Nutrition Education and Practice in University Dental and Oral Health Programmes and Curricula: A Scoping Review

ABSTRACT

Introduction

Dentists and oral health practitioners have a potential role in supporting the prevention and management of noncommunicable diseases. However, the extent to which university education prepares practitioners to provide nutrition care is unclear. This scoping review identifies and synthesises the evidence related to university‐level nutrition education provided to dental and oral health students globally.

Methods

A scoping review identified relevant literature through search terms “dentistry,” “oral health,” or “oral hygiene”; “dental students” or “dental education”; “nutrition education” or “nutrition science.” Articles were included that examined nutrition education in undergraduate oral health training; or nutrition knowledge, attitudes, confidence, or skills or dietary habits; experts' opinion papers; and position statements. No limitations on the publication years or languages of the articles were applied.

Results

A total of 136 articles were included. Half were surveys of students (n = 49) or academic staff (n = 21). The remainder comprised reports of curriculum initiatives (n = 26), opinion papers or narrative reviews (n = 24), position statements (n = 6), curriculum development (n = 6) and curriculum guidelines (n = 9). While dental and oral health students and curriculum experts overwhelmingly recognised the importance of nutrition, most studies that assessed nutrition knowledge of students revealed limited knowledge. Students were not confident in their skills to provide nutrition care. Lack of nutrition experts on teaching teams and unclear expectations about developing nutrition competencies were identified as barriers to greater nutrition education.

Conclusion

Nutrition education in university dental and oral health degrees is highly variable. The potential for oral health professionals of the future to promote oral health through nutrition is unrealised.

1. Introduction

Poor oral health is a worldwide public health problem [1, 2]. Oral diseases are the most prevalent health condition [3], affecting approximately 3.5 billion people globally [4]. Preventing poor oral health through health promotion is increasingly recognised as worthwhile, including a focus on healthy eating, good oral hygiene practices and regular dental visits [5]. Oral healthcare integrates into primary care systems worldwide to meet the diverse healthcare needs of the ageing population [6]. Therefore, oral health practitioners of the future will be expected to provide more comprehensive, preventive care [7, 8] and ongoing interaction with patients [9]. Nutrition care is defined as an interaction focused on nutrition (including assessment, counselling and advice) provided by a health professional to improve a patient's health [10]. Through oral examinations, oral health practitioners can screen for nutrition‐related oral conditions (e.g., diabetes) and provide nutrition care [11, 12] to prevent disease progression.

Recent research suggests that oral health practitioners (dentists, dental therapists and hygienists) do not routinely discuss nutrition or healthy eating with their patients. A recent survey in the United Kingdom (UK) showed that although two‐thirds (66%) of dentists in the UK report nutrition is essential for periodontal health, only 14% report discussing the role of healthy eating in periodontal disease management with their patients [13]. A similar proportion of United States (US) dentists reported nutrition is important, but few reported providing nutrition care to patients [14]. Moreover, for dentists who provide nutrition care in their practice, 40% discussed nutrition for 2 min or less, limiting the opportunity for meaningful impact [14]. Most (78%) dentists and dental specialists report being asked nutrition‐related questions by their patients, but few (30%) report feeling confident about their nutrition knowledge [15]. Barriers to providing nutrition care include lack of time [14], lack of reimbursement for the service [16], lack of skills in communication [17] or nutrition counselling [14], uncertainty and lack of awareness about the evidence base for nutrition and dental disease [18] and lack of training in nutrition [17]. Many oral health professionals report being ill‐equipped to provide adequate nutrition care [19] and are unable to offer this care [16, 17].

Since the 1940s, including nutrition education in dental schools has been recommended [20, 21], and the American Dental Association recommends promoting healthy eating for oral health benefits [22]. However, little is known about the delivery of nutrition education in tertiary dental and oral health programmes (including dental therapy, dental hygiene and oral health therapy), despite the link between diet and nutrition and the mouth, teeth and gums. Therefore, this scoping review aimed to identify and synthesise evidence related to nutrition education provided to university dental and oral health students globally.

The aims of this review were as follows:

1. How has nutrition education been implemented in dental and oral health programmes? What and how is it taught? Have competencies been developed?

2. Have specific competencies (defined by the National Institutes of Health as ‘knowledge, skills, abilities and behaviours that contribute to individual and organizational performance’) [23] relating to nutrition and oral health care been identified?

3. What are the barriers to teaching nutrition in dental and oral health programmes?

4. What are dental and oral health students' knowledge of and attitudes towards receiving nutrition education during entry‐level training?

5. If nutrition education has been implemented, how have nutrition education initiatives been evaluated, and what outcomes have been reported?

2. Methods

2.1. Overview

A scoping review was undertaken to answer the broad research question: ‘What is currently known about nutrition education provided to dental and oral health students?’, with attention to the five specific questions outlined above. The scoping review aimed to ‘systematically identify and map the breadth of evidence available on a particular topic, field, concept or issue, …’ [24] in line with the JBI definition of scoping reviews. The review followed a protocol in accordance with the JBI methodology for scoping reviews [25]: (1) defining the research objective(s) and question(s); (2) developing inclusion criteria (population, concept and context, and types of evidence sources) based on the research objectives and questions; (3) describing the search strategy, selection, data extraction and presentation; (4) searching for the evidence; (5) selecting the evidence; (6) extracting the evidence; (7) analysing evidence; (8) presenting the results; and (9) summarising the evidence in relation to the purpose of the review [25]. The review was registered in PROSPERO (CRD42022342876).

2.2. Study Criteria

The Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) flow diagram (Figure 1) shows the search strategy, study selection procedure and screening process. The reason for excluding articles was documented and is presented in Figure 1. Table 1 describes inclusion and exclusion criteria for articles aligned with the PCC (Population, Concept and Context) format [25] in the scoping review.

FIGURE 1.

PRISMA flow chart for scoping review on nutrition education in dental and oral health curricula.

TABLE 1.

Inclusion and exclusion criteria.

