelines.
The message would read,
Individuals of all ages should follow a daily oral hygiene
routine, which includes brushing their teeth with fluoridated toothpaste, cleaning between their teeth where possible,
chewing sugarfree gum for 20 minutes after meals or snacks
if possible, drinking fluoridated water where available, and
limiting frequent or constant use of dietary fermentable
The committee will present a formal report to USDA and DHHS
by May 2020, before the agencies issue the final Dietary Guidelines for
America by December 2020.
1. American Dental Hygienists’ Association. Standards for Clinical Dental Hygiene
Practice. 2016. Available at:
2. American Dental Hygienists’ Association. Policy Manual. 2018. ADHA.
Available at:
Congratulations to the 2019-2020 IOH Scholarship Recipients
ADHA’s Institute for Oral Health (IOH) Scholarship Program supports dental hygiene professionals
throughout their careers. IOH offers academic financial assistance to dental hygiene students and
dental hygienists at all levels of their education who demonstrate a commitment to the discipline
of dental hygiene. Not pictured: Lorenna Fernandes, Florida, Palm Beach State College, Colgate
“Bright Smiles, Bright Futures” Minority Scholarship and Megan Warfield, Michigan, Lansing
Community College, Hu-Friedy/Esther Wilkins Instrument Scholarship
Armani Alexander, Illinois
Malcolm X College
The ADHA Institute for Oral Health
General Scholarship
Dariana Estrada, Texas
University of Texas School of
Johnson & Johnson Scholarship
for Academic Excellence
Hatem Salim, Michigan
Lansing Community College
Colgate “Bright Smiles, Bright
Futures” Minority Scholarship
Mary Andrews, Arkansas
University of Arkansas
Johnson & Johnson Scholarship
for Academic Excellence
Anna Gentry, RDH, California
Idaho State University
Wilma Motley Memorial California
Merit Scholarship
Cyndra Schmidt, Oregon
Portland Community College
Hu-Friedy/Esther Wilkins
Instrument Scholarships
Jacqueline Burgess, Wisconsin
Minnesota State University
The ADHA Institute for Oral Health
General Scholarship
Marcus Hicks, Texas
Pima Medical Institute
The ADHA Institute for Oral Health
General Scholarship
Meg Schwalger, Utah
Dixie State University
Karla Girts Memorial Community
Outreach Scholarship
Mallory Canzoneri, South
Midlands Technical College
The ADHA Institute for Oral Health
General Scholarship
Caitlin May, Michigan
Baker College
The ADHA Institute for Oral Health
General Scholarship
Lauren Sciarratta, North
Asheville Buncome Technical
Community College
Hu-Friedy/Esther Wilkins
Instrument Scholarship
Lori Carlson, Illinois
University of Missouri – Kansas City
Sigma Phi Alpha Graduate
Daniella Montero, California
Cerritos College
Wilma Motley Memorial California
Merit Scholarship
Elizabeth Shavlik, Nebraska
The University of Nebraska Medical
Center College of Dentistry
Crest Oral-B Laboratories Dental
Hygiene Scholarship
Madison Collins, Louisiana
Louisiana State University School
of Dentistry
Crest Oral-B Laboratories Dental
Hygiene Scholarship
Anthony Nguyen, Pennsylvania
BridgeValley Community &
Technical College
The ADHA Institute for Oral Health
General Scholarship
Marissa Shumpert, South
Midlands Technical College
The ADHA Institute for Oral Health
General Scholarship
Jamie Cramer, Ohio
Rhodes State College
Johnson & Johnson Scholarship for
Academic Excellence
Sadie Nguyen, Texas
Texas A&M College of Dentistry
The ADHA Institute for Oral Health
General Scholarship
Cheyenne Stallions, Idaho
Idaho State University
The ADHA Institute for Oral Health
General Scholarship
Selvi Das Purkayastha, RDH,
Idaho State University
Irene Woodall Graduate
Sarah Palme, Arizona
Northern Arizona University
The ADHA Institute for Oral Health
General Scholarship
Kristen Valenzuela, Texas
The University of Texas School of
Dentistry Houston
The ADHA Institute for Oral Health
General Scholarship
Roxanne Dsouza, North
North Carolina State University
Sigma Phi Alpha Graduate
Katie Peterson, Wisconsin
Chippewa Valley Technical College
Carol Bauhs Benson Scholarship
Samantha Vest, Virginia
Old Dominion University
Alice Hinchcliffe Williams, RDH, MS
Merit Scholarship
Caroline Dunham McLeod,
North Carolina
University of North Carolina Chapel Hill
Sigma Phi Alpha Graduate
Shelby Ruder, Indiana
Indiana University School of
Wilma E. Motley Scholarship
Avery Wood, Michigan
Lansing Community College
The ADHA Institute for Oral Health
General Scholarship
Leah Elkins, West Virginia
BridgeValley Community and
Technical College
Johnson & Johnson Scholarship
for Academic Excellence
Stacey Rudolph, Wisconsin
Waukesha County Technical
Johnson & Johnson Scholarship
for Academic Excellence
Sarah Youssef, RDH, Ohio
The Ohio State University
Dr. Esther Wilkins Scholarship
Trendy Diets and
Oral Health
ost patients know sugar is
bad for their teeth. But they
may not realize that a diet
they’ve chosen — perhaps to
lose weight or feel healthier — could have
unexpected consequences on oral health. This
article looks at the impact on oral health of
some of today’s popular diet trends.
