Dental Nutrition Assessment

Community College of Philadelphia 24-Hour Recall Form Dental Hygiene Clinic

Patient Name Date

Session Student Name

List all of the foods and beverages that the client consumed in the last 24 hours.

TIME PLACE FOOD AMOUNT PREPARATION Community College of Philadelphia Case Notes Dental Hygiene Clinic

Patient Name ______Student______Date: ______

VISIT I (Assessment )

Rationale for Patient Selection:

Admission Summary:

Personal and Social Information:

Diet History and Current Dietary Practices:

Visit II (Education)

Pertinent Information from Diet Analysis:

Principles Taught:

Visit III (Goals and Follow-up)

Additional Information/Modification of Plan: Comparison/Improvements

Grady/nutdentassessment

Community College of Philadelphia Nutrition Education Summary Sheet Dental Hygiene Clinic

Patient Name Student Name

Folder Number

Visit I Visit II (education only) Visit III

Date ______Age ______Height ______Weight ______DMF ______Plaque Index ______

Food Groups (Total Servings) Bread and Cereal ______Vegetable ______Fruit ______Milk ______Meat ______Fats, Oils, and Sweets ______

Sucrose Exposures ______Non-retentive ______Retentive ______

Vitamin/Mineral Supplements ______Name Type ______

Water Fluoridated ______Non-Fluoridated ______

Oral Hygiene (Times day and when) Brushing ______Flossing ______Swishing ______Community College of Philadelphia Dental Hygiene Clinic

EDUCATIONAL GOALS AND PLAN

Please address your objectives, goals and any usage of visual aids during educational visits.

Gradydentassessment Community College of Philadelphia Diet and Oral Hygiene Relationship Dental Hygiene Clinic

A. The Caries Process

FOOD + BACTERIA = ACID

ACID + SUSCEPTTIBLE TOOTH = DECAY

B. Oral Hygiene Care

Objective: To decrease the amount of food in contact with the tooth and the numbers of bacteria through Brushing, Flossing, Swishing.

Times/Day When BRUSHING FLOSSING SWISHING

C. Fluoride

To Strengthen Teeth a. Fluoride in water b. Topical application of fluoride c. Fluoridated dentifrice WATER ...... Fluoridated Non-fluoridated Amount / day DENTIFRICE ...... Brand Fluoridated

D. Decrease Added Sugar Consumption

a. From 24 hour recall, list food and drinks sweetened with added sugar – Please Circle in red. b. Differences between retentive vs. non-retentive foods sweetened with added sugar.

Sucrose Foods with meals Between meals Foods with Added Sugar Retentive Non-retentive Total added sugar Exposures + =

Potential Acid Production Total Added Sugar Exposures X 20 minutes of AVERAGE ACID PRODUCTION 20 = MINUTES Community College of Philadelphia Diet and Oral Hygiene Dental Hygiene Clinic Modification Prescription

TO AID IN DENTAL CARIES PREVENTION AND PLAQUE CONTROL

Name Date

My diet can be improved by including these foods from the Food Guide Pyramid. Name of foods: When:

My diet can be improved by adding these hard textured foods requiring chewing: Name of foods: When:

My diet can be improved by: Decreasing these foods AND Substituting these foods which sweetened with added do not contain added sugar: sugar:

I will reduce the number of between-meal snacks to times each day.

I will brush my teeth after the following meals and snacks:

I will swish my mouth after the following meals and snacks:

I will floss my teeth

Next appointment: Patient Signature

Student Signature

TG/rm/DAH/Grady/Dental Nutrit Assessmnt/S Drive Community College of Philadelphia Food Guide Pyramid Analysis Dental Hygiene Clinic

Patient’s Name ______

Date ______Student’s Name ______

Food Group Soft/Liquid Hard/Solid Total Recommended Difference Serving Sizes Textured Textured Servings (+,-, ok) Grain (hard crusts) 6-11 1 slice bread ¾ c. – 1 c. dry cereal = 1 oz. Ready-to-eat ½ c. cooked cereal ½ c. pasta/rice/grits 3-4 plain crackers 1 pancake/waffle ½ bagel, hamburger roll ½ English muffin 1 pita Vegetables (crunchy raw 3-5 1 small potato vegs.) ½ c. cooked vegetable 1 c. green leafy vegetable 10 French fries* Fruits (crunchy raw 2-4 ¾ c. fruit juice fruits) 1 medium piece fruit ¼ c. raisins/dried fruit Milk 2-3 1 c. Milk/yogurt/pudding 1 ½ oz natural cheese* 2 oz process cheese* 1 ½ c. ice cream*/ice milk Meat, Poultry, Dry 2-3 Beans 2 ½ - 3 oz. Lean meat/poultry, fish 2 wings, 1 drumstick, thigh 2 hot dogs 2 T peanut butter, 1 egg,* or ½ c. cooked, dry peas, beans = 1 ounce meat Other Foods Butter, margarine, mayonnaise, oils, candy cookies, cake, pie, rich desserts, chips & other salty snacks, jello, fruit drinks, ades, punch, soda *Foods high in fat.