Inclusion criteria	Exclusion criteria
Population Articles about dental or oral health students (including postgraduates and new graduates if the focus of the study was on undergraduate experience)	Articles about practising dentists or oral health professionals exploring their current practice Articles included dental or oral health students as well as other discipline students that the results did not differentiate dental or oral health students from other students
Concept Articles that reported content and teaching related to nutrition in dental and oral health programmes Articles that reported knowledge; attitudes; practices; behaviours about nutrition or diet Articles that evaluated existing nutrition education in dental or oral health programmes	Articles not about nutrition (e.g., smoking) Nutrition education in other professional programmes (e.g., medical schools and nursing)
Context Peer reviewed journal articles about nutrition education in tertiary dental or oral health programmes Curriculum guidelines or position papers about nutrition education in dental or oral health programmes	Conference abstract, conference poster; conference proceedings Theses Textbook chapters Articles that were unable to be retrieved through the University library services

A three‐step search strategy [25] was applied. A preliminary search was conducted between May and June 2022 in two online databases (MEDLINE (Ovid) and Scopus). A university librarian helped develop a search strategy and search terms. Text words contained in the title and abstracts were identified, including any index terms that could be used as alternative search terms (Appendix S1). Using these terms, another search was conducted in selected databases MEDLINE (Ovid), Embase (Ovid), Scopus, ERIC (Educational Resource Information Centre), Education Research Complete (EBSCO), CINAHL and Cochrane Database of Systematic Reviews in July 2022. This search was updated in May 2024. Additionally, the reference lists of all identified review articles were examined to find relevant studies that met the inclusion criteria. To maximise the rigour, the Journal of Dental Education was hand searched to confirm that relevant studies were included in the search results. Using the search terms, grey literature in Google Scholar was identified (Appendix S1). Appendix S1 includes the full search strategy including the relevant databases used for the study along with the inclusion/exclusion criteria.

All articles were collated and uploaded into Endnote20 software (Clarivate Analytics, PA, USA) [26], and citation details were imported into Covidence software (Veritas Health Innovation, Melbourne, Australia) [27], where duplicates were removed. Five authors (M.K., R.M., L.A., L.B. and J.C.) independently screened the titles and abstracts in duplicate against the inclusion and exclusion criteria. Each article was screened by two reviewers. The lead author (M.K.) screened all articles, and the other four authors (R.M., L.A., L.B. and J.C.) screened approximately a quarter of the articles each.

The articles published in non‐English languages were translated using Google Translate (https://translate.google.com) and assessed if they met the inclusion criteria. If the abstract did not provide enough information to make a decision, the full text of the article was obtained for review. Any differences in screening decisions were resolved through group discussions. Then, all remaining articles were retrieved in full. Two reviewers (M.K. and R.M.) independently assessed these against the inclusion and exclusion criteria (Table 1). Discrepancies that arose between the reviewers were resolved through discussion until consensus was reached.

2.3. Data Extraction

One reviewer (M.K.) extracted data from the included articles using a data extraction tool developed by the review team (Appendix S2). Data were extracted on the author(s), year of publication, country of study, study title, study aims, study design, study participants, sample size, study methodology and key findings regarding the research questions. Any disagreements were resolved through discussion.

2.4. Data Analysis

Since this is a scoping review, we did not assess the risk of bias of individual studies to be consistent with the proposed scoping review methodology [25, 28]. We conducted a basic descriptive analysis that involved frequency counts of populations, concepts and contexts. The results of the descriptive analysis are in tables. We used descriptive qualitative techniques [25], categorising the retrieved articles according to our five research questions outlined in the Introduction, as well as the JBI research methodologies.

3. Results

3.1. Selection and Characteristics of Sources of Evidence

The database and hand searches identified 4658 articles for potential inclusion, as shown in Figure 1. After removing duplicates and screening by title and abstract, 211 full texts were retrieved for further consideration. Of these, 136 articles met the inclusion criteria of this scoping review. Reasons for the exclusion of the 75 articles are provided in Figure 1. Of the included articles (n = 136), around half were surveys of students (n = 49) [9, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76] or academic staff (n = 21) [21, 32, 39, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94], and the remainder comprised reports of curriculum initiatives (n = 26) which include intervention and evaluation studies [11, 80, 91, 95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117], opinion papers or narrative reviews (n = 24) [6, 12, 20, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131, 132, 133, 134, 135, 136, 137, 138], position statements (n = 6) [8, 139, 140, 141, 142, 143], curriculum development (n = 6) [104, 144, 145, 146, 147, 148] and curriculum guidelines (n = 9) [6, 149, 150, 151, 152, 153, 154, 155, 156]. Of the 49 surveys of students, almost all involved undergraduate dental students (n = 46), four involved postgraduate dental students [32, 50, 57, 65], five involved interns or residents [50, 51, 60, 64, 65], and three surveyed graduates about their undergraduate education experiences [32, 33, 51]. Three surveys were conducted among undergraduate dental hygiene students [36, 49] or oral health students [44].

More than half of the 136 articles were published in the US, followed by India (n = 11). All 11 articles from India were surveys of students [9, 42, 45, 48, 50, 51, 56, 57, 59, 60, 65]. Three‐quarters of the surveys of academic staff focused on dental schools (n = 15) [21, 32, 39, 77, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 90], while the remainder focused on dental hygiene or oral health schools (n = 7) [78, 84, 89, 91, 92, 93, 94]. There were no studies involving dental therapy programmes. Over half of the 136 articles (n = 69) were published between 1940 and 2010. Of the remaining 67 articles published after 2010, most (n = 39) were published between 2010 and 2019 [6, 9, 11, 12, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 89, 90, 91, 92, 107, 108, 109, 110, 111, 134, 135, 136, 137, 142, 143, 148, 152, 153, 154, 155, 156].

3.2. Implementation of Nutrition Education Into Curricula

Twenty‐one surveys of academic staff [21, 32, 39, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94] described how nutrition is incorporated in dental and oral health curricula. Of the 21 surveys, two were qualitative studies [80, 94] and two were mixed methods studies [91, 92]. Sixteen surveys reported cumulative hours of nutrition education [21, 32, 77, 78, 81, 82, 83, 87, 93] and aspects of nutrition care [21, 77, 78, 80, 82, 83, 86, 87, 88, 89, 91, 93] such as nutrition counselling (Table 2). Three surveys reported that around 60%–70% of US and Canadian dental schools provided nutrition education to students [21, 81, 82]. The reported mean hours of total nutrition education across programmes (7 dental and 2 dental hygiene and oral health programmes) varied between 14 and 29 h, while the range of total number of hours was 10–60 h per programme [81] (Table 2).