The keto diet is a high-fat, very low-carbohydrate, moderate-protein regimen.1 With
this diet, the body breaks down fat into
ketones, which become its principal source
of energy (rather than carbohydrates). This
process is called ketosis.1,2
The keto diet may reduce intake of
important minerals and vitamins such as
A, C, K, and folate.1 Vitamin C deficiency,
for example, can lead to tooth loss and poor
wound healing.2 Additionally, “keto breath”
is a common problem. Keto breath smells
fruity or even like nail polish remover because
the body burning fat for energy produces
chemicals such as acetone, acetoacetate, and
beta hydroxybutyrate.3
To help patients manage keto breath,

Drinking plenty of water

Eating less protein and more healthy fats
(avocados, nuts)

Increasing carbohydrate consumption
a little

Focusing on good oral hygiene.
The Atkins diet starts by limiting carbohydrate consumption (which can put the body
into ketosis), then gradually increases carbohydrates. Atkins permits much greater protein
consumption than keto does.4 However, a
diet high in protein may also contribute to
bad breath because protein that breaks down
in the body produces ammonia.3
Nutrition consultant, author and speaker
Ellen Karlin, MMSc, RDN, LDN, FADA,
said, “Even though protein is a cariostatic
food, I do not recommend high-protein
diets such as Atkins and keto for optimal
oral health. These diets limit nutrient-dense
foods such as whole grains, fruits, beans [and]
legumes as well as low-fat/nonfat dairy and
nuts, which the American Academy of Nutrition and Dietetics recommends eating daily
for healthy teeth and [periodontal tissues]. In
addition, these diets allow diet soda, which
contains citric acid, shown to weaken tooth
enamel. Xerostomia is also a problem, as it
increases the risk of caries, gingivitis and oral
Lisa Mallonee, MPH, RDH, RD, LD,
professor and graduate program director
in the Caruth School of Dental Hygiene at
Texas A & M College of Dentistry, noted, “As
a dual licensed dental hygienist and dietitian,
I am keenly alert to subtle nuances in the oral
cavity and quick to question a patient about
dietary habits to rule out risky patterns of
eating or a new trend … . The impacts of the
Aktins/keto/high-protein diets are probably
the most noticeable. Excess bleeding may be
present due to the softer consistency of foods
consumed in a high-protein diet. Consumption of softer foods/less detergent-cleansing
foods (such as crunchy fruits and vegetables)
We asked dental hygienists
Are there diet-related questions on your
practice’s health history?
Do you typically discuss diet with your patients?
Have you seen the effects of diet on oral health
in your patients?
Upon recognizing symptoms of these effects on
oral health, do you ask about diet?
Respondents were asked if patients said they were following any of several listed diets. The results: keto (86%),
paleo (71%), vegan (68%), vegetarian (68%), intermittent fasting (57%), Atkins (41%), juice cleanses (39%), low-fat
(30%), DASH (11%), and other (FODMAP/SIBO) (11%) (N=49).
often results in greater accumulation of
biofilm on teeth, which subsequently leads
to increased inflammation. Keto breath is
instantly recognizable — it smells more like
rotting fruit than fresh tropical fruit.”
The American Academy of General
Dentistry notes that a vegetarian regimen
(especially one with no food of animal origin)
could lead to deficiencies in nutrients such
as vitamin D, calcium, vitamin B12 and
riboflavin (vitamin B2).5 Lack of vitamin
D and calcium could increase the risk of
periodontal disease and contribute to teeth
becoming softer and more susceptible to decay.6 Deficiencies in vitamins B2, B3, B6, and
B12 may result in oral ulcers, stomatitis and
glossitis.7 Vegetarians and vegans may also be
at risk of protein deficiency, which can lead
to issues such as poor structural integrity of
dentition, deterioration of support structures
for dentition and weakened resistance to oral
Since animal products are the
primary dietary sources of B12, I
recommend that vegan clients
include foods fortified with B12
daily — such as cereals, soy
products and plant milks.
—Ellen Karlin
In a study in the European Journal of
Clinical Nutrition, researchers looked at 200
subjects — split evenly between nonvegetarians and vegetarians — to evaluate the effect
of a vegetarian diet on periodontal conditions. Both groups were matched for known
risk factors such as smoking. All subjects
underwent a full-mouth assessment and completed questionnaires. Researchers concluded
that a vegetarian diet/lifestyle has a positive
impact on periodontal conditions. Vegetarians displayed less periodontal damage, fewer
signs of inflammation, fewer missing teeth,
and (as a result of better dental home care),
better plaque scores. However, vegetarians exhibited more decayed teeth and more erosion.
Frequent consumption of acidic foods such as
raw vegetables and fruits including tomatoes
might be a contributing factor. The authors
noted that they did not assess physical activity
and BMI, which could have impacted the
An Italian study observed 15 subjects who
had followed a vegan regimen for 18 months
to 20 years. A control group of 15 individuals on an omnivorous regimen met the
same age, gender and place of origin criteria.
