nutritional deficiencies and dentofacial growth / orthodontic courses by indian dental academy

Nutritional deficiencies and Nutritional deficiencies and dentofacial growth.dentofacial growth.

INDIAN DENTAL ACADEMY

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ContentsContents-Introduction-Introduction-classes of nutrients-classes of nutrients-disturbances in carbohydrates-disturbances in carbohydrates-disturbances in lipids-disturbances in lipids-protein deficiencies-protein deficiencies-mineral deficiencies-mineral deficiencies-vitamin deficiencies-vitamin deficiencies-nutrition and growth and development-nutrition and growth and development


-nutrition and skeletal maturation-nutrition and skeletal maturation-nutrition and dental tissues-nutrition and dental tissues-nutrition and the oral mucosal tissues-nutrition and the oral mucosal tissues-nutrition and craniofacial malformations-nutrition and craniofacial malformations-nutritional status on tooth movement and tissue response-nutritional status on tooth movement and tissue response-conclusion-conclusion


IntroductionIntroduction

- Nutrition- Nutrition is defined as the science of how the body utilizesis defined as the science of how the body utilizes the food to meet requirements for development ,growth,the food to meet requirements for development ,growth, repair and maintenance.repair and maintenance. -There are six classes of nutrients found in foods-There are six classes of nutrients found in foods CarbohydratesCarbohydrates ProteinsProteins Fats Fats VitaminsVitamins MineralsMinerals WaterWater


--These nutrients can be further divided into 2 typesThese nutrients can be further divided into 2 types essential –essential –they are that which the body cannot manufacture in they are that which the body cannot manufacture in

sufficient amounts. sufficient amounts. proteins ,fats,water soluble and fat soluble vitamins and proteins ,fats,water soluble and fat soluble vitamins and

minerals.minerals. non essential- non essential- they can be manufactured in the body from the they can be manufactured in the body from the

raw materials supplied by the food.raw materials supplied by the food. glucose,fructose,lecithin,cholesterol.glucose,fructose,lecithin,cholesterol.


Energy producing nutrientsEnergy producing nutrients –they provide calories and enable the –they provide calories and enable the body to generate energy for carrying on it many functions.body to generate energy for carrying on it many functions.

carbohydrates,proteins, fats come under this category.carbohydrates,proteins, fats come under this category.Vitamins ,minerals and water on the other hand do not provide Vitamins ,minerals and water on the other hand do not provide

energy but facilitate a variety of activities in the body.energy but facilitate a variety of activities in the body.RECOMMENDED DIETARY ALLOWANCESRECOMMENDED DIETARY ALLOWANCES have been used have been used

as a standard for energy and nutrient intakes.RDA’S are as a standard for energy and nutrient intakes.RDA’S are established for energy, proteins and many vitamins and established for energy, proteins and many vitamins and minerals.They are nutrient amounts in excess of what 98 pc of minerals.They are nutrient amounts in excess of what 98 pc of the population requires to maintain health.They are not the population requires to maintain health.They are not minimum requirements or optimal intakes for all people.minimum requirements or optimal intakes for all people.


CarbohydratesCarbohydrates

--major source of energy within the human dietmajor source of energy within the human diet-provide -provide 4 kcal/gm4 kcal/gm-also called ‘spare protein’as adequate amounts of carbohydrate -also called ‘spare protein’as adequate amounts of carbohydrate allows proteins to be used for tissue anabolism and not as anallows proteins to be used for tissue anabolism and not as an energy source.energy source.Simple sugars -monosaacharides (glucose,fructose,galactose)Simple sugars -monosaacharides (glucose,fructose,galactose) - disaacharides (sucrose, lactose, maltose)- disaacharides (sucrose, lactose, maltose)Complex sugars – polysaacharidesComplex sugars – polysaacharides (starch, glycogen, cellulose)(starch, glycogen, cellulose)


ProteinsProteins

-They hold a central position in the architecture and functioning -They hold a central position in the architecture and functioning of all living matter.Are the major components of bone , skin of all living matter.Are the major components of bone , skin

hair ,muscle and also play a vital role in living processes.hair ,muscle and also play a vital role in living processes.-Used as an energy source in need ( -Used as an energy source in need ( 4kcal/ gm4kcal/ gm). ).

EssentialEssential amino acids- methionine,threonine,valine,trypthophan, amino acids- methionine,threonine,valine,trypthophan, isoleucine,lysine,phenylalanine,histidine,leucine.isoleucine,lysine,phenylalanine,histidine,leucine.

Non essential Non essential amino acids – glycine ,alanine ,serine ,aspartic acid amino acids – glycine ,alanine ,serine ,aspartic acid glutamic acid ,proline ,citrulline, tyrosine ,cystine,proline.glutamic acid ,proline ,citrulline, tyrosine ,cystine,proline.


LipidsLipids

-They are the energy store house of the human body providing-They are the energy store house of the human body providing 9 kcal/gm9 kcal/gm of energy of energy-They serve as adipose tissues in the body, serve to protect -They serve as adipose tissues in the body, serve to protect

internal organs, regulate temperature , carry fat soluble internal organs, regulate temperature , carry fat soluble vitamins .vitamins .