TABLE 2.

Overview of studies that examined hours of nutrition taught.

Author; Year	Country	Survey participants	Response rate	Number of the schools responded about hours (percentage of the respondents)	Mean hours of total nutrition education (ranges)
Dental schools (n = 7)
ADA 1940 [78]	US	39 deans	89%	35 schools (90%)	NS (8–34 h)
Hadjimarkos 1948 [21]	US	35 deans	88%	22 schools (63%)	17 h (16–36 h)
DePaola et al. 1982 [81]	US Canada	53 deans 9 deans	90%	62% 67%	20 h (10–50 h) 29 h (10–60 h)
Ng et al. 1984 [82]	Canada	10 dental schools	100%	7 schools (70%)	22 h (10–30 h)
Beeley 1986 [83]	UK and Ireland	15 dental schools	83%	NS	14 h (6–34 h)
Beeley 1991 [32]	26 European countries	99 dental schools	53%	All 99 schools UK and Ireland France Netherlands	17 h 10 h 8 h (0–30 h) 44 h
Beeley 1997 [87]	18 European countries	58 dental schools	36%	NS	22 h (2–50 h)
Dental hygiene or oral therapy schools (n = 2)
Leske et al. 1968 [78]	US	56 dental hygiene schools	90%	55 schools (98%)	52 h (91% had ≥ 24 h)
Franks et al. 2021 [93]	AUS	Academic staff of 6 oral therapy programmes	86%	6 schools (100%)	(10–15 h)

Abbreviations: ADA, American Dietetic Association; AUS, Australia; h, hours; NS, not specified; UK, the United Kingdom; US, the United States.

The year(s) of the programme where nutrition education was included varied widely across studies, as did whether nutrition was taught as a stand‐alone subject or integrated into several subjects [21, 77, 78, 80, 82, 93]. From the six studies, three of the surveys found some schools included nutrition across 3 years [77, 80, 93], and the other three surveys found nutrition was taught in only 1 or 2 years during their programmes [21, 78, 82].

Among five surveys that investigated dental schools in the US and Canada, 50%–70% of schools reported having a separate nutrition course [21, 77, 79, 81, 82] whereas, all of the 15 surveyed dental schools in European countries investigated nutrition courses integrated into other subjects [83]. From the studies on US dental hygiene schools, two surveys reported over 90% of schools having nutrition as a separate course [78, 91]. In contrast, a more recent survey in Australia found that five out of six oral health programmes provided nutrition education through several subjects [93]. Although the response rates of surveys were very high (> 80%), those with high response rate were either in the US or Canada. Most surveys (Table 2) were conducted a few decades ago (between 1940s and 1990s). A lack of studies in countries outside North America and Europe and recent years limits the interpretation.

Table 3 outlines the focus of nutrition education provided in surveyed schools. Most of the 21 surveys of academic staff examined whether clinical or applied nutrition training existed in dental [21, 32, 39, 77, 80, 81, 82, 83, 88, 90], dental hygiene [78, 86, 89, 91] or oral health [93] programmes (Table 3). Thirteen surveys identified that more than 40% of the responding schools taught clinical nutrition, while two surveys of dental hygiene schools reported no or little input of applied nutrition [86, 91]. However, aspects within clinical nutrition varied greatly, for example, assessing patients' diet intake [21, 93] or patients' nutrition status [87, 88, 91], dietary assessment [87] or counselling [88], and communicating with patients [39, 93] (Table 3). A survey of 169 dental hygiene schools in eight countries showed that the proportion of dental hygiene schools that provided dietary counselling varied among countries and ranged from 29% of dental hygiene schools in Japan to 100% in Sweden and Denmark [89]. Study limitations included the absence of a definition of clinical nutrition, as many surveys did not provide a specific definition [77, 80, 81, 82, 83]. Moreover, the information on how clinical nutrition was taught (e.g., in lectures, tutorials or clinics) and the number of teaching hours were limited.

TABLE 3.

Clinical/Applied nutrition training included in dental and oral health schools.

Author; Year	Country	Surveyed schools	Schools taught	Type of nutrition training	Mean hours dedicated to clinical/applied nutrition
Dental schools (n = 11)
ADA 1940 [77]	US and Canada	35	19	Nutrition teaching in clinics	NS
Hadjimarkos 1948 [21]	US	35	20	Evaluate patient's diets	NS
Bozdech et al. 1978 [80]	US	1	1	Applied and technical nutrition	NS
DePaola et al. 1982 [81]	US Canada	53 9	37 4	Clinical nutrition	7 h (1–22 h) 16 h (2–25 h)
Ng et al. 1984 [82]	Canada	10	4	Nutrition in clinical practicum	3 h
Beeley 1986 [83]	UK	15	15 a	Aspects of nutrition in the clinical course	3 h
Beeley 1991 [32]	UK and Ireland	18	16	Preclinical (biochemistry, physiology) Clinical (preventive dentistry, child dental health)	6 h 4 h
Beeley 1997 [87]	UK and Ireland	17	14	Clinical nutrition Take diet diaries and assess students' own nutritional intake; assess the statues of patient's nutrition; and give dietary advice	6 h
	17 European countries (incl. UK and Ireland)	59	59	Clinical nutrition	8 h
Touger‐Decker et al. 2001 [88]	US	44 44 43	23 16 4	Nutrition screening; Assessing patient's nutritional health; Prescribing modified diets	NS
Hermont et al. 2011 [39]	Brazil	84	74	Communication about tooth erosion and diet	NS
Yuan et al. 2012 [90]	US	62	34	Questions about weight, height and BMI in practice (0 h)	0
Dental hygiene schools (n = 5)
Leske et al. 1968 [78]	US	52 52	41 10	General concept of nutrition Patient‐oriented instruction in nutritional activities	NS
Afifi et al. 1996 [86]	Kuwait	2	2	Basic nutrients; and nutrition and health. No applied nutrition (e.g., counselling, nutrition assessment/ education, diet therapy or meal planning)	NS
Inukai et al. 2012 [89]	8 countries US, Canada, UK, Sweden, Denmark, Thailand, South Korea and Japan	1 US 9 Denmark 4 Sweden 10 Canada 29 Japan	1 9 4 8 3	Dietary counselling	NS
Johnson et al. 2016 [91]	US	55 55 55 55	43 41 3 1	‘Minimal’ of Patient contact opportunities ‘Greater than average’ of Applied nutrition elements and oral relationships ‘Average’ of Integrated nutrition assessments ‘Greater than average’ of Required comprehensive nutrition care plan for one patient each semester for 3 semesters	NS
Franks et al. 2021 [93]	AUS	6 6	6 4	Assessing diet and nutrition in the clinical environment Assessing students on dietary component when targeting patients on placement	NS