Participants completed questionnaires and
received comprehensive oral examinations.
The authors noticed major oral changes in the
vegan group. There was a greater incidence of
demineralization and precarious lesions/white
spots in those subjects. The authors said that
evaluating the study sample for a longer peri-
od of time might determine a more definitive
cause-effect relationship.9
Following a low-fat regimen can interfere
with the absorption of fat-soluble vitamins
A, D, E and K.10 Vitamin A helps maintain
the mucosal membranes, salivary glands and
teeth.7 Vitamin D aids in the absorption of
calcium. If the body can’t absorb calcium,
teeth can start to deteriorate.10 Additionally,
foods labeled “reduced fat” often contain added sugar, which can contribute to cavities.10
Fat provides essential fatty acids
(such as linoleic acid) … and
helps the body absorb fat-soluble vitamins…. Foods high in
Omega 3 fatty acids (fatty fish,
flaxseed, chia seeds, walnuts,
extra virgin olive oil) may help
prevent periodontitis.
—Ellen Karlin
Intermittent fasting and fasting diets could
negatively impact oral health. According to
Mallonee, reduced mastication can result in
xerostomia and diminished saliva. As noted
earlier, xerostomia is associated with a number of oral health problems.
A juice cleanse regimen involves drinking
only fruit and vegetable juices, perhaps to lose
weight quickly.11 Ellen Karlin opposes this
trend, saying, “The natural fruit sugars can stay
on the teeth and combine with the bacteria in
the mouth. Acid production occurs, leading
to enamel erosion and tooth decay … . The
harmful acids can also attack the [periodontal tissues], leading to periodontal disease.”
Another problem with juice cleanses is that
saliva production decreases when solid food is
not chewed.12
In a German study, researchers soaked cow
teeth in nonalcoholic beverages for seven
days then evaluated the loss of tooth enamel
and dentin. They found that apple juice and
orange juice were three times more corrosive
than cola.12
If patients want to mitigate the dental
impact of a juice cleanse, suggest:11

Using a straw to decrease contact between the juice and teeth

Drinking water after juice

Waiting an hour after drinking juice to
brush teeth.
The Dietary Approaches to Stop Hypertension (DASH) plan is high in fiber, fruits and
vegetables; and low in sodium, added sugars
and saturated fats.13 This regimen may have a
positive impact on oral health.
1. Gordon B. What is a ketogenic diet? Academy of
Nutrition and Dietetics website. May 15, 2019. Available
what-is-the-ketogenic-diet. Accessed July 3, 2019.
2. Carr AC, Frei B. Toward a new recommended dietary
allowance for vitamin C based on antioxidant and health
effects in humans. Am J Clin Nutr. 1999;69:1086-1107.
3. Higuera V. Everything you need to know about keto
breath. Healthline website. Available at: https://www. Accessed July 3, 2019.
Researchers for the Veterans Affairs Dental
Longitudinal Study followed 533 male subjects aged 47 to 90. About every three years
for 20 years, the subjects underwent comprehensive dental exams. Questionnaires assessed
how well the men’s diets followed the DASH
plan. Subjects whose DASH adherence scores
were in the highest quartile had a 30% lower
mean adjusted root caries increment (1.86
teeth) than those in the lowest quartile (2.68
teeth) (P=.03).14 Although there was not a definitive cause-and-effect relationship shown,
the results are encouraging.14,15
any oral symptoms that have developed since
beginning that regimen.
Finally, educate patients about the possible
impact of dietary choices — and encourage
healthful behavior.16
Where indicated, Lisa Mallonee has her
students do a 24-hour dietary recall with a
patient, then sends the patient home with a
three-day food record. The information gathered provides valuable insights into dietary
habits and cariogenic eating patterns — and
serves as the basis for patient education and
promoting healthful habits.
The literature has shown that “in general,
dental hygienists often feel uncomfortable
asking patients questions about their diet,”
said Lisa Mallonee. “However, I provide
continuing education on a variety of nutrition-related topics including diet trends that
might impact oral health, and my courses are
always well attended, so I know there is a desire among licensed hygienists to learn more
about nutrition and to increase their comfort
level in disseminating preventive education
with regard to diet/oral disease risk during
patient care.”
Dental hygienists can play an important
role by screening patients for diet-related oral
issues. Ask if the patient is following a special
diet to manage a chronic condition or weight.
Then inquire whether the patient has noticed
6. Delta Dental. How vegetarians can ensure good oral
health. Updated February 2014. Available at: https://
Accessed August 1, 2019.
7. Pflipsen M, Zenchenko Y. Nutrition for oral health
and oral manifestations of poor nutrition and unhealthy
habits. Gen Dent. 2017;65(6):36-43.
8. Staufenbiel I, Weinspach K, Förster G, et al.
Periodontal conditions in vegetarians: a clinical study. Eur
J Clin Nutr. 2013;67:836-40.
9. Laffranchi L, Zotti F, Bonetti S, et al. Oral implications
of the vegan diet: observational study. Minerva Stomatol.