-Lipids are divided into fats and oils.-Lipids are divided into fats and oils.-also classified as triglycerides, phospholipids and sterols.-also classified as triglycerides, phospholipids and sterols.-also into saturated and unsaturated fats-also into saturated and unsaturated fats-unsaturated are further divided into mono and polyunsaturates-unsaturated are further divided into mono and polyunsaturates


Polyunsaturated fats divided into Omega 3-fatsPolyunsaturated fats divided into Omega 3-fats Omega 6-fatsOmega 6-fats--Omega 3 fatsOmega 3 fats –they have their 1 –they have their 1stst double bond at the 3 double bond at the 3rdrd carbon carbon

from the methyl end of the molecule.These fats include from the methyl end of the molecule.These fats include Linolenic acid, may decrease cholesterol and reduce cardiac Linolenic acid, may decrease cholesterol and reduce cardiac

disease risk by lowering BP and preventing blood clots.Hence disease risk by lowering BP and preventing blood clots.Hence they are beneficial.they are beneficial.

--Omega 6 fatsOmega 6 fats – they are named so as their 1st double bond is at – they are named so as their 1st double bond is at the 6th carbon from the methyl end.They include essential the 6th carbon from the methyl end.They include essential fatty acid Linoleic acid and are found mainly in vegetables and fatty acid Linoleic acid and are found mainly in vegetables and meats.meats.


The polyunsturated fatty acids cannot be synthesized The polyunsturated fatty acids cannot be synthesized in the body and are therefore considered in the body and are therefore considered essential essential fatty acidsfatty acids . They include the . They include the linoleic acid ,linolenic linoleic acid ,linolenic acid and arachidonic acid.acid and arachidonic acid.

Fats are important to oral health from the standpoint Fats are important to oral health from the standpoint that phospholipids are a structural component of cell that phospholipids are a structural component of cell membranes , tooth enamel,dentine .They are involved membranes , tooth enamel,dentine .They are involved in the calcification and mineralization of teeth and in the calcification and mineralization of teeth and bones .In addition research indicates that high fat bones .In addition research indicates that high fat foods tend to be inhibitory towards dental caries . foods tend to be inhibitory towards dental caries .


VitaminsVitamins

-They are a group of essential nutrients required in very minute -They are a group of essential nutrients required in very minute amounts to participate and regulate chemical reactions within amounts to participate and regulate chemical reactions within the body.the body.

-not energy producing nutrients-not energy producing nutrients -are available from foods and can be in an active or an inactive state-are available from foods and can be in an active or an inactive state -They are of two types-They are of two types FAT SOLUBLE - A ,D FAT SOLUBLE - A ,D calciferolcalciferol , E , E tocopheroltocopherol , K , K menadionemenadione WATER SOLUBLE – C , B (thiamine ,riboflavin , niacin , folate ,WATER SOLUBLE – C , B (thiamine ,riboflavin , niacin , folate , pyridoxine ,vit B 12 , biotin , choline, inositol , pantothenic acid )pyridoxine ,vit B 12 , biotin , choline, inositol , pantothenic acid )


MineralsMinerals

-They provide structural components for the body.(bones ,teeth )-They provide structural components for the body.(bones ,teeth )-They allow for nerve muscle function ,blood clotting ,tissue -They allow for nerve muscle function ,blood clotting ,tissue

growth ,repair,acid base balance of fluids .growth ,repair,acid base balance of fluids .-classified as major and trace minerals -classified as major and trace minerals - Major minerals –needed in amounts greater than 100mgs/ day- Major minerals –needed in amounts greater than 100mgs/ day Ca ,Mg ,P ,K ,Na ,Cl ,S.Ca ,Mg ,P ,K ,Na ,Cl ,S.-Trace minerals -needed in lesser amounts –F ,Zn ,Se ,Cu ,I ,Mo -Trace minerals -needed in lesser amounts –F ,Zn ,Se ,Cu ,I ,Mo

Mn. Mn.


Protein deficienciesProtein deficiencies

Protein calorie malnutrition among children is the most Protein calorie malnutrition among children is the most important and widespread nutritional problem .It occurs in important and widespread nutritional problem .It occurs in children as two distinct clinical diseases.( PEM )children as two distinct clinical diseases.( PEM ) Kwashiorkar and MarasmusKwashiorkar and Marasmus.. KwashiorkarKwashiorkar , a disease caused caused by protein deficiency , a disease caused caused by protein deficiency

when the weaned child is given starchy and low protein food, when the weaned child is given starchy and low protein food, though the calorie intake may be sufficient. Mostly affects though the calorie intake may be sufficient. Mostly affects children between 1 – 3 yrs whose diet are grossly deficient in children between 1 – 3 yrs whose diet are grossly deficient in protein. protein.


Many factors contribute to its rapid development ,the rapid Many factors contribute to its rapid development ,the rapid growth of the child and its high protein requirementgrowth of the child and its high protein requirement

Clinical findingsClinical findings - growth failure,height ,weight affected.- growth failure,height ,weight affected.- wasting of muscles masked by edema.- wasting of muscles masked by edema.- characteristic changes in skin –areas of depigmentation and - characteristic changes in skin –areas of depigmentation and

other areas of deeper pigmentation (other areas of deeper pigmentation (flaky paint dermatosisflaky paint dermatosis))- hair changes also characteristic.black hair loses its color and - hair changes also characteristic.black hair loses its color and

becomes streaked with grey,red or blond color.(becomes streaked with grey,red or blond color.(flag signflag sign))- liver is enlarged,lesions of mouth,tongue also seen. - liver is enlarged,lesions of mouth,tongue also seen.