Abbreviations: AUS, Australia; BMI, Body Mass Index; h, hours; NS, not specified; UK, United Kingdom; US, United States.

^a Including school(s) taught 0 h of clinical aspect.

3.3. The Need for Nutrition Education

Several opinion papers described the importance of nutrition education in dental schools [20, 118, 129, 134, 135], incorporating applied or clinical nutrition as well as education regarding basic nutrition concepts [20, 118, 119, 120, 121, 122, 125, 127, 128, 131, 132, 135, 137]. The most frequently suggested aspect of clinical nutrition to include in university training was nutrition counselling (n = 8) [20, 122, 125, 127, 128, 131, 137, 138], although other skills (e.g., screening, nutrition assessment and motivational interviewing) were also encouraged [47, 87, 88]. While the majority of respondents from the 43 US dental schools felt students performing nutrition screening (74%) and nutrition assessment (63%) in practice were necessary, less than 40% felt counselling patients on modified diets was necessary [88]. Articles published after 2010 were more likely to emphasise nutrition education as part of interprofessional education [6, 12, 134, 135] or incorporating behaviour change theories or techniques [108, 114, 138, 156].

3.4. Students' Knowledge of and Attitudes Towards Nutrition Education

3.4.1. Knowledge

Half of the 49 surveys of students reported on nutrition knowledge among dental students (n = 24) [9, 30, 31, 32, 37, 38, 39, 40, 42, 45, 46, 48, 49, 50, 51, 52, 54, 56, 57, 58, 59, 60, 61, 65]. While dental students described the importance of nutrition education [29, 36, 47, 51, 60, 65], most surveys that objectively assessed nutrition knowledge in dental or oral health students revealed limited nutrition knowledge. Surveys revealed that dental students had inadequate knowledge about micronutrients [42, 46], polysaccharides [9] or dietary habits [39]. Other surveys demonstrated that students had variable nutrition knowledge [51, 54, 57, 60].

Two intervention studies assessed students' nutrition knowledge after receiving nutrition education and found little improvement occurred [97, 103]. Conversely, four studies demonstrated some knowledge gain after receiving nutrition education [11, 99, 107, 115]. Recent nutrition intervention studies in the US tested web‐based nutrition modules and demonstrated a significant increase in nutrition knowledge [11, 107]. The interventions in these studies varied by design and length and were focused on specific topic, such as screening alcohol consumption [107] and secondary prevention of disordered eating behaviours [11].

3.4.2. Attitudes

Ten surveys investigated students' attitudes towards nutrition in dental or oral health programmes [29, 36, 37, 42, 45, 47, 51, 63, 65, 66]. All of the surveys studied dental students except one that studied dental hygiene students' practice [36]. Four relatively recent surveys conducted in India relatively recently (2016 or later) [45, 51, 60, 65] reported that the majority of the students identified nutrition as an essential part of health care [45, 65], or believed dietary counselling supports positive oral health [9, 45, 50, 51, 60]. Dental students believed assessing a patient's diet was an important part of their clinical practice [36]. In a survey in Iran, dental students with the highest scores on nutrition knowledge tests were more likely to have a positive attitude towards caries prevention [37]. In a survey in Japan, two‐thirds of dental students reported they wanted more nutrition education [63]. Dental students felt that they did not receive enough nutrition education during their training [32, 36, 60].

3.4.3. Perceived Competence and Confidence in Nutrition Care

Table 4 illustrates dental or oral health students' self‐perceived competence and confidence in nutrition care. Eight surveys assessed students' self‐perceived confidence [36, 40, 45, 47, 114], comfort [36, 66, 114] or competence [37, 47, 52] in providing dietary advice (Table 4). Of the three surveys that assessed self‐perceived competency, two surveys from Iran and Turkey showed that less than half of the dental students felt competent to conduct nutrition counselling [37, 52]. Dental students in Switzerland did not increase their self‐reported competence in nutrition care after 2 clinical years [47]. In contrast more than two‐thirds of US dental students felt comfortable discussing diet and nutrition with parents and caregivers of children [66]. However, the same study revealed that only 27% of students felt comfortable discussing obesity prevention [66]. Similarly, another survey showed that dental and dental hygiene students felt uncomfortable asking obese adult patients about their dietary habits [36]. Reasons for discomfort were a lack of education about obesity, stigma towards obese people (e.g., lack of willpower), peers' and clinical instructors' negative attitudes about obesity [36], and appearing judgmental and fear of offending patients [66]. Consequently, one‐third of students did not discuss obesity when clinically indicated [66]. A survey of 34 dental school deans in the US reported limited awareness of obesity issues in dentistry [90]. Only 20% of academic staff were familiar with the effect of obesity on oral health [90]. More recently, an intervention of a short PowerPoint presentation on obesity and its treatment helped dental students feel less uncomfortable asking obese patients about their dietary habits [115]. Dental hygiene students were reported that they increased their comfort and confidence after a nutrition module combined with motivational interviewing [114]. The self‐report nature of the surveys on knowledge, attitudes, and confidence or competence, as well as the use of survey questionnaires that were not validated and/or pilot tested, limit the interpretation of the study results.

TABLE 4.

Dental or oral health students' self‐perceived competence, confidence, comfort and practice of providing nutrition care.

