chapter 8 vitamins required for calcified structures copyright © 2015, 2010, 2005, 1998 by...

CHAPTER 8CHAPTER 8

VITAMINS REQUIREDVITAMINS REQUIREDFOR CALCIFIED STRUCTURESFOR CALCIFIED STRUCTURES

Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

Copyright © 2015, 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. 2

Overview of VitaminsOverview of Vitamins

From Fehrenbach MJ, Herring SW: Illustrated Anatomy From Fehrenbach MJ, Herring SW: Illustrated Anatomy of the Head and Neck, ed 4. St. Louis: Saunders, 2012.of the Head and Neck, ed 4. St. Louis: Saunders, 2012.



Deficiencies result when adequate amounts of a Deficiencies result when adequate amounts of a nutrient are not available to sustain biochemical nutrient are not available to sustain biochemical functionsfunctions

Groups at risk for deficienciesGroups at risk for deficienciesPatients with periods of rapid growthPatients with periods of rapid growthMedically compromised patientsMedically compromised patientsPatients with substance abuse issues Patients with substance abuse issues

(alcohol, tobacco, methamphetamine)(alcohol, tobacco, methamphetamine)Those with psychological & physical stressThose with psychological & physical stressVegansVegans


Overview of VitaminsOverview of VitaminsCharacteristics of fat-soluble vitaminsCharacteristics of fat-soluble vitamins

1.1. Called fat-soluble because they Called fat-soluble because they dissolve in lipid and fat solventsdissolve in lipid and fat solvents

rather than waterrather than water

2.2. Fairly stable to heat, as in cookingFairly stable to heat, as in cooking

3.3. Organic substances (contain carbon)Organic substances (contain carbon)

4.4. Absorbed in intestine along with fats Absorbed in intestine along with fats and lipids in foodsand lipids in foods

5.5. Require bile for absorptionRequire bile for absorption

6.6. Transported via the lymphatic systemTransported via the lymphatic system

7.7. Stored in liver and adipose tissuesStored in liver and adipose tissues


Vitamin AVitamin AClassesClasses

Retinoids (preformed): in animal productsRetinoids (preformed): in animal products 70% to 90% absorption70% to 90% absorption

Carotenoids (precursors): fruits and vegetablesCarotenoids (precursors): fruits and vegetables 9% to 22% absorption9% to 22% absorption

FunctionsFunctionsVision in dim lightVision in dim lightGrowth: cell differentiation (DNA/RNAGrowth: cell differentiation (DNA/RNA

synthesis), bone, tooth developmentsynthesis), bone, tooth developmentIntegrity of skin, mucous membranesIntegrity of skin, mucous membranesMaintenance of immune functionMaintenance of immune function

From Daniel SJ, Harfst SA, Wilder RS: From Daniel SJ, Harfst SA, Wilder RS: Mosby’s Dental Hygiene: Concepts, Mosby’s Dental Hygiene: Concepts,

Cases, and Competencies, ed 2. St. Louis: Cases, and Competencies, ed 2. St. Louis: Mosby, 2008.Mosby, 2008.


Sources: Vitamin ASources: Vitamin ARetinoids (preformed) Retinoids (preformed)

Found in animal productsFound in animal products LiverLiver Fortified dairyFortified dairy FishFish Fortified foodsFortified foods

Carotenoids (precursor)Carotenoids (precursor)Deep-colored fruits and vegetablesDeep-colored fruits and vegetablesDark green, yellow & orangeDark green, yellow & orange

CarrotsCarrots CantaloupeCantaloupe SquashSquash


Requirements: Vitamin ARequirements: Vitamin ARDARDA

Women Women >>19 years19 years 700 mcg700 mcg Pregnancy: 770 mcgPregnancy: 770 mcg Lactation: 1300 mcgLactation: 1300 mcg

Men Men >>19 years19 years 900 mcg900 mcg

Median dietary intake: 1168 mcg (NHANES)Median dietary intake: 1168 mcg (NHANES)Median intake from supplements: 1430 mcgMedian intake from supplements: 1430 mcg