MarasmusMarasmus ,is a type of malnutrition caused primarily by a ,is a type of malnutrition caused primarily by a deficiency of proteins and calories.It occurs in infants under 1 deficiency of proteins and calories.It occurs in infants under 1 year of age.(overall lack of calories.)year of age.(overall lack of calories.)Clinical findingsClinical findings - growth failure- growth failure- extreme wasting of muscles,limbs are thin ,belly may be - extreme wasting of muscles,limbs are thin ,belly may be protuberant , edema is absent.protuberant , edema is absent.- skin is dry ,atrophic, loose ,wrinkled.- skin is dry ,atrophic, loose ,wrinkled.- anemia ,hair changes ,vitamin deficiencies may be present.- anemia ,hair changes ,vitamin deficiencies may be present.- the mental status is unaffected in contrast to kwashiorkar where - the mental status is unaffected in contrast to kwashiorkar where the child is irritable or disinterested.the child is irritable or disinterested.


Kwashiorkar


Flag sign in kwashiorkar


Vitamin B -1 (Beri beri)Vitamin B -1 (Beri beri)

-Beriberi, which means weakness is a disease produced by the -Beriberi, which means weakness is a disease produced by the deficiency of thiamine. deficiency of thiamine. - Symptoms include fatigue, irritability, restlessness, loss of - Symptoms include fatigue, irritability, restlessness, loss of appetite, and vague abdominal discomfort. appetite, and vague abdominal discomfort. - Patients develop burning sensations, tingling in the extremities,- Patients develop burning sensations, tingling in the extremities, and changes in sensation such as numbness. Patients may and changes in sensation such as numbness. Patients may develop mental confusion and psychosis. develop mental confusion and psychosis. Heart manifestationsHeart manifestations include heart failure with shortness of breath (dyspnea) andinclude heart failure with shortness of breath (dyspnea) and cyanosis (bluish tinged skin). cyanosis (bluish tinged skin). Neurologic symptomsNeurologic symptoms are caused are caused by degeneration of the nerve fiber and its insulation (myelin). by degeneration of the nerve fiber and its insulation (myelin).


There are two kinds of beriberi: dry and wet.There are two kinds of beriberi: dry and wet. Dry beriberiDry beriberi is associated with energy deprivation and is associated with energy deprivation and

inactivity characterized by mental confusion, peripheral inactivity characterized by mental confusion, peripheral neuropathy, muscular wasting with loss of function or neuropathy, muscular wasting with loss of function or paralysis of the lower extremities. (paralysis of the lower extremities. (neuromuscular symptomsneuromuscular symptoms))

Wet beriberiWet beriberi is resultant of high carbohydrate intake along is resultant of high carbohydrate intake along with strenuous exercise characterized by edema, tachycardia, with strenuous exercise characterized by edema, tachycardia, pulmonary congestion, and enlarged heart.(pulmonary congestion, and enlarged heart.(edemaedema))

Cardiac beri beriCardiac beri beri – cardiac decompensation – cardiac decompensation Wernicke kosakoff syndromeWernicke kosakoff syndrome in alcoholics. in alcoholics.


Vitamin B 2 (riboflavin)Vitamin B 2 (riboflavin)

-Riboflavin deficiency is particularly common in children.-Riboflavin deficiency is particularly common in children.-The diagnostic lesions are usually limited to the mouth and -The diagnostic lesions are usually limited to the mouth and

perioral regions.perioral regions.-Mild form begins with glossitis .Filiform papillae become -Mild form begins with glossitis .Filiform papillae become

atrophic while the fungiform papillae are normal.In severe atrophic while the fungiform papillae are normal.In severe cases the tongue becomes glazed and smooth owing to the loss cases the tongue becomes glazed and smooth owing to the loss of all papillae, assumes a purplish red colouration (of all papillae, assumes a purplish red colouration (magenta magenta colouredcoloured))

-maceration and fissuring of the angles of the mouth ( -maceration and fissuring of the angles of the mouth ( angular angular cheilosischeilosis))

-lips are red and shiny due to desquamation.-lips are red and shiny due to desquamation.-white moist maceration can be seen (-white moist maceration can be seen (perlecheperleche).).


-Riboflavin deficiency also effects the nasolabial folds and alae -Riboflavin deficiency also effects the nasolabial folds and alae nasi ,which exhibit a scaly ,dermatitis.nasi ,which exhibit a scaly ,dermatitis.-Ocular changes consisiting of corneal vascularization -Ocular changes consisiting of corneal vascularization photophobia are also seen.photophobia are also seen.-Prenatal riboflavin deficiency can cause the following postnatal-Prenatal riboflavin deficiency can cause the following postnatal effects.effects. -shortness of the maxilla and mandible -shortness of the maxilla and mandible -cleft palate and anomalies of incisor teeth.-cleft palate and anomalies of incisor teeth. -angle `s class II maloclusion-angle `s class II maloclusion


NiacinNiacin

-The deficiency of niacin leads to a condition called -The deficiency of niacin leads to a condition called pellagrapellagra which means rough skin.which means rough skin.-This syndrome is identified by the three D `s.-This syndrome is identified by the three D `s. Dermatitis –bilaterally symmetrical scaly , red , thickened Dermatitis –bilaterally symmetrical scaly , red , thickened

keratotic areas of the skin.keratotic areas of the skin. DiaorrheaDiaorrhea DementiaDementia- Oral manifestations include- entire oral mucosa is fiery red and - Oral manifestations include- entire oral mucosa is fiery red and

painful. edema of the tongue. salivation is profuse.painful. edema of the tongue. salivation is profuse.