Surveys of students	Country	Study sample	Perceived confidence/competence; or practice
Competence (n = 3)
Khami et al. 2007 [37]	Iran	Dental students (n = 270)	47% felt competent to provide preventive dental care (incl. dietary counselling)
Rindlisbacher et al. 2017 [47]	Switzerland	Dental students (n = 157)	Competence in modifying patient's diet remained unchanged throughout two clinical years
Pinar Erdem et al. 2019 [52]	Turkey	Final year dental students (n = 126)	47% felt competent to conduct nutrition counselling
Comfort (n = 4)
Magliocca et al. 2005 [36]	US	Dental students (n = 387) DH students (n= m77)	31% comfortable asking obese patient about their dietary habits
Smith et al. 2021 [66]	US	Dental students, Y2 (n = 101)	23% felt discomfort to discuss obesity prevention with caregivers of children
Anderson et al. 2023 [114]	US	Senior DH students (n = 22)	Comfort with nutrition counselling significantly increased after nutrition and MI education followed by 3‐week practice
Biary et al. 2024 [115]	US	Dental students: Y1 (n = 34)	Significantly more students reported feeling less uncomfortable asking dietary habits of obese patients
Confidence (n = 5)
Magliocca et al. 2005 [36]	US	Dental students (n = 387) DH students (n = 77)	< 40% confident to define WHO classification of obesity
Shah et al. 2011 [40]	UK	Dental students (n = 74)	65% confident, but only 18% based their advice on evidence
Sivakumar et al. 2016 [45]	India	Dental students (n = 220)	30% felt not having confidence in diet counselling patient
Rindlisbacher et al. 2017 [47]	Switzerland	Dental students (n = 157)	High level of confidence in communicating with patients
Anderson et al. 2023 [114]	US	Senior DH students (n = 22)	Confidence in nutrition counselling significantly increased after nutrition and MI education followed by 3‐week practice
Practice of nutrition care (n = 10)
Tseveenjav et al. 2002 [34]	Mongolia	Dental students: Y3–Y5 (n = 79)	46% provided nutrition counselling at least often
Tseveenjav et al. 2003 [35]	Mongolia	Dental students: Y3–Y5 (n =  73)	Frequency of nutrition counselling increased from Years 3 to 5
Hayes et al. 2016 [44]	AUS	DH students: Y3 (n = NS)	Frequency of providing dietary advice was 7% of 1189 patients received dietary advice (≥ 15 min)
Sivakumar et al. 2016 [45]	India	Dental students: Y5 (n = 220)	21% took patients' diet history 27% provided diet advice 34% gave diet counselling ‘often’
Chavan et al. 2019 [50]	India	Dental students: Y1, interns, and postgraduate (n = 647)	≥ 85% counselled patients about healthy dietary practices
da Costa et al. 2019 [51]	India	Dental students: Y3 and Y4, and residents (n = 203)	68% ‘always’ counselled patients with caries risk
Ram et al. 2021 [65]	India	Dental students: Y1–Y4, postgraduate and Interns (n = 100)	Only 36% counselled patients ‘always’, 48% ‘sometimes’
Smith et al. 2021 [66]	US	Dental students: Y2 (n = 101)	68% discussed nutrition but 33% did not discuss obesity prevention (self‐reported)
Abdullah et al. 2021 [60]	India	Dental students: Y3–Y5 (n = 175)	71% ‘always’ counselled patients with high dental caries risk, but only 64% believed dietary counselling is important to prevent dental caries
Anderson et al. 2023 [114]	US	Senior DH students (n = 22)	68% (n = 15) reported an increase in nutrition counselling in their practice after nutrition and MI education

Abbreviations: AUS, Australia; DH, dental hygiene; MI, Motivational Interviewing; NS, not specified; UK, United Kingdom; US, United States; Y, year.

3.5. Students' Nutrition Practice and Their Dietary Habits

3.5.1. Nutrition Practice

Nine surveys of students described nutrition care in practice [34, 35, 44, 45, 50, 51, 60, 65, 66] (Table 4). Of the nine surveys, only one studied dental hygiene students' practice [44]. In an audit conducted on Australian dental hygiene students that assessed over 1000 patient records of Year‐3 oral health students over 12 months, it was identified that only 7% of the patients were counselled by dental hygiene students (at least 15 min) about their diet [44]. According to two recent studies audited patients' records taken by dental students, nutrition counselling was provided in < 1% of the patients [113, 116]. A recent study of 39 dental hygiene students included a pre‐and postsurvey for a course in nutrition and motivational interviewing [114]. Following the course, students were asked to practice nutrition counselling with their patients for 3 weeks. Postsurvey results demonstrated that 68% of the students increased nutrition counselling sessions [114].

3.5.2. Dietary Habits

Twelve surveys explored students' own dietary habits [38, 41, 43, 46, 53, 55, 58, 59, 62, 63, 64, 67]. All surveys studied dental students. Ten of the 12 surveys showed that students' self‐reported diet included foods or drinks high in calories or sugar, such as fast foods [53, 59], sugar‐sweetened or acidic beverages (including sports drinks) [41, 43, 58, 72], sugar [38, 53, 58, 64, 76], and in‐between meals snacking regularly [41, 71]. Three surveys reported that students self‐reported having moderately healthy eating habits [55]. A US survey showed that students' intakes of all food groups except fruit were lower than recommended [62]. Messer and Calache concluded that students did not apply their nutrition knowledge to improve their own diet [41].

3.6. Barriers to Including Nutrition Education in Dental or Oral Health Training

Students and academic staff identified a lack of teaching [32, 66, 78, 80, 94] or training [44, 45, 85] in nutrition. Eight surveys of academic staff reported that the most common reason for this lack of teaching was not having a staff member within the department the necessary skills and qualifications in nutrition [39, 77, 85, 88, 91, 93, 133, 137]. As early as the 1940s, the proportion of nutrition experts in dental schools has always been reported as low [137]. In the early 2000s, one in five US dental schools had a dietitian in their teaching team [88]. In 2019, having a qualified staff member to teach nutrition in dental or dental hygiene schools in the US was still rare [137]. Academic staff of US dental hygiene programmes commented, ‘there is no time to review evidence‐based material’ in nutrition [91]. An Australian survey examining six oral health programmes did not identify any nutrition‐qualified academic staff in any programmes, although their programmes had some external input from nutritionists or dietitians, which was supplementary to curriculum design [93].

