Bon Appétit!
A Caries Puzzle, a Diet Chart, and a Cultural Awakening: How One Patient’s Question Changed My Perspective
As I sat reviewing my patient’s treatment plan at dental school, the tooth chart in front of me displayed thirty-two teeth in the Universal Numbering System. Red markings indicated carious lesions, while black filled the spaces for existing restorations. The chart was nearly full of red. The treatment plan easily stretched beyond two pages. I was focused, immersed in charting out an elaborate restorative plan, when my patient gently interrupted with a question that gave me pause.
She said, “I will get all the work you plan for me, doctor. But I wonder what is causing all this. I like chocolates, but I’m scared to eat them. I brush and floss my teeth twice every day. I still have cavities. Can you help me figure this out?”
She wasn’t wrong. Her oral hygiene was commendable. She had demonstrated excellent brushing and flossing skills when I quizzed her during a prior visit. Her concern was valid, and her confusion, justified. And it really got me thinking.
I remembered the Keyes’ Triad from dental school back in India—a simple, often memorized diagram composed of three intersecting factors: plaque (bacteria), tooth, and diet. It was a staple in exams, yet the depth of its practical application had eluded me until now. I had treated caries countless times, but rarely discussed with patients why they occurred or how to reduce their risk. Some patients were indifferent, others unaware, and the structured treatment planning system in dental school often left little time for such conversations.
Now, immersed in a more dentally aware community in the U.S., I found myself needing to apply the Keyes Diagram in real-time. The three causes weren’t just theoretical—they were a foundation. But to truly help my patient, I had to go deeper, and identify her probable cause for high caries risk.
That same week, one of my professors introduced us to the idea of a Diet Analysis—asking patients to recall everything they ate in a 24-hour period. It was a simple method, yet powerful in identifying cariogenic foods and dietary habits. I gave my patient a ‘One Day Diet Chart’ and what I discovered surprised me.
Her meals reflected the American food environment—convenient, processed, and sugar-laden. It was a stark contrast to what I was used to in India. Breakfast in India was carbohydrate-rich, yes, but typically consisted of home-cooked meals—idlis, dosas, parathas—not bagels, cookies, or donuts. Indian households, like my own growing up, rarely had cold cereals. Pizza was a luxury. Coffee was not consumed in giant mugs with multiple sugar packets. This realization was a cultural awakening.
I began connecting the dots. The foods my patient consumed—sticky cereals, sugary beverages, frequent snacking—created long and frequent exposures to fermentable carbohydrates, feeding acidogenic bacteria in her mouth. Even with good hygiene, the risk of caries was amplified by the diet alone.
I explained this to her. We discussed how reducing the duration of sugar exposure could make a big difference. Simple interventions like rinsing her mouth after meals, brushing when possible, and chewing xylitol gum were added to her routine. She was already flossing. I introduced a high fluoride toothpaste to aid in remineralization and scheduled fluoride treatments every six months during her cleaning visits.
We also explored doing a bacterial analysis to assess mutans streptococci levels, and later conducted a saliva analysis to evaluate flow and viscosity—factors often overlooked but important in caries risk.
That one question from my patient—honest and curious—opened a Pandora’s box. It pushed me to grow not just as a clinician, but as a communicator and cultural observer. I realized how diverse oral health perspectives can be across different societies. Food is central to our lives, but understanding what, when, and how we eat has a profound impact on our dental health.
Completely banning chocolates and sweets isn’t practical—or fair. I learned that moderation, along with post-snack oral care, was a more realistic and widely accepted solution. Over the next few months, I saw changes in my patient. She followed my recommendations, adjusted her diet, and remarkably, remained caries-free for the next two years—up until our last follow-up.
The diet chart wasn’t perfect, but it made a big impact. For those motivated to change, it proved to be a turning point. They could enjoy their favorite foods—without guilt, and without cavities.
And isn’t that what we all want?
Bon Appétit!
Author: Dr. Meenakshi Umapathy, a dedicated General Dentist, embarked on her professional journey in India before expanding her horizons in the United States. She earned her Doctor of Dental Surgery (DDS) from the esteemed New York University College of Dentistry and now specializes in pediatric dentistry in Indiana. Since 2017, she has been a valued practitioner at Monarch Dental, bringing her expertise and compassionate care to young patients.
Through her evocative narratives, Dr. Umapathy shares her rich experiences practicing in both India and the U.S., offering profound insights into the evolving landscape of dentistry. Her blog, originally published on DentistryUnited.com in 2012, has been thoughtfully republished, ensuring that her wisdom continues to educate and inspire dental professionals and enthusiasts alike.