- Epithelium of the tongue desquamates- Epithelium of the tongue desquamates-Tongue is beefy red in chronic states and scarlet red in acute-Tongue is beefy red in chronic states and scarlet red in acute conditions.conditions.-Tenderness ,pain ,redness and ulcerations begin at the -Tenderness ,pain ,redness and ulcerations begin at the

interdental gingiva and spread rapidly.interdental gingiva and spread rapidly.- Superimposed ANUG infection can be present.- Superimposed ANUG infection can be present.


Casals necklace in pellagraCasals necklace in pellagra


Bilaterally symmetrical lesions


Vitamin B- 6(pyridoxine)Vitamin B- 6(pyridoxine)

-Pyridoxine is involved in a variety of metabolic processes, major -Pyridoxine is involved in a variety of metabolic processes, major role in amino acid metabolism.role in amino acid metabolism.-The features of its deficiency include dermatitis , glossitis-The features of its deficiency include dermatitis , glossitis angular stomatitis , peripheral neuropathy.angular stomatitis , peripheral neuropathy.-The oral lesions bear a striking resemblance to pellagrous -The oral lesions bear a striking resemblance to pellagrous stomatitis.stomatitis.


Vitamin B-12 and Folic acid

-Deficiency leads to megaloblastic anemia symptoms of which include pallor ,weight loss ,glossitis ,degeneration of spinal cord.


Biotin deficiency

-scaly changes in the skin ,muscle pains ,glossitis and mental depression


Vitamin AVitamin A

Vitamin A, made from carotene exists as retinol, retinal, Vitamin A, made from carotene exists as retinol, retinal, retinoic acid, ( formerly called "prealbumin" or retinoic acid, ( formerly called "prealbumin" or "transthyretin"). It is responsible for maintaining the "transthyretin"). It is responsible for maintaining the differentiation of certain special kinds of epithelium and in differentiation of certain special kinds of epithelium and in deficiency states, epithelial surfaces of all kinds tend to deficiency states, epithelial surfaces of all kinds tend to undergo squamous metaplasia and hyper-keratinize. undergo squamous metaplasia and hyper-keratinize.

The best known symptoms of deficiency are The best known symptoms of deficiency are xerophthalmia xerophthalmia (from loss of differentiation of the mucus cells of the cornea), (from loss of differentiation of the mucus cells of the cornea), Bitot's spotsBitot's spots (masses of desquamated keratin on the cornea or (masses of desquamated keratin on the cornea or conjunctiva),conjunctiva), keratomalacia keratomalacia (excess keratin on the cornea, (excess keratin on the cornea, which gets macerated and infected ) resulting in blindness. which gets macerated and infected ) resulting in blindness.


-Deficiency of this can lead to night blindness (-Deficiency of this can lead to night blindness (nyctalopianyctalopia))-Due to keratinization of the epithelial tissues ,there is increased -Due to keratinization of the epithelial tissues ,there is increased

susceptibility to infections of all membranes protected by susceptibility to infections of all membranes protected by mucus.mucus.

--Follicular keratosisFollicular keratosis –skin change –skin change ( goose flesh( goose flesh ) )-Dental changes include -retarded erruption rate -Dental changes include -retarded erruption rate -hyperplastic giniva-hyperplastic giniva -retarded alveolar bone formation-retarded alveolar bone formation -pdl disease and microabscesses-pdl disease and microabscesses -disturbed enamel and dentine formation-disturbed enamel and dentine formation - enamel hypoplasia - enamel hypoplasia


Vitamin CVitamin C

-it is involved in the formation of collagenous intercellular -it is involved in the formation of collagenous intercellular substance,found in cartilage ,bone ,dentine ,vascular substance,found in cartilage ,bone ,dentine ,vascular epithelium,it helps maintain body structure.epithelium,it helps maintain body structure.

-other functions include synthesis of steroid hormones ,release of -other functions include synthesis of steroid hormones ,release of iron, formation of folinic acid, antioxidant property.iron, formation of folinic acid, antioxidant property.

-deficiency results in the condition called SCURVY-deficiency results in the condition called SCURVY-joint pains ,poor growth , poor wound healing and susceptibility -joint pains ,poor growth , poor wound healing and susceptibility

to infections.to infections.-easy bruising – ecchymoses-easy bruising – ecchymoses-petechial hemorhhages ,bleeding gums , loose teeth-petechial hemorhhages ,bleeding gums , loose teeth


-tenderness associated with the joints.-tenderness associated with the joints.-the hair of the body assume a corkscrew form and pinpoint -the hair of the body assume a corkscrew form and pinpoint

bleeding around the hair follicles can confirm the diagnosis.bleeding around the hair follicles can confirm the diagnosis.-the osteoblasts fail to form osteoid and the calcified matrix -the osteoblasts fail to form osteoid and the calcified matrix

material is not destroyed with a wide zone of nonossified material is not destroyed with a wide zone of nonossified matrix called the matrix called the scorbutic lattice.scorbutic lattice.

-there is fracturing of the calcified matrix material leading to the -there is fracturing of the calcified matrix material leading to the characteristic characteristic Trummerfeld zone.Trummerfeld zone.

-the area between this zone is free of hematopoietic cells and is -the area between this zone is free of hematopoietic cells and is made of connective tissue cells –so called made of connective tissue cells –so called Gerustmark.Gerustmark.