Seven of the 24 expert opinion papers addressed the status of nutrition education in dental curricula [6, 12, 132, 133, 134, 135, 138]. Nutrition was generally undervalued [133, 134] or less prioritised [135] in dental programmes. While 13 opinion papers suggested curricula should include applied [20, 119, 120, 121, 122, 128, 137] or clinical [118, 125, 127, 128, 131, 132, 135] nutrition, no specific definitions of applied or clinical nutrition and the skills students were expected to obtain were identified in these articles. In general, clinical nutrition included practical experiences in clinical practice such as nutrition assessment and education [125, 127, 131], and providing supervision for students' practice [127, 128]. However, most of the 55 dental hygiene programmes in the US had varied scope and practice for nutrition content and inconsistent learning objectives [91]. A lack of guidance for assessing nutrition competency by the Commission on Dental Accreditation (CODA) in the US was identified [94, 138]. Among academic staff, understanding of applied nutrition and patient contact opportunity varied from nutrition care for every patient to no opportunities for application [91]. Lack of calibration in nutrition education among educators was also raised as a barrier [94].

3.7. Recommendations for Nutrition Education in Position Statements

Six position papers about oral health and nutrition were identified in this review [8, 139, 140, 141, 142, 143]. Five of them were published by the Academy of Nutrition and Dietetics (previously known as the American Dietetic Association). The position statements about oral health and nutrition remained the same in 1996 [139], 2003 [8], and 2007 [141], emphasising the integration of nutrition with oral health and encouraging oral health professionals to learn to provide nutrition screening, baseline education and referrals for in‐depth services of dietitians as part of comprehensive patient care [8, 139, 141, 143]. The National Heart, Lung and Blood Institute emphasised the importance of nutrition education in health professional programmes, including dental and oral health programmes [142]. Nevertheless, since 2012, no other published position statements on nutrition education or training from oral health professional organisations were found. This limits our understanding of the recent attitudes of oral health professional organisations towards nutrition in their profession.

3.8. Curriculum Guidelines

Nine curriculum guidelines related to nutrition were identified [91, 150, 151, 152, 153, 154, 155, 156, 157]. All were from the US (n = 7) [149, 150, 151, 153, 154, 155, 157] or Europe (n = 2) [152, 156]. Four guidelines focused on dental curricula [150, 152, 156, 157], and three applied to dental hygienists or allied dental education programmes [149, 151, 155] (including dental hygiene, dental therapy, dental assisting and dental laboratory technology) [158]. The latter three were published in the US. Two guidelines described nutrition competence in dental caries prevention and management [152, 154]. Nutrition knowledge and skills were endorsed in cardiology guidelines and identified that dentists must have knowledge and competence to assess patient's diets and provide nutrition care [152]. In Europe, nutrition knowledge, dietary analysis and advice were described under patient care [156]. The US guidelines only briefly included nutrition under health promotion [155, 157].

The guidelines for dental hygienists [149] or allied dental education programmes [151, 153] were published by the same US organisation (i.e., American Association of Dental Schools (AADS) or American Dental Association (ADEA)) [159]. The oldest guidelines, published in 1984, were specific to biochemistry and nutrition and included more detail [149] than the later guidelines (i.e., basic principles and application of nutrition including 13 nutrition knowledge and skills statements). Clinical nutrition skills were also clearly described in more recent guidelines (e.g., determining which patients would benefit from nutrition counselling, assessing and evaluating patients' diets and providing nutrition counselling) [149]. More recent ADEA guidelines revised the 1984 guidelines and included patient‐centred wording (e.g., identifying the priority nutrition issues and enlisting the patient in setting small measurable goals) [151, 153] and the nutrition care process (including nutrition screening, assessment, counselling and referral) [153]. These clinical nutrition skills were suggested in addition to teaching basic nutrition knowledge. Limitations of these guidelines were that they were primarily published in the US, and there are no recent updates of curriculum guidelines that contain nutrition education after 2017. Six opinion papers [6, 128, 132, 134, 135, 136] and three surveys of academic staff [88, 91, 94] addressed the need for nutrition competencies in dental programmes. Barriers to effective nutrition education included: lack of guidance from the accrediting organisation on how nutrition can be implemented and assessed [91, 94], lack of autonomy of the programme directors to modify overloaded curriculum [94], fragmented curricula [151], lack of consensus on what the aim should be [85], and different scopes and extent of teaching among schools [91, 93].

4. Discussion

This scoping review synthesised evidence about nutrition education provided to dental and oral health students. Overall, nutrition education is inadequate in dental and oral health programmes and poorly integrated into curricula. The included studies show that the importance of nutrition education in dental and oral health programmes has been acknowledged since the 1940s [20, 21, 77]. Nevertheless, the reviewed articles demonstrate a perpetual challenge of inadequate nutrition education, ultimately suggesting that oral health professionals of the future are not well‐equipped to reach their potential in promoting oral health through nutrition. The ongoing challenge of providing sufficient nutrition education also exists for medical students, where a recent review concluded that students received insufficient nutrition education despite students' desire to study nutrition [149, 150, 151, 152, 153, 154, 155, 156, 157, 160, 161, 162, 163, 164, 165, 166]. The need for nutrition education in medical schools has been discussed extensively [160, 161, 162, 163, 164, 165, 166], as a doctor's role in providing nutrition care is increasingly well recognised [167, 168, 169]. Clearly, further action is required to genuinely resolve the ongoing challenge of incorporating nutrition education into oral health professional training.