ULUL3000 mcg/day3000 mcg/day


Hyperstates: Vitamin AHyperstates: Vitamin AHigh doses referred to as hypervitaminosis AHigh doses referred to as hypervitaminosis A

Birth defects reported in children of women taking 13-Birth defects reported in children of women taking 13-ciscis-retinoic -retinoic acid (isotretinoin) for skin conditions during pregnancy acid (isotretinoin) for skin conditions during pregnancy

Catabolism of collagen and bone resorption by osteoclastsCatabolism of collagen and bone resorption by osteoclasts DiplopiaDiplopia AlopeciaAlopecia Dry, rough skin and mucosaDry, rough skin and mucosa Reddened gingivaReddened gingiva Cracked lips Cracked lips Thinning of epitheliumThinning of epithelium

Carotene excessCarotene excess Hypercarotenemia: skin turnsHypercarotenemia: skin turns

deep yellow, especially ondeep yellow, especially onpalms and solespalms and soles

From Patton KT, Thibodeau GA: Anatomy & Physiology, ed From Patton KT, Thibodeau GA: Anatomy & Physiology, ed 8. St. Louis: Mosby, 2013.8. St. Louis: Mosby, 2013.


Hypostates: Vitamin AHypostates: Vitamin AGrowth restriction in Growth restriction in

children children Impaired dark adaptation Impaired dark adaptation

and night blindnessand night blindnessKeratinization of lung, GI Keratinization of lung, GI

tract, and urinary tract tract, and urinary tract epithelia epithelia

Susceptibility to infectionsSusceptibility to infectionsFollicular hyperkeratosis of Follicular hyperkeratosis of

the skinthe skinSometimes deathSometimes death

Enamel hypoplasiaEnamel hypoplasiaXerophthalmia, Xerophthalmia,

keratomalacia, and Bitotkeratomalacia, and Bitot’’s s spots in advanced spots in advanced deficiencydeficiency

From Daniel SJ, Harfst SA, Wilder RS: Mosby’s Dental From Daniel SJ, Harfst SA, Wilder RS: Mosby’s Dental Hygiene: Concepts, Cases, and Competencies, ed 2. Hygiene: Concepts, Cases, and Competencies, ed 2.

St. Louis: Mosby, 2008.St. Louis: Mosby, 2008.


Vitamin D (Calciferol)Vitamin D (Calciferol)Called a vitamin, but more appropriately Called a vitamin, but more appropriately

classified as a classified as a hormone hormone Skin cells able to make vitamin D precursor Skin cells able to make vitamin D precursor

7-dehydrocholesterol with further processing 7-dehydrocholesterol with further processing by liver and kidneysby liver and kidneys

Physiological rolesPhysiological rolesEnhances intestinal calcium and phosphorus Enhances intestinal calcium and phosphorus

absorptionabsorptionMay be involved in cells in May be involved in cells in hematopoiesis hematopoiesis (the (the

formation of RBC), the skin, cardiovascular formation of RBC), the skin, cardiovascular functionfunction,, and immune response and immune response

From Patton KT, Thibodeau GA: Anatomy & From Patton KT, Thibodeau GA: Anatomy & Physiology, ed 8. St. Louis: Mosby, 2013.Physiology, ed 8. St. Louis: Mosby, 2013.


Requirements: Vitamin DRequirements: Vitamin D

AI (conversion 1 mcg = 40 IU)AI (conversion 1 mcg = 40 IU)19 to 50 years19 to 50 years