Corkscrew hair in scurvyCorkscrew hair in scurvy


Peringual hemorrhagesPeringual hemorrhages


Oral manifestations of scurvy


Scorbutic rosaryScorbutic rosary


Vitamin DVitamin D

- It occurs in two forms , vit D2-- It occurs in two forms , vit D2-ergocalciferolergocalciferol and vit D3- and vit D3- cholecalciferol.cholecalciferol.-It is not a dietary essential when there is adequate exposure to -It is not a dietary essential when there is adequate exposure to sunlight and it is the only vitamin known to be converted to a sunlight and it is the only vitamin known to be converted to a hormonal form.hormonal form.-Plays a key role in regulation of calcium and phosphorus -Plays a key role in regulation of calcium and phosphorus effecting bone mineralization.effecting bone mineralization.-Deficiency results in faulty mineralization , resulting in -Deficiency results in faulty mineralization , resulting in RICKETSRICKETS in children and in children and OSTEOMALACIAOSTEOMALACIA in adults. in adults.


Rickets


--Dental manifestationsDental manifestations include include disturbed calcifications of enamel and dentine.disturbed calcifications of enamel and dentine. delayed erruption of deciduous and permanent teethdelayed erruption of deciduous and permanent teeth jaw bones are thickenedjaw bones are thickened maxilla is narrow and palate is high,mandible is shortmaxilla is narrow and palate is high,mandible is short misalignment of teeth in the jaws. misalignment of teeth in the jaws. higher caries indexhigher caries index enamel hypoplasia enamel hypoplasia


OsteomalaciaOsteomalacia

-it is also called as Adult rickets.-it is also called as Adult rickets.-characterized by poor calcification of bones and resulting -characterized by poor calcification of bones and resulting

deformities.deformities.-it differs in etiology as it is a degenerative change –a -it differs in etiology as it is a degenerative change –a

decalcification of bone already formed rather than faulty decalcification of bone already formed rather than faulty growth.growth.

-its common in women during pregnancy.-its common in women during pregnancy.-softening and distortion of the skeleton with increased tendency -softening and distortion of the skeleton with increased tendency

towards fracture. (brittle bones)towards fracture. (brittle bones)-pelvic deformities are common.-pelvic deformities are common.


Vitamin EVitamin E

-It has also been given the name –-It has also been given the name –tocopheroltocopherol which means ,the which means ,the alcohol which brings forth offspring.alcohol which brings forth offspring.

- its mainly known for its antioxidant properties.- its mainly known for its antioxidant properties.- also prevents the peroxidation of polyunsaturated fatty acids.- also prevents the peroxidation of polyunsaturated fatty acids.- its deficiency can have the following effects - its deficiency can have the following effects - increased fragility of the red blood cells ( hemolysis ,anemia)- increased fragility of the red blood cells ( hemolysis ,anemia) fat malabsorption , cystic fibrosis .fat malabsorption , cystic fibrosis .- vit E has gained a great deal of public and scientific attention - vit E has gained a great deal of public and scientific attention

due to its due to its anti aging effectanti aging effect ( antioxidant property prevents the ( antioxidant property prevents the accumulation of free radicals causing cell damage in aging ) accumulation of free radicals causing cell damage in aging )


Vitamin KVitamin K

-it exists in three forms K1 –phylloquinone-it exists in three forms K1 –phylloquinone K2 - menaquinoneK2 - menaquinone K3 – menadioneK3 – menadione-it is necessary for synthesis of prothrombin and other blood-it is necessary for synthesis of prothrombin and other blood clotting factors by the liver.clotting factors by the liver.-also helps in growth.-also helps in growth.-deficiency rare in adults but can be seen in new born infants -deficiency rare in adults but can be seen in new born infants resulting in hypoprothrombinemia.resulting in hypoprothrombinemia.-most common oral mainfestation is gingival bleeding.-most common oral mainfestation is gingival bleeding.


MineralsMinerals

-They provide structural components for the body.(bones ,teeth )-They provide structural components for the body.(bones ,teeth )-They allow for nerve muscle function ,blood clotting ,tissue -They allow for nerve muscle function ,blood clotting ,tissue

growth ,repair,acid base balance of fluids .growth ,repair,acid base balance of fluids .-classified as major and trace minerals -classified as major and trace minerals - Major minerals –needed in amounts greater than 100mgs/ day- Major minerals –needed in amounts greater than 100mgs/ day Ca ,Mg ,P ,K ,Na ,Cl ,S.Ca ,Mg ,P ,K ,Na ,Cl ,S.-Trace minerals -needed in lesser amounts –F ,Zn ,Se ,Cu ,I ,Mo -Trace minerals -needed in lesser amounts –F ,Zn ,Se ,Cu ,I ,Mo

Mn. Mn.


Menke`s kinky hair syndrome

-Depigmentation of the skin and hair ,hypotheria ,seizures ,cerebral degeneration ( impaired activity of cu containing enzyme )www.indiandentalacademy.comwww.indiandentalacademy.com

Wilson`s diseaseWilson`s disease

-This disease is characterized by markedly reduced serum copper -This disease is characterized by markedly reduced serum copper and cerucoplasmin levels,not due to a deficiency but rather due and cerucoplasmin levels,not due to a deficiency but rather due to abnormal hepatic copper storage.to abnormal hepatic copper storage.-most of the copper remains loosely bound to albumin and can be-most of the copper remains loosely bound to albumin and can be transferred more readily to the tissues.transferred more readily to the tissues.-the liver and the lenticular nucleus of the brain contain -the liver and the lenticular nucleus of the brain contain abnormally large amounts of copper.abnormally large amounts of copper.-Kayser-Fleischer rings - eye signs.-Kayser-Fleischer rings - eye signs.