4. Lawler M. What’s the difference between keto and
Atkins? Everyday Health website. Updated June 18, 2018.
Available at:
Accessed July 23, 2019.
10. Delta Dental. The skinny on dieting and your teeth.
October 2015. Available at: https://www.deltadentalins.
com/oral_health/diets.html. Accessed July 23, 2019.
5. American Academy of General Dentistry. Dentist
should advise vegetarians on good oral health. Available
article/?abc=n&iid=315&aid=1273. Accessed July 18,
11. Delta Dental. Juice cleanses: a quick way to lose
weight and … erode enamel? Grin. Grin. Winter 20182019. Available at:
html. Accessed July 23, 2019.
Joy Void-Holmes, RDH, DHsc is a dental
hygiene educator in Maryland and expert in
nutrition. She provided Access with links to
additional resources.
On artificial sweeteners and oral health:
On nutrition and periodontal health:
On lipids and periodontal disease: https://
Julie Edwards is a freelance writer in
Chicago, Illinois.
Ellen Karlin, MMSc, RDN, LDN, FADA,
speaks on nutrition. She can be reached at
12. Jacobs M. How fad diets and faulty nutrition can spell
dental doom. Dallas News (Better Living). November
2015. Available at:
better-living/2015/11/02/how-fad-diets-and-faultynutrition-can-spell-dental-doom. Accessed July 19, 2019.
13. Academy of Nutrition and Dietetics. DASH diet:
reducing hypertension through diet and lifestyle.
May 15, 2018. Available at:
Accessed July 16, 2019.
14. Kaye EK, Heaton B, Sohn W, et al. The Dietary
Approaches to Stop Hypertension diet and new and
recurrent root caries events in men. J Am Geriatr Soc.
15. Harvard Health Publishing. DASH diet linked to
better dental health. November 2015. Available at: https:// Accessed July
16, 2019.
16. Mobley C. Fad diets: facts for dental professionals. J
Am Dent Assoc. 2008;139:48-50.
Dental Hygienist Liaisons:
Nutritional Education Q&A
ental hygienist liaisons (DHLs)
provide oral health education,
including nutrition education,
to parents of children enrolled in
Head Start or child care to help ensure optimal
oral health for children. Access spoke with
three DHLs about nutrition education in their
Carla M. Bassett, RDH, DHL for Mississippi, is regional oral health consultant in the Office of Oral Health, Mississippi State Department of Health.
Ann Hoffman, RDH, BSDH, DHL for
Missouri, is oral health program
consultant, Missouri Department of
Health and Senior Services, Office of
Dental Health.
Mariela Leyba, RDH, DHL for New
Mexico, is a dental hygienist for the
Office of Oral Health in New Mexico.
What do parents know about eating
healthy foods?
Bassett: Parents are often taught about
nutrition by family members such as parents
or grandparents, or they may be influenced
by their spouse’s childhood experience. I
have heard a few parents say that if it weren’t
for services such as WIC, they wouldn’t
know how much juice or milk to give their
baby. But not all parents we encounter are
enrolled in WIC, so oral health professionals
and educators have to get creative when
providing oral education. With social media
and the internet such a big part our lives
these days, parents and other caregivers seem
to rely on popular sites and blogs for information about nutrition and oral health. At a
recent conference, a parent shared with me
that their family — including a 3-year-old
— is on a low-carb diet because testimonials
from a popular social media site suggest that
limiting carbs leads to better health.
Hoffman: Some parents with children enrolled in Head Start or child care are aware
of the importance of giving their children
healthy foods, and some are not. Our
monthly Brush Up on Oral Health tip sheet
provides ideas about healthy and tasty foods
to offer children. However, convenience
can influence which foods parents choose;
it is much easier to grab a fast food meal at
a drive-through than to prepare a healthy
home-cooked meal.
Leyba: The population we work with in
Head Start is mostly low income, and parents often lack basic nutrition knowledge.
Many times, they rely on information from
internet searches, marketing, social media
and friends or family members.
What do parents want to learn about
eating healthy foods?
Bassett: I see more parents interested in
giving their infant or child organic foods.
Conversations I’ve had suggest that there
is a generalized fear of processed foods and
concerns about linkages between such foods
and developmental or growth issues. Some
parents look for foods with “all natural”
ingredients — or those advertised as such —
including foods that do not include fluoride
on the label despite the fact that fluoride is
a mineral bound in natural bodies of water
that can has a large impact on reducing and
potentially stopping early tooth decay.
Hoffman: Many parents are open to learning more about healthy food options for
their children. Most parents want options
that are quick and easy to prepare and that
their children will like. Guiding parents
away from packaged foods and encouraging
them to offer fresh fruits and vegetables
daily is ideal.
Leyba: Most parents want what’s best
for their children and also to be healthy
themselves so that they can be there for their
children as long as possible and remain active and able to run around with them. But
our habits were created at a time when we
thought that packaged foods were nutritious
and that “fat” caused weight gain — foods
labeled “fat free” were healthy options. We
now know a lot more about healthy eating
than before.
Parents would benefit from a basic interdisciplinary nutrition program including
a nutritionist, dental provider and medical
provider, especially if co-morbidities exist.