4.1. Nutrition Education in Dental or Oral Health Programmes

Nutrition education in dental and oral health curricula is heterogeneous worldwide. The wide range of time committed to nutrition education among schools (Table 2) suggests that the intensity of nutrition education varies among dental and oral health programmes. Furthermore, the year of training, the delivery mode and the aspects of nutrition that schools teach also differ. The discordance of scope and depth in nutrition education [91] and teaching strategies [93] among dental and oral health schools is apparent in the reviewed literature. Inukai et al. [89] described critical curriculum differences in dental hygiene schools among eight countries due to the differences in the extent of clinical training curricula. However, particularly in clinical training, dental and oral health programmes need common minimum standard competencies and skills at the global level [170]. The WHO's Global Strategy on Human Resources for Health recommends that health professional programmes take more effective and efficient curricula to enhance the performance and quality of future health workforce [171]. Also, the EAT‐Lancet encourages all healthcare professionals to conduct dietary assessments, provide guidance and promote the planetary health diet [172]. The inconsistency discovered in our scoping review implies that future oral health professionals are likely to have different interpretations of their roles in providing nutrition care and may provide variable amounts or quality of nutrition care [173]. Since many oral diseases are preventable and relate to diet [3], inconsistent nutrition care will inhibit the optimal role of oral health professionals in resolving the public health priority of oral diseases.

4.2. Effectiveness of Nutrition Education

Nutrition education in dental and oral health schools is not necessarily effective at improving students' nutrition competence and confidence. Dental and oral health students show limited nutrition knowledge [30, 31, 39, 42, 46, 50, 51, 54, 57, 60, 61], despite some receiving nutrition education. Three systematic reviews [16, 17, 174] demonstrated that practising dentists and oral health professionals do not feel confident or competent to provide nutrition care to their patients due to inadequate training [13, 16, 17]. This is consistent with our findings, implying challenges remain for adequate and effective nutrition education in dental and oral health programmes. If nutrition education remains insufficient and ineffective, oral health professionals' lack of confidence will persist, and their patients may not receive high‐quality nutrition care when clinically warranted. Receiving insufficient and ineffective nutrition care will limit the oral health professional's potential individual and public health impact.

Our findings suggest that nutrition education in dental and oral health programmes needs to be reviewed to maximise learning effectiveness. The programme review should focus on not only the number of teaching hours, alongside programme contents and teaching methods. Aronson suggested that the use of various venues and opportunities will help make nutrition teaching effective [175]. Our scoping review identified that studies that use web‐based nutrition modules increased dental and dental hygiene students' knowledge [11, 107]. Web‐based learning is as effective as traditional learning approaches [176] and could support the programmes that have teaching teams with no nutrition expertise [177]. The advantages of web‐based learning are that students can work at their own pace [178], and the resource can reinforce their learning using multimedia [179]. Disadvantages of web‐based include the need for training educators and their time and interest [180] because a substantial time commitment is required to develop resources and making them standardise them for use [179]. Finding strategies for effective nutrition education is challenging, especially since dental and oral health programmes are already overcrowded [11]. However, our review indicates that ineffective teaching will not resolve a lack of confidence in providing nutrition care among oral health professionals and will limit potential positive impacts of the workforce on patient outcomes. Paediatric dentists with greater nutrition knowledge levels were 18 times as likely to provide nutrition care to their patients than dentists with lower knowledge levels [181]. Braithwaite et al. [181] concluded that knowledge and confidence were essential to provide nutrition care. As patients are willing to accept dietary advice provided by dental professionals [182], and medical doctors value dentists screening for NCDs in dental settings [183], adequate and effectively trained future oral health professionals with nutrition knowledge, skills and confidence will become members of the interdisciplinary team to help manage patient's various health conditions with other health professionals.

4.3. Students' Practical Skills and Dietary Habits

Dental students do not appear to have healthy dietary habits [41, 43, 53, 58, 59, 62]. This finding reflects not only a lack of nutrition knowledge but also knowledge application [132]. Students were unlikely to apply their nutrition knowledge into practice, or they were not able to follow healthy eating habits, even after they had received nutrition education. Schwartz suggested that nutrition knowledge gain has a positive but only weak relationship with practices, as nurses who received nutrition education do not necessarily apply their knowledge into practice or to their own behaviour [184], and a suggestion also supported by others [185].^(p9) Since clinical nutrition components solidify students' knowledge about basic nutrition [186], these components should be well incorporated into nutrition education. However, how much clinical nutrition should be provided remains unknown. As with medical education, a spiral curriculum may be recommended where the level of complexity of the subject or topic increases each time it is revisited [187]. Knowledge and skills students learned in the early loop of the curriculum become prerequisites for the subsequent knowledge and skills the students learned in the later loop [187, 188]. Thereby, learning is reinforced, leading to increased students' competency [187]. Year 3 dental students at the University of Plymouth, UK, perceived the benefit of a spiral curriculum for continuous consolidation of learning, which occurs in the final loop of the curriculum [189]. In medical nutrition education, the initiative of the medical school at the University of Cambridge recommends enhancing their current nutrition education by starting early (i.e., in preclinical years; Years 1 to 3) and continuing throughout the clinical years (Years 4 to 6) [190]. Medical students who received a nutrition course that was primarily didactic (13 h) with a small amount of practical activity only slightly changed their eating behaviour afterwards [191]. By contrast, a 4‐year intervention study improved personal health behaviours (i.e., diet, exercise, tobacco smoking and alcohol consumption) in Year 4 medical students and patient counselling practices in intervention groups who were offered constant reinforcements of health behavioural information throughout the four‐year medical curriculum [192]. Nutrition education is most impactful when two teaching approaches are combined together—didactic (e.g., lecture) and practical experiences (e.g., cooking class) [193, 194], in a spiral curriculum. Since our findings suggest that more effective nutrition education is necessary, innovative culinary nutrition can potentially increase students' nutrition knowledge, their skills to provide nutrition care [195], their confidence in knowledge and skills [194], and improve their own eating behaviour [196]. Future studies could design an intervention for innovative teaching methods, such as culinary nutrition or interactive online nutrition for dental and oral health students and test its effectiveness for students' knowledge and confidence levels.