Wilson`s disease


Iron deficiency anemia


Fluorine deficiency


Disturbances in carbohydratesDisturbances in carbohydrates

-Since carbohydrates form a large part of our diet , nothing is -Since carbohydrates form a large part of our diet , nothing is known of the effects of carbohydrate deficient diets.There is known of the effects of carbohydrate deficient diets.There is an important group of diseases representing disturbances of an important group of diseases representing disturbances of mucopolysaacharide metabolism.mucopolysaacharide metabolism.

-The -The Hurler syndromeHurler syndrome is their prototype and is the most common is their prototype and is the most common with the following manifestations.with the following manifestations.-begins in first two years of life and terminates in death before -begins in first two years of life and terminates in death before puberty.puberty.-Prominent forehead ,broad saddle nose ,hypertelorism,thick lips-Prominent forehead ,broad saddle nose ,hypertelorism,thick lips coarse tongue ,open mouth , nasal congestion. coarse tongue ,open mouth , nasal congestion.


-short neck , spinal abnormalities , flexion contractures result in -short neck , spinal abnormalities , flexion contractures result in claw hand claw hand --oral manifestations includeoral manifestations include- short broad mandible,wide intergonial distance- short broad mandible,wide intergonial distance- spacing of teeth- spacing of teeth- localized areas of bone destruction with represent hyperplastic - localized areas of bone destruction with represent hyperplastic dental follicles with large pools of mucopolysaccharides.dental follicles with large pools of mucopolysaccharides.- gingival enlargements, enlarged tongue.- gingival enlargements, enlarged tongue.


In the skull, changes of Hurler syndrome consist of premature closure of the sagittal and metopic sutures, resulting in

scaphocephaly. The sphenoid bone is hypoplastic, resulting in a shoe" shaped sella. The skull itself is typically thick with frontal

bossing and small facial bones.


Disturbances in lipidsDisturbances in lipids

-disturbances of lipid metabolism though rare do occur and result-disturbances of lipid metabolism though rare do occur and result in a particular group of diseases –the lipid storage diseases.in a particular group of diseases –the lipid storage diseases.-these include the following-these include the following Hand Schuller Christian diseaseHand Schuller Christian disease Eosinophilic GranulomaEosinophilic Granuloma Letterer –Siwe diseaseLetterer –Siwe disease--Oral manifestationsOral manifestations Ulcerative lesions,gingival hyperplasia,diffuse destruction of Ulcerative lesions,gingival hyperplasia,diffuse destruction of the maxilla and mandible causing loosening of teeth and the maxilla and mandible causing loosening of teeth and premature loss.premature loss.


Osteolytic lesions of frontal, parietalBone.Skin lesions

Hand Schuller Christian disease


Nutrition and dentofacial growthNutrition and dentofacial growth

-Growth is defined as an increase in size resulting from the -Growth is defined as an increase in size resulting from the multiplication and enlargement of cells and comprises of three multiplication and enlargement of cells and comprises of three phases.phases.

first phase – hyperplasiafirst phase – hyperplasia second phase --- hyperplasia and hypertrophysecond phase --- hyperplasia and hypertrophy third phase ---hypertrophythird phase ---hypertrophy-Growth and development are affected by nutritional environment-Growth and development are affected by nutritional environment-The diet can affect the process of cell replication and -The diet can affect the process of cell replication and enlargement thus influencing tissue and organ growthenlargement thus influencing tissue and organ growth- Many nutrients affect the enzymatic processes of the body - Many nutrients affect the enzymatic processes of the body and thus enzymatic regulation is also influenced by diet.and thus enzymatic regulation is also influenced by diet.


- The points at which a nutrient deficit occurs during the growth- The points at which a nutrient deficit occurs during the growth can have just as important an impact as the type of nutrition can have just as important an impact as the type of nutrition deficit involved .These are often referred to as the deficit involved .These are often referred to as the ‘critical‘critical period period of growth .of growth .-For ex- permanent damage from decreased cell numbers of a -For ex- permanent damage from decreased cell numbers of a

particular tissue or organ may be the result of inadequate particular tissue or organ may be the result of inadequate nutrition during the hyperplastic phase of growth.If the same nutrition during the hyperplastic phase of growth.If the same deficit occurred during a hypertrophic phase , however, then it deficit occurred during a hypertrophic phase , however, then it may be compensated for later, in the way of may be compensated for later, in the way of catch up growthcatch up growth when nutrition is adequate.when nutrition is adequate.


-The critical period concept reveals the importance of nutrition in -The critical period concept reveals the importance of nutrition in allowing the body to attain its full growth and development allowing the body to attain its full growth and development potential.Oral tissues are no less susceptible to nutritional potential.Oral tissues are no less susceptible to nutritional stresses that may affect a person`s oral health and wellness stresses that may affect a person`s oral health and wellness througout life.througout life.

LAW OF MINIMUM (formulated by Justus von Liebig 1843)LAW OF MINIMUM (formulated by Justus von Liebig 1843) … …. Among the nutrients essential for growth , the one which is . Among the nutrients essential for growth , the one which is

furnished in minimum amount (relative to the need for growth furnished in minimum amount (relative to the need for growth at normal rate ) will thereby determine the rate of growth ,the at normal rate ) will thereby determine the rate of growth ,the organism growing only to extent that it can increase in size .organism growing only to extent that it can increase in size .


- The law of minimum is applicable to proteins but not to - The law of minimum is applicable to proteins but not to minerals since the body may grow to adult size although poor minerals since the body may grow to adult size although poor in calcium and other minerals. Children with poor bone in calcium and other minerals. Children with poor bone structure may still grow to average or normal size.structure may still grow to average or normal size.