The likelihood of this happening is slim,
especially in rural and frontier areas. In my
experience, parents are usually willing to listen to nutritional advice, if it is convenient
for them to attend and provides practical,
specific suggestions.
What are parents’ challenges in accessing and eating healthy foods?
Bassett: Mississippi is a rural state with the
worst oral health in the nation. As in many
states, healthy food is not widely available in
certain zip codes and geographic areas. For
example, it is not uncommon for parents to
drive 30 miles to buy produce from farmers
and at multiple grocery stores. For those
who struggle with transportation and lack
of time, the local grocery store may be the
only option, and it may have limited healthy
food options.
Hoffman: Challenges for parents include
cost, the time required to go grocery
shopping and prepare healthy foods, and
the fact that healthy foods may not always
appeal to children. The low cost of fast food
in comparison to shopping and preparing
a meal at home can present a hard decision
when feeding a family. A wonderful option
is ordering the food online and using the
pickup service many stores offer.
Leyba: There are many challenges when it
comes to accessing and eating healthy foods.
It is tough to break old bad habits and change
incorrect ways of thinking, and inaccurate
food labels and marketing do not help. There
are fast food places on every corner that
parents love because it’s cheap, fast and easy
and appeals to children. It’s easy to think of
just the moment instead of how things will
turn out in the long run: who can resist the
temporary smile on a child’s face when they
get a Happy Meal? In that moment, we don’t
think of the tears that could come later when
getting a restoration or being bullied for
being an overweight child.
These days, most moms work, and
there are too many convenient unhealthy
options in grocery stores that are full of
preservatives, sodium, fat and sugar and
lack fiber, vitamins and minerals. Here in
New Mexico, there are many “food deserts”
without grocery stores that sell produce and
fresh meats. Two hundred years ago, 90%
of the U.S. population lived on farms and
produced their own food. Now, 2% of the
population produces food for the world to
When parents realize that diet plays a
huge role in the prevention of many health
problems, it gets their attention. But even
when parents are educated, it takes change
to put information into action. We need to
consider all of these challenges and provide
practical, specific recommendations to help
parents make healthier choices.
What nutritional guidance have DHLs
shared with parents with low incomes
and parents who live in food deserts?
Bassett: Sharing the importance of healthy
eating as it relates to oral health is my first
line of defense when counseling a parent or
speaking at a Head Start parent conference.
I emphasize taking advantage of seasonal
produce when addressing nutrition with
parents with low incomes in rural areas. Fall
gardens yield fresh cabbage and collards we
love so much in the South, and eating these
foods are a great way to add calcium to the
diet, which benefits strong bones and teeth.
In our world of water additives, parents
are finding it harder to get young children
to drink plain water. Adding fresh strawberries or oranges to a small cup of water is a
great way to get children to consume water
without additives.
Hoffman: Our monthly tip sheets offer
many healthy, inexpensive ideas for parents
about foods and drinks to offer children. We
recommend foods and drinks low in sugar:
drinking water instead of juice, pop (soda),
or sports drinks and eating fresh foods
from the produce section. Every tip sheet
includes a recipe for a healthy snack that
can be prepared at home. We also encourage
parents to model choosing healthy foods for
their children.
Leyba: Since a lot of sugar children
consume comes in the liquid form, I find
one of our most useful tools is a sugar
board with bags of sugar attached, showing
parents exactly how much sugar beverages
contain. They are usually shocked when
it is presented this way. We explain how
exposure to sugar creates an “acid attack”
that leaves teeth susceptible to decay for 2040 minutes, and how simply drinking water
can help buffer the acid and rinse away
food particles, helping to prevent caries. We
remind parents that water should be our
first choice and to offer water throughout
the day. Most people have access to clean
drinking water — purchased at a gas station
or dollar store if not available from the tap.
We also remind parents to model good
behaviors themselves and refrain from
having sodas and junk food in the family
home. We explain how “snack” is not synonymous with “junk food,” and that most
snacks should be tiny, healthy meals. We
remind parents that their children are just
developing their taste for foods, and that
they will never be able to taste the sweetness
of a strawberry if they’re frequently exposed
to cookies and candy. We emphasize that
what is good for our teeth is also good for
our bodies, and that we know a lot more
about nutrition now than we knew growing
up: parents have the power to instill good
habits in their children and set them up for
a lifetime of health.
Do cultural differences affect some
parents’ nutritional knowledge?
Bassett: We are in an age where more
grandparents and great grandparents are
raising children, and parenting practices
today in a world of instant and fast food
options. The internet has changed the world
with information access at the click of a
button. Pew Research reported in 2018 that
34% adults over 65 are using social media,
so there are more opportunities for this
generation to seek nutritional answers.
Our state lost a child due to complications of a dental infection in 2007. Parents
are deeply affected when I share that story.
It is an effective way to link nutritional
habits and the benefits of a healthy mouth
to overall health.
Hoffman: Cultural differences can influence
food choices. Some cultures consume large
quantities of sugar; a practice that can be
modified to help decrease tooth decay in
children. We must accept that different
cultures differ in their practices related to
food and work together to find healthy
alternatives to unhealthy practices.