5 mcg (200 IU)/day5 mcg (200 IU)/day51 to 70 years51 to 70 years

10 mcg (400 IU)/day10 mcg (400 IU)/day> 70 years> 70 years

15 mcg (600 IU)/day15 mcg (600 IU)/day

Median intake (NHANES)Median intake (NHANES)90 to 114 mcg/day90 to 114 mcg/day

ULUL50 mcg (2000 IU)/day50 mcg (2000 IU)/day


Factors Affecting Vitamin D Factors Affecting Vitamin D RequirementsRequirements

AgingAgingFourfold Fourfold in production in in production in

those >65 yrthose >65 yrMalabsorption conditionsMalabsorption conditions

Sprue, CrohnSprue, Crohn’’s disease, cystic s disease, cystic fibrosisfibrosis

Kidney failureKidney failure

Exposure to sunlightExposure to sunlightUse of sunscreenUse of sunscreen skin melanin skin melanin

pigmentationpigmentationLatitude, time of day, Latitude, time of day,

season of yearseason of yearHomebound or Homebound or

institutionalized elderlyinstitutionalized elderlyReligious/cultural Religious/cultural

habits requiring habits requiring covering the bodycovering the body


Sources: Vitamin DSources: Vitamin D

SunlightSunlightFood sourcesFood sources

Fish liver oilsFish liver oilsFatty fishFatty fishFortified foodsFortified foods

MilkMilk 10 mcg (400 IU) per quart

CerealsCereals Orange juiceOrange juice

SupplementsSupplements


Hyperstates: Vitamin DHyperstates: Vitamin D

Toxic effects occur in adults receiving 2500 Toxic effects occur in adults receiving 2500 µg (100,000 IU)/day for several months µg (100,000 IU)/day for several months Anorexia, nausea, and vomiting initiallyAnorexia, nausea, and vomiting initiallyFollowed by polyuria, polydipsia, weakness, Followed by polyuria, polydipsia, weakness,

nervousness, and pruritus nervousness, and pruritus HypercalcemiaHypercalcemia

Calcification of renal and cardiac tissuesCalcification of renal and cardiac tissues


HypostatesHypostates: Vitamin D: Vitamin D

Vitamin D deficiency a pandemic problem in Vitamin D deficiency a pandemic problem in 40% to 60% of adults and teens40% to 60% of adults and teens

RicketsRicketsMost visible lower ends of radius and ulna Most visible lower ends of radius and ulna Characteristic deformities result from bones Characteristic deformities result from bones

bending at the cartilage-shaft junctionbending at the cartilage-shaft junctionEnamel hypoplasiaEnamel hypoplasia

Osteomalacia Osteomalacia Decreased bone mineralization or softening; leads Decreased bone mineralization or softening; leads

to deformities of limbs, spine, thorax, and pelvis to deformities of limbs, spine, thorax, and pelvis Symptoms are skeletal pain and muscle weakness Symptoms are skeletal pain and muscle weakness Loss of the lamina duraLoss of the lamina dura

From Kumar V, Abbas AK, From Kumar V, Abbas AK, Fausto N: Robbins and Fausto N: Robbins and

CotranCotran.. Pathologic Basis of Pathologic Basis of Disease, ed 8. Philadelphia: Disease, ed 8. Philadelphia:

Saunders, 2010.Saunders, 2010.


Hypostates: Vitamin DHypostates: Vitamin D

OsteoporosisOsteoporosisVitamin D deficiency interferes withVitamin D deficiency interferes with

mineralization mineralization bone density bone density

and and risk for fracture risk for fracture

Cancer and cardiovascular riskCancer and cardiovascular riskVitamin D may be protective against some cancersVitamin D may be protective against some cancers

Higher levels in blood associated with reduced colon and Higher levels in blood associated with reduced colon and colorectal cancerscolorectal cancers

In animal studies, tumor growth has been decreased with vitamin In animal studies, tumor growth has been decreased with vitamin D supplementationD supplementation

Low levels may increase risk for heart attackLow levels may increase risk for heart attack

From Patton KT, Thibodeau GA: From Patton KT, Thibodeau GA: Anatomy & Physiology, ed 8. St. Anatomy & Physiology, ed 8. St.

Louis: Mosby, 2013.Louis: Mosby, 2013.