Nutrition and craniofacial malformationsNutrition and craniofacial malformations

-Animal experiments show that maternal dietary deficiency even -Animal experiments show that maternal dietary deficiency even when experienced for a brief time during a critical period when experienced for a brief time during a critical period results in some biochemical alterations followed by results in some biochemical alterations followed by morphologic changes.This is true when vitamins are disturbed morphologic changes.This is true when vitamins are disturbed and nucleic acid synthesis suffers.Maternal diet affects the and nucleic acid synthesis suffers.Maternal diet affects the later part of antenatal life rather than during the early weeks of later part of antenatal life rather than during the early weeks of organogenesis. organogenesis.

-Suboptimal levels of these nutrients may potentiate other -Suboptimal levels of these nutrients may potentiate other terratogenic factors .The possibility of vitamins and trace terratogenic factors .The possibility of vitamins and trace minerals being suboptimal during pregnancy is great.The use minerals being suboptimal during pregnancy is great.The use of alcohol and other drugs may increase the requirement for of alcohol and other drugs may increase the requirement for certain nutrients.certain nutrients.


-The administration of riboflavin or pyridoxine to mice reduced -The administration of riboflavin or pyridoxine to mice reduced the incidence of cortisone induced cleft palate.the incidence of cortisone induced cleft palate.

-Zinc provides an example of a nutrient for which even a short -Zinc provides an example of a nutrient for which even a short term dietary deficiency could be terratogenic.No mobilizable term dietary deficiency could be terratogenic.No mobilizable store exists for zinc necessitating that it regularly be present in store exists for zinc necessitating that it regularly be present in diet.diet.

-A large variety of malformations have been found in the new -A large variety of malformations have been found in the new born of mothers with severe vit A deficiencyborn of mothers with severe vit A deficiency

-Deficiency of riboflavin - results in shortening of mandible -Deficiency of riboflavin - results in shortening of mandible cleft palate and other skeletal malformations. cleft palate and other skeletal malformations.


- Cleft lip and palate is one craniofacial anomaly of particular - Cleft lip and palate is one craniofacial anomaly of particular interest.This condition can be induced in animals by interest.This condition can be induced in animals by nutritional deficiencies such as those of folic acid , riboflavin nutritional deficiencies such as those of folic acid , riboflavin and zinc .and zinc .

- Retrospective studies of the histories of pregnancies resulting - Retrospective studies of the histories of pregnancies resulting in clefts suggest that vitamin and trace metal levels have an in clefts suggest that vitamin and trace metal levels have an influence. influence.


Nutrition and the teethNutrition and the teeth

-As tooth development begins in utero and extends into adult life -As tooth development begins in utero and extends into adult life nutrition exerts a pre erruptive and a post erruptive effect.nutrition exerts a pre erruptive and a post erruptive effect.-Hence teeth are affected in 2 distinct ways -Hence teeth are affected in 2 distinct ways Local effectLocal effect –depends on the intra oral chemical or physical –depends on the intra oral chemical or physical

action on the external surfaces of the teeth and oral tissues due action on the external surfaces of the teeth and oral tissues due to the products of masticatory and bacterial action on various to the products of masticatory and bacterial action on various food stuffs.food stuffs.

Systemic effectSystemic effect –is important during the period of tooth –is important during the period of tooth development. Nutritional deficiencies during tooth development. Nutritional deficiencies during tooth development affect the tooth size ,formation ,erruption time development affect the tooth size ,formation ,erruption time and caries attack and caries attack


- Protein deficiency – poor bone calcifications ,retarded centres of - Protein deficiency – poor bone calcifications ,retarded centres of calcifications ,delayed tooth erruption ,retarded jaw growth calcifications ,delayed tooth erruption ,retarded jaw growth crowded dentitions.crowded dentitions.

- Calcium ,Vit D,P deficiency –result in retarded jaw ,tooth and - Calcium ,Vit D,P deficiency –result in retarded jaw ,tooth and condyle development ,defective enamel and dentine,loss of Pdl condyle development ,defective enamel and dentine,loss of Pdl and bone resorptions.and bone resorptions.

- Vit C deficiency – loss of connective tissue ,gingival bleeding - Vit C deficiency – loss of connective tissue ,gingival bleeding

tooth mobility ,incresed pdl disease .As it is vital to collagen tooth mobility ,incresed pdl disease .As it is vital to collagen production for formation of teeth and bones .Also important in production for formation of teeth and bones .Also important in healing of oral tissues due to its anti oxidant property. healing of oral tissues due to its anti oxidant property.


-Vit A is indispensable for the proper growth and development -Vit A is indispensable for the proper growth and development of the periodontium ,teeth ,salivary glands and oral epithelium.of the periodontium ,teeth ,salivary glands and oral epithelium.

Deficiency can lead to the followingDeficiency can lead to the following -changes in the ameloblasts –loss of physiologic ability and -changes in the ameloblasts –loss of physiologic ability and

anatomical changes resulting in defective and decreased anatomical changes resulting in defective and decreased matrix formation. Enamel hypoplasia.matrix formation. Enamel hypoplasia.

-endochondral or replacement bone growth is retarded.-endochondral or replacement bone growth is retarded.-arrest in compact bone formation-arrest in compact bone formation-eventually all skeletal growth development dependent upon -eventually all skeletal growth development dependent upon

replacement of endochondral bone formation ceases.replacement of endochondral bone formation ceases.