Leyba: In New Mexico, we have a huge
population of Hispanic and Native American people whose diet consists of a lot of
bread and fried foods, which are absolutely
delicious, but not the healthiest. The good
news is the huge effort, in the pueblo
communities especially, to make healthier
variations on traditional foods. The Head
Start in Jemez Pueblo offers classes to teach
families how to make whole wheat bread as
a variation on traditional white flour bread.
They also take the students out to grow and
harvest fresh vegetables and try to bring
back the older, healthier ways. The health
of Native Americans suffered greatly with
the introduction of food stamps. People
switched from traditional ways to more
convenient, modern ways and it resulted in
drastic health consequences.
Are there messages about feeding
and eating practices that either promote or help prevent tooth decay that
commonly surprise parents?
Bassett: DHLs often use the National
Center on Early Childhood Health and
Wellness’s Checklist for Child Care Staff:
Best Practices for Good Oral Health. Although this handout was intended for child
care staff, the messages are simple and can
help parents and other caregivers understand how nutrition affects teeth. I present
one recommendation from the handout,
for example to serve only 4 ounces of 100%
fruit juice to a toddler, even though sippy
cups are often larger. I then expand on that
point by using visual aids to show parents
exactly how much sugar is in a serving of
100% fruit juice. Something as simple as
filling an empty fruit juice bottle with the
serving size in sugar or sugar cubes is quite
compelling. I also encourage replacing fries
or chips with apple slices and yogurt.
Hoffman: Some parents do not believe that
primary teeth are important and should
be cared for if decay is present, and culture
could be a contributing factor. In our
monthly tip sheets, we stress the importance
of preventing decay in both primary and
permanent teeth by eliminating or greatly
reducing the amount of fruit juice. We suggest placing only breast milk, infant formula
or water in a child’s bottle and never putting
a child to sleep with a bottle. Our tip sheets
recommend limiting snacking to specific
times only.
Leyba: We use the sugar board to show
exactly how much sugar is in the beverages,
but it’s not just beverages — many foods
have added sugars that parents have no idea
about. Cereal, instant oatmeal, applesauce,
granola bars, pork and beans are just a few
foods that contain significant added sugar.
Parents are also shocked to learn the daily
recommendations for carbohydrates and
how most foods exceed those dramatically.
We try to stress proper use of the sippy
cup and encourage only water in sippy cups
and between meals to avoid a constant acid
attack. When children drink sugary beverages out of a sippy cup throughout the day,
that sugar hits the front teeth repeatedly,
and this is the most common site of decay
in Head Start children.
It is very rewarding to know that as
DHLs, we are in a position to share this
kind of life-changing knowledge and also a
good reminder to practice what we preach. I
feel blessed to have the opportunity to serve
in this unique role.
Incorporating Chairside
Blood Glucose Testing As
a Vital Sign in Patient Risk
ost dental professionals are well aware of the increasing
incidence of diabetes and how this endocrine disease can
adversely affect healing and treatment outcomes. However, because awareness without action cannot help dental
patients to clearly understand the bidirectional relationship between
their diabetic and periodontal health status, early diagnosis is more important than ever. Oral health care providers are in the perfect position
to emphasize the oral/systemic connection by performing chairside
blood sugar diagnostics during routine dental appointments.
10 DECEMBER 2019
In 2015, the American Diabetes Association (ADA) stated that that just over 30
million Americans (9.4% of the population)
have diabetes, and nearly 1.5 million new
cases are diagnosed each year. Among those
30 million individuals, 1.25 million have
Type 1 diabetes, and the remainder have Type
2 diabetes. Nearly 7.2 million of those 30
million identified in 2015 were undiagnosed.1
According to 2015 data from the American
Diabetes Association (ADA), diabetes is
ranked as the seventh leading cause of death
in the United States, and it is listed as an
underlying cause of death on nearly 250,000
death certificates each year.
As of 2018, ADA also estimates that one
out of every three adults is at risk for Type 2
diabetes.2 Even worse, ADA reported in 2019
that a staggering 84 million individuals already have prediabetes, most of which is also
undiagnosed.2 While a number of patients
may visit the dental office several times a year,
research shows many of them have not seen
a physician in over 12 months to have their
blood sugar evaluated. This number includes
a rising number of children and teenagers
with Type 2 diabetes.3
Risk factors for developing diabetes are
well documented and include varied responses among different ethnicities and age groups,
according to 2018 ADA data. However, one
variable common to all groups at risk is obesity. Estimates of obesity incidence in adults
over the age of 20 years has steadily increased.
In 1962, it was estimated that 23% of the
population was obese. That statistic reached
over 39% in 1997, 44% in 2004 and over
56% in 2007.4
The primary culprit in America’s weight
gain is sugar consumption, especially sugary
beverages. Research tracking worldwide sugar
consumption places the United States firmly
in first place. In 1915, the average American
consumed approximately 15-20 pounds of
sugar each year. In 2018, that number had
risen to nearly 156 pounds of sugar per year.3
The gold standard for measuring blood glucose is the glycated hemoglobin (HbA1c) test.