Physiological Roles: Vitamin EPhysiological Roles: Vitamin EAntioxidantAntioxidant

Protects polyunsaturated fats in phospholipid cell Protects polyunsaturated fats in phospholipid cell membranesmembranes

Prevents oxidation of fatty acids and vitamins A and CPrevents oxidation of fatty acids and vitamins A and CEnhances release of a prostaglandin that inhibits the Enhances release of a prostaglandin that inhibits the

aggregation of platelets, enhances vasodilation and aggregation of platelets, enhances vasodilation and immune responseimmune response

AnticoagulantAnticoagulant

From Patton KT, Thibodeau GA: Anatomy & Physiology, ed From Patton KT, Thibodeau GA: Anatomy & Physiology, ed 8. St. Louis: Mosby, 2013.8. St. Louis: Mosby, 2013.

..


Requirements: Vitamin ERequirements: Vitamin ERDARDA

15 mg/day α-tocopherol (α-TE) 15 mg/day α-tocopherol (α-TE) ULUL

1000 mg/day1000 mg/dayConversion units vary accordingConversion units vary according

to the type of tocopherolto the type of tocopherolα-TE 1 mg = 1.5 IUα-TE 1 mg = 1.5 IU

Median intakeMedian intake13.6 to 18.4 mg/day13.6 to 18.4 mg/day


Sources: Vitamin ESources: Vitamin E

Vegetable oils, especially soybean oilVegetable oils, especially soybean oilUnprocessed cereal grains or fortified cerealsUnprocessed cereal grains or fortified cerealsNuts and seedsNuts and seedsWheat germWheat germGreen leafy vegetablesGreen leafy vegetablesSome fruits, such as apples, Some fruits, such as apples,

apricots, and peachesapricots, and peaches


Hyperstates: Vitamin EHyperstates: Vitamin ESupplementation may significantly Supplementation may significantly

increase risk of mortalityincrease risk of mortalityOccasionally, muscle weakness, Occasionally, muscle weakness,

fatigue, nausea, and diarrhea have fatigue, nausea, and diarrhea have occurred in persons taking 800 to occurred in persons taking 800 to 3200 mg/day 3200 mg/day

Most significant effect at >1000 Most significant effect at >1000 mg/day is antagonism to vitamin K mg/day is antagonism to vitamin K action and enhancement of the action and enhancement of the effect of oral anticoagulants effect of oral anticoagulants (warfarin) (warfarin)


Hypostates: Vitamin EHypostates: Vitamin EDeficiencyDeficiency

Mild hemolytic anemia associated with increased Mild hemolytic anemia associated with increased erythrocyte hemolysis erythrocyte hemolysis

Peripheral neuropathyPeripheral neuropathySubsequent decline in physical functionSubsequent decline in physical function

At-risk groupsAt-risk groupsSickle cell anemiaSickle cell anemiaSmokersSmokersThose on an extremely low-fat dietsThose on an extremely low-fat diets


Physiological Roles: Vitamin KPhysiological Roles: Vitamin K

Naturally occurring vitamins are KNaturally occurring vitamins are K11

(phylloquinone), in green plants, and K(phylloquinone), in green plants, and K22

(menaquinone) formed by (menaquinone) formed by Escherichia coliEscherichia coli bacteria in the large intestine bacteria in the large intestine

FunctionsFunctionsCoenzyme for proteins involved in bone crystalline Coenzyme for proteins involved in bone crystalline

formationformationCatalyst for synthesis of blood-clotting factors Catalyst for synthesis of blood-clotting factors


Requirements: Vitamin KRequirements: Vitamin K


Sources: Vitamin KSources: Vitamin K

Human gut contains bacteria that produce a Human gut contains bacteria that produce a form of vitamin K, but it is unclear how this form of vitamin K, but it is unclear how this contributes to maintenance of vitamin K statuscontributes to maintenance of vitamin K status

Green leafy vegetablesGreen leafy vegetablesAbsorption enhancedAbsorption enhanced

with presence of dietary fatwith presence of dietary fatFats and oilsFats and oils