4.4. Barriers for Nutrition Education

Nutrition education is more challenging when nutrition experts (e.g., nutritionists or dietitians) are not members of dentistry or oral health teaching teams [39, 77, 85, 88, 91, 93]. Without nutrition experts, programmes appear unlikely to be able to provide effective nutrition education. Dental students report challenges when teaching material has little clinical context and feel they are not supported in integrating knowledge [197]. Fugill suggests that students who do not have clinical experience find it difficult to integrate information into practice [197]. Topics in clinical nutrition need to be discussed in depth and with evidence‐based nutrition to foster the development of a professional interest in nutrition among students [119]. Accordingly, educators should keep up with their practice as well as evidence‐based nutrition. As nutrition is an evolving science [175] that requires continual updating of knowledge and evidence [94, 198], qualified, experienced, and knowledgeable nutrition experts will best prepare dental and oral health students. Community nurses with clinical experiences nutrition knowledge scores were significantly higher when taught by a nutritionist or dietitian than when taught by nursing staff [184]. Burch et al. reported on dietitians' experiences teaching in medical training [199], and this provides a relevant parallel to dietitians teaching in dental or oral health programmes.

4.5. Nutrition Competencies in Dental and Oral Health Programmes

Guidelines exist regarding nutrition education in dental and oral health programmes, yet nutrition competence standards are desired [88, 91, 132, 135, 200]. Curriculum guidelines such as the ADEA compendium of curriculum guidelines were developed by allied‐dental health educators in the US [153]. Nutrition was included, yet only briefly and not specific enough to instruct dental and oral health educators about how basic and clinical nutrition education could be implemented, what areas need to be taught, and how didactic and clinical knowledge and practices should be assessed [94]. This omission is because the guidelines were intended as a curriculum development aid for entry‐level educational programmes [153] leaving freedom to the educational institutes. However, this freedom does not help educators, as US dental hygiene education programme directors desired more guidance from the organisations [94]. Generally, competence for health care professional training programmes is developed by accrediting organisations, such as the Commission on Dental Association (CODA) in the US [201]. Nutrition is mentioned as one component in biomedical science only in accreditation documents for dental therapy and dental hygiene education programmes [202, 203], but not in dental education programmes [201]. The gap between the curriculum guidelines from the professional organisation, the accreditation guidelines from the accrediting organisation, and dental and oral health programmes needs to be addressed. Heterogenous scope and learning objectives among schools reported in our scoping review [91, 94] might be due to lack of identified competencies to work towards, or prohibitively broad recommendations for nutrition education for oral health programmes. To reduce the heterogeneity among oral health programme and those in different countries, global‐ or country‐specific competencies are warranted to promote consistent approaches to nutrition education within oral health programmes.

A competency‐based approach has been suggested to define the health issues first, develop essential competencies that help challenge the health issues, design the curriculum to achieve the competencies and evaluate students' achievement [204]. Competency‐based education focuses on the outcomes of the curriculum. It differs from traditional curriculum‐based education, where the curriculum is set first and then educational objectives and assessments are designed [204]. Global standard competencies are needed to combat oral diseases and NCDs, using background nutrition knowledge and skills developed and shared among countries. Country‐specific nutrition competencies are also necessary to tailor nutrition education to help resolve country‐specific health issues (e.g., malnutrition) in a culturally specific manner. US health sector organisations, such as the National Dental Association and the National Medical Association, have recently signed a pledge for new actions to strengthen health professionals' education in nutrition [205]. Professional training programmes should include nutrition education as a foundational competency and at least one nutritional science expert [205].

A strength of this scoping review is the wide variety of studies that used various methods and objectives to provide a broad overview of nutrition education for dental or oral health students. Opinion papers of experts and curriculum guidelines of professional organisations were also included. The retrieved articles presented a comprehensive picture of nutrition education in dental and oral health curricula. Having no limitations on the publication years or languages of the articles helped us comprehend the historical trends in nutrition education research. There are a number of potential limitations of this review. The focus on mapping the breadth of the evidence has meant that a wide variety of study types are included. In line with scoping review methodological guidelines [25, 28], a formal appraisal of study quality has not been undertaken. While every effort was made to include all studies that met our inclusion criteria, some may have been missed, particularly in grey literature. With regard to the reviewed articles, half of the reviewed articles were cross‐sectional studies, and studies were predominantly conducted in the US. The authors of the all opinion papers were from the US. These limit the generalisability of the overall review results across other countries or regions. Also, most students and academic surveys studied dental students or programmes. Therefore, generalisability of the review results is limited for dental hygiene, dental therapy and oral health therapy students or programmes. While the majority of the reviewed studies are descriptive, there were 26 curriculum initiatives, including intervention and programme evaluation studies in this review, which imply future intervention opportunities to investigate the effectiveness of nutrition education. The majority of the reviewed studies were of dental students or schools. Therefore, a gap in nutrition education in oral health professional (i.e., dental hygiene, dental therapy and oral health therapy) programmes exists. Future studies can consider this gap in nutrition education programmes.

5. Conclusion

Nutrition education has been implemented in many dental and oral health programmes globally. However, hours of teaching, teaching content and curricula vary substantially. The nutrition education provided was generally not effective in increasing dental and oral health students' nutrition knowledge, skills and confidence to provide nutrition care. Curricula reviews demonstrated that clinical aspects of nutrition education were generally included, and students did not regularly apply nutrition knowledge into practice or to their own eating behaviour. A lack of nutrition‐qualified teaching team members and nutrition competencies with sufficient details from accrediting organisations were barriers to effective nutrition education. Future studies could investigate the long‐term outcomes of nutrition education initiatives on dental or oral health students' knowledge, skills and confidence in their clinical practice. Lack of detailed nutrition competencies and guidance from accrediting organisations are also barriers for the training programmes to plan effective nutrition education. Inputs from clinical nutrition experts to revise the competencies are suggested. A systematic approach is required at different levels such as competencies, training programmes and teaching staff members.

This review will help inform education providers and professional organisations to make decisions about policies and initiatives to improve nutrition education in university dental and oral health schools. Global and country‐specific nutrition competency standards for dental and oral health programmes are warranted to promote consistent approaches to nutrition education within oral health programmes. This may increase the contribution of oral health practitioners to preventing and managing NCDs. Designing curricula to achieve the competencies and communicating them with programme educators could support students to receive sufficient, effective nutrition education to effectively integrate nutrition into their clinical practice for the benefit of all.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Appendix S1. Search strategy.

Appendix S2. Characteristics of included studies (n = 136).

Data Availability Statement

The authors have nothing to report.