The A1c test measures the percentage of hemoglobin that is covalently bound (glycated)
with glucose, giving health care professionals
a three-month average blood sugar level.5 Increased A1c not only helps predict poor blood
sugar control, but it also corresponds to an
increased burden of systemic inflammation.5
A blood A1c score of 6.4% is considered
prediabetic. As non-diagnosed patients see
their A1c score approaching 7%, a future
diabetic diagnosis is increasingly likely.6
Patients can monitor their daily blood sugar levels using spot measurements from blood
glucose monitors. Patients may also utilize
continuous monitoring devices placed subdermally to measure glucose levels in interstitial
fluids.7 Regardless of technique, blood testing
may be performed by the patient daily or
multiple times a day, depending on how well
they control their blood sugar levels.
With a growing number of individuals in
a prediabetic or undiagnosed diabetic state,
it is incumbent upon dental professionals to
incorporate more measures to ensure that
patient readiness for treatment has been adequately evaluated.8 In a study by Greenberg,
et al. (2010), the majority of dental professionals surveyed considered medical screening
(in identifying at-risk patients) an important
assessment tool, and were willing to incorporate such measures into their practices.9
Fortunately, diabetes status assessment is
not difficult to incorporate, taking minimal
appointment time while yielding invaluable
insight into at-risk patients prior to commencement of treatment.8
Also of primary importance is obtaining
patients’ most recent blood panel report,
especially their A1c score.2 Dental professionals’ ability to evaluate recent blood work and
lab reports not only helps to prevent medical
emergencies, but also provides great insight
into possible treatment limitations as well
as the patient’s healing ability after involved
dental procedures.10
Another simple tool to employ is the
American Diabetes Association’s Diabetes
Risk Assessment.2 This one-page survey
scores the individual’s risk for diabetes by
evaluating various measures of susceptibility.
When diagnosed with Type 2
diabetes in early 2018, I was
blindsided. No one in my immediate
family had diabetes, yet I had just
become another statistic in this
horrible disease.
As I struggled to stabilize my
health, it became clear that my
own malady could turn into a prime
learning opportunity for patients
and students. After unanimous
faculty consensus at the beginning
of this past school year, our program
decided to include testing patients’
blood glucose levels as a vital sign
during routine patient assessment.
After devising safe infection
control protocols for using the
monitors, the faculty taught students
to take accurate readings. While this
technique is easy to incorporate into
patient’s health assessment, there is
a learning curve for mastering the
technique. Students have enjoyed
this type of discovery learning, and
the patients appreciate the service.
I am proud of the Broward College
Class of 2019 for enthusiastically
embracing routine blood sugar
testing as part of the patient’s overall
health assessment. Importantly,
this venture provided students and
patients alike with validation of the
direct correlation between high
blood sugar readings and poor
periodontal health and/or healing.
As a personal outreach to my
fellow colleagues: I implore you
to routinely test your own blood
glucose level. The line is thin
between prediabetic and full-blown
diabetes. Awareness is important,
but routine blood glucose monitoring
is the essential component in this
disease’s prevention.
12 DECEMBER 2019
The form could be filled out by the patient
in the reception room prior to the scheduled
appointment time, then evaluated by the
dental professional during the medical history
An important but underutilized technique
of evaluating the patient’s blood sugar control
involves dental chairside blood glucose monitoring.11 Instead of using a lancet to obtain
blood, the clinician simply connects a testing
strip to a properly barriered glucose monitor,
then collects a sulcular blood sample by probing or scaling.12 This noninvasive technique
gives clinicians the potential to identify
patients with undiagnosed blood glucose control problems right in the dental operatory.13
Costs for testing are minimal, including the
cost of monitor ($12-50 range), strips ($.201.00 per strip) and barriers, which could be
simple light handle barriers modified with
autoclave tape to stay closed.
Finally, there are devices available to test
A1c levels chairside. This testing involves a
finger stick, but results can be analyzed within
minutes chairside prior to commencement of
involved dental procedures such as periodontal surgery, quadrant scaling, implant
placement or extractions.14
Dental hygiene programs are in a prime
position to make blood glucose testing part
of routine patient medical assessment. The
simplicity of using readily available blood
makes chairside blood glucose monitoring
1. Centers for Disease Control and Prevention. New
CDC report: More than 100 million Americans have
diabetes or prediabetes. 2017. Available at: https://www.
2. American Diabetes Association. Statistics about
diabetes. 2019. Available at:
3. Centers for Disease Control and Prevention. Prevalence
of obesity among adults and youth: United States 20152016. 2017. Available at:
4. Adeyemi B, Abimbola O, Kolude B. A comparative
study of oral health status in diabetic and non-diabetic
patients. Oral Surg Oral Med Oral Pathol Oral Radiol.
5. Giblin LJ, Rainchuso L, Rothman A. Utilizing a
diabetes risk test and A1c point-of-care instrument to
comfortable and much more likely to be accepted by the patient as a regular assessment
procedure.14 To ensure the accuracy of the
monitor reading, the strip should be placed
into the device just prior to actual testing.