Hypostates: Vitamin KHypostates: Vitamin K

Disease or drugs may cause deficiencyDisease or drugs may cause deficiencyConditions blocking bile flow (celiac disease, sprue)Conditions blocking bile flow (celiac disease, sprue)Diarrheal diseases (ulcerative colitis)Diarrheal diseases (ulcerative colitis)Hemorrhagic disease of the newbornHemorrhagic disease of the newbornAdults with marginal dietary intake who have Adults with marginal dietary intake who have

undergone trauma, extensive surgery, or long-term undergone trauma, extensive surgery, or long-term parenteral nutrition with or without treatment with parenteral nutrition with or without treatment with broad-spectrum antibiotics broad-spectrum antibiotics

Drugs, including anticonvulsants, anticoagulants, Drugs, including anticonvulsants, anticoagulants, certain antibiotics (particularly cephalosporins), certain antibiotics (particularly cephalosporins), salicylates, and megadoses of vitamin A or Esalicylates, and megadoses of vitamin A or E


Physiological Roles: Vitamin C Physiological Roles: Vitamin C (Ascorbic Acid)(Ascorbic Acid)

FunctionsFunctionsCoenzyme in hydroxylation ofCoenzyme in hydroxylation of

proline for hydroxyproline inproline for hydroxyproline incollagen synthesiscollagen synthesis

Promotes capillary integrityPromotes capillary integrityEnhances iron absorptionEnhances iron absorptionAids in utilization of folic acid and vitamin BAids in utilization of folic acid and vitamin B1212

Coenzyme function in metabolism of amino acids and Coenzyme function in metabolism of amino acids and biosynthesis of bile acids, thyroxine, epinephrine, and biosynthesis of bile acids, thyroxine, epinephrine, and steroid hormonessteroid hormones

AntioxidantAntioxidant


Requirements and Sources: Vitamin C Requirements and Sources: Vitamin C (Ascorbic Acid)(Ascorbic Acid)

RDARDAMen: 90 mg/dayMen: 90 mg/dayWomen: 75 mg/dayWomen: 75 mg/daySmokers +35 mg/daySmokers +35 mg/day

ULUL2 g/day2 g/day

SourcesSourcesCitrus fruitsCitrus fruitsTomatoesTomatoesRaw, leafy vegetablesRaw, leafy vegetablesStrawberriesStrawberriesPotatoes and sweet Potatoes and sweet

potatoespotatoes


Hypostates: Hypostates: Vitamin C (Ascorbic Acid)Vitamin C (Ascorbic Acid)

Delayed wound healingDelayed wound healingPoor bone and tooth developmentPoor bone and tooth developmentScurvyScurvy

Red, swollen gingivaRed, swollen gingivaSore, burning mouthSore, burning mouthGingival friability, spontaneous bleedingGingival friability, spontaneous bleedingPeriodontal destruction/tooth mobilityPeriodontal destruction/tooth mobility risk of candidiasis and susceptibility to risk of candidiasis and susceptibility to

infectioninfectionMalformed enamel and inadequate dentinMalformed enamel and inadequate dentin

From Swartz MH: Textbook of Physical From Swartz MH: Textbook of Physical Diagnosis: History and Examination, ed 7. Diagnosis: History and Examination, ed 7.

St. Louis: Saunders, 2014.St. Louis: Saunders, 2014.


Hypostates: Vitamin CHypostates: Vitamin C (Ascorbic Acid) (Ascorbic Acid)

Marginal intakesMarginal intakes intake results in 1.2 times greater risk of PDintake results in 1.2 times greater risk of PD intake in smokers results in a 1.6 times greater riskintake in smokers results in a 1.6 times greater risk

Deficiency does not CAUSE gingivitis or Deficiency does not CAUSE gingivitis or periodontal disease, but may be a periodontal disease, but may be a contributing contributing factorfactor


Nutritional ConsiderationsNutritional ConsiderationsAssess nutrient intake of groups at Assess nutrient intake of groups at

high risk for developing nutritional high risk for developing nutritional deficiencies (low income, medically deficiencies (low income, medically compromised)compromised)

Encourage consumption of dairy and Encourage consumption of dairy and vitamin D–fortified foodsvitamin D–fortified foods

Supplement in excess of RDA should Supplement in excess of RDA should not be recommendednot be recommended

Encourage daily intake of foods high in Encourage daily intake of foods high in vitamin Cvitamin C

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