Some monitors may shut off automatically if
the strip is inserted too far ahead of taking the
blood sample. In the time it takes to restart
the monitor, the blood sample may have begun to coagulate, which can cause inaccurate
Anterior teeth are optimal for testing, as
adaption and angulation to any posterior
teeth past the premolars becomes difficult if
not impossible in most patients. The principle
selection criteria should include accessibility
and bleeding facially or in the interdental
space.15 Lack of readily available blood will
usually generate an error message or can
seriously skew the accuracy of readings (most
often as underreporting actual blood glucose
The selected testing area must first be
wiped clean of biofilm, clotting, suppuration
and food debris. Once the testing site is located, it may be necessary to clear the site first
to ensure more accurate reading. Avoid using
clotting blood — it must be flowing freely
when the strip touches it. Gently advance
the strip’s pipette into the blood at an angle
perpendicular to the long axis of the tooth. To
reduce risk of inaccurate test results, take care
to not press the strip against tissue or to allow
suppuration, clotting blood, calculus or other
debris to contact the blood to be tested. Once
the reading is completed, the used test strip
should be discarded in a sharps container.
Dental health care professionals are in a
prime position to help detect patients who
may have issues with blood glucose stability.
While not intended as a definitive diagnostic,
diabetes risk assessment by sulcular blood
glucose monitoring is a simple technique that
can easily be incorporated into routine patient care. Early detection of changes in blood
glucose control can then be relayed to the
patient’s primary physician for follow up.
Barbara Graham Hammaker, CRDH, BASDH, MHSc, holds a master’s degree from Nova
Southeastern University in health science, and
a Bachelor of Applied Science in dental hygiene
from St. Petersburg College. She has over 34
years of private practice experience in south
Florida and over 26 years of dental hygiene and
health sciences educational experience. She has
been the lead professor of Dental Hygiene at
Broward College in Davie, Florida for 10 years.
identify increased risk for diabetes in an educational
dental hygiene setting. J Dent Hyg. 2016; 90(3):197-202.
crevicular blood for assessment of blood glucose in
diabetic patients. J Periodontol. 1993;64(7): 666-72.
6. Guide to HbA1c. 2019. Available at:

Guide to HbA1c

12. Yamaguchi M, Kawabata Y, Kambe S, et al. Noninvasive monitoring of gingival crevicular fluid for
estimation of blood glucose level. Med Biol Eng Comput.
7. American Diabetes Association. Device technology.
2019. Available at:
8. Centers for Disease Control and Prevention. Adult
obesity facts. 2018. Available at:
9. Greenburg BL, Glick M, Frantsve-Hawley J, Kantor
ML. Chairside screening: dentists’ attitudes toward
chairside screening for medical conditions. J Am Dent
Assoc. 2010;141(1):52-62.
10. Lalla E, Kunzel C, Burkett S, et al. Identification of
unrecognized diabetes and pre-diabetes in a dental setting.
J Dent Res. 2011;90(7):855-60.
13. Muller HP, Behbehani E. Screening of elevated
glucose levels in gingival crevice blood using a novel,
sensitive self-monitoring device. Med Princ Pract. 2004;
14. Bossart M, Calley KH, Gurenlian JR, et al. A pilot
study of an HbA1c chairside screening protocol for
diabetes in patients with chronic periodontitis: the dental
hygienist’s role. Int J Dent Hyg. 2015;14(2):98-107.
15. Beikler T, Kuczek A, Petersilka G, Flemmig TF. Indental-office screening for diabetes mellitus using gingival
crevicular blood. J Clin Periodontol. 2002;29(3): 216-8.
11. Parker RC, Rapley JW, Isley W, et al. Gingival
The U.S. Centers for Disease Control
and Prevention (CDC) recognizes
dental hygienists as leading tobacco
cessation experts. For that reason, they
partnered with ADHA to promote
their 2019 Tobacco Cessation
Campaign – Tips From Former
Smokers® (Tips®).
The strategy of the cam
mpaign is to show
real patient cases of peeople whose lives
have been affected by tobacco in some
» Are you a provider and want to
learn more on how to be an effective tobacco cessation expert?
» Are you an educator wanting resources for teaching tobacco cessation to your students?
» Would you like materials to share
Since the initiation of this campaign in
2012, CDC estimates that more than
16.4 million people wh
ho smoke have
attempted to quit and approximately 1
million have quit for go
ood because of
the Tips® campaign
with your patients?
» Need office resources to show in
your operatories or waiting rooms?
ADHA has a brand new website
14 DECEMBER 2019
The use of
electronic cigarettes
has increased by 7% just
in the last year? 20.8%
to 27% among high
school students.
Cigarette smoking is still the
leading cause of preventable
disease and death in the
United States, accounting for
more than 480,000 deaths
every year, or about 1
in 5 deaths.
Current Cigarette Use Among Adults
15.9% –< 19.4% 15.9% AK 22.9% - 26.4% WA MT ME ND VT MN OR ID NH CT MI WY HI PA IA NE NV IL UT MA NY WI SD OH IN DC WV CO KS CA AZ MO 19.4% 19.4% - < 22.9% VA KY NC TN OK NM NJ AR SC MS AL GA LA TX 8.9% 8.9% -

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