Nutritional effect on tooth movement and tissue Nutritional effect on tooth movement and tissue response to appliancesresponse to appliances

-Tooth movement relies on the biologic response of the pdl and -Tooth movement relies on the biologic response of the pdl and alveolar bone to applied forces and this tissue response is alveolar bone to applied forces and this tissue response is analogus to analogus to healinghealing

-And as the orthodontic patient is selectively treated during the -And as the orthodontic patient is selectively treated during the adolescent growth spurt which provides an additional adolescent growth spurt which provides an additional challenge to his nutritional status.challenge to his nutritional status.

-During this healing some nutrients which are nonessential -During this healing some nutrients which are nonessential become essential or are required in higher levels.become essential or are required in higher levels.

AspargineAspargine which although is categorized as a non essential amino which although is categorized as a non essential amino acid has been shown when deficient to inhibit growth and acid has been shown when deficient to inhibit growth and healing in demineralized bone matrix implants in rats.healing in demineralized bone matrix implants in rats.


Ascorbic acid is a classical example of a nutrient that may Ascorbic acid is a classical example of a nutrient that may influence the biologic response to forces.It has been reported influence the biologic response to forces.It has been reported that 17 to 72 pc of orthodontic patients may have suboptimal that 17 to 72 pc of orthodontic patients may have suboptimal levels of ascorbic acid. The rationale for its effect is based in levels of ascorbic acid. The rationale for its effect is based in part on the fact that a lack of it interferes with collagen part on the fact that a lack of it interferes with collagen synthesis by preventing hydroxylation of proline to synthesis by preventing hydroxylation of proline to hydroxyproline, affecting the pdl and formation of osteoid.hydroxyproline, affecting the pdl and formation of osteoid.

Ascorbic acid may also influence Retention. In a study using Ascorbic acid may also influence Retention. In a study using separation of guinea pig incisors the group that was deficient separation of guinea pig incisors the group that was deficient showed a more rapid relapse.showed a more rapid relapse.


-Nutritional status may also play a role in the gingival response to -Nutritional status may also play a role in the gingival response to orthodontic bands and brackets. Since bands and brackets orthodontic bands and brackets. Since bands and brackets present a stress to the periodontium, especially in regard to present a stress to the periodontium, especially in regard to increased exposure to retained debris, tissue tolerance needs to increased exposure to retained debris, tissue tolerance needs to be maximized.be maximized.

--Dusterwinkle et al. (J .Periodontology 1966Dusterwinkle et al. (J .Periodontology 1966) studied the tissue ) studied the tissue tolerance to orthodontic banding.He concluded that oral health tolerance to orthodontic banding.He concluded that oral health and disease is a function of the product of the degree of host and disease is a function of the product of the degree of host resistance and the magnitude of the environmental challenge.A resistance and the magnitude of the environmental challenge.A nutritional status adequate to support a healthy pdl in a non nutritional status adequate to support a healthy pdl in a non banded situation may provide suboptimal host resistance in a banded situation may provide suboptimal host resistance in a banded situation.banded situation.


Nutrition and skeletal maturationNutrition and skeletal maturation

- Prolonged nutritive failure in growing children shows a Prolonged nutritive failure in growing children shows a retarding influence on each of the 28 bone centres in the hand retarding influence on each of the 28 bone centres in the hand and the wrist which are used as indicators of skeletal and the wrist which are used as indicators of skeletal maturation.maturation.

- Correction of dietary deficiencies brings an acceleration in the Correction of dietary deficiencies brings an acceleration in the overall rate of skeletal maturation but does not equally affect overall rate of skeletal maturation but does not equally affect all the bone centres.all the bone centres.

- The fastest growing centres generally show the greatest The fastest growing centres generally show the greatest relative response to dietary correction,whereas the slowest relative response to dietary correction,whereas the slowest growing centres do not demonstrate a preferential utilization growing centres do not demonstrate a preferential utilization of nutrients.of nutrients.


Nutrition and the oral mucosal tissuesNutrition and the oral mucosal tissues

-The nutritional state of a person is often manifested in oral -The nutritional state of a person is often manifested in oral tissues due to the rapid turnover of cells in this area and the tissues due to the rapid turnover of cells in this area and the bacterial onslaught the area receives .The soft oral tissues are bacterial onslaught the area receives .The soft oral tissues are sensitive to nutritional and dietary deficiencies.sensitive to nutritional and dietary deficiencies.

-Healthy oral epithelium experiences a 3 day to 7 day cell -Healthy oral epithelium experiences a 3 day to 7 day cell turnover and acts as an effective barrier to toxins.Inadequate turnover and acts as an effective barrier to toxins.Inadequate nutrition may cause the tissues to breakdown ,become infected nutrition may cause the tissues to breakdown ,become infected and develop lesions. and develop lesions.

Vit B complex deficiency – magenta , raw, fissures ,smooth or Vit B complex deficiency – magenta , raw, fissures ,smooth or swollen tongue.Angular chelitis ,itchy eyes and scaly swollen tongue.Angular chelitis ,itchy eyes and scaly dermatitis may also occur.dermatitis may also occur.


-Patients with iron deficiency may present with pallor ,spoon -Patients with iron deficiency may present with pallor ,spoon shaped nails ,pale ,atrophic tongue ,pale conjuctivae and shaped nails ,pale ,atrophic tongue ,pale conjuctivae and sensitivity to cold.sensitivity to cold.

-Routine periodical examination of the mucosa ,the tongue ,lips -Routine periodical examination of the mucosa ,the tongue ,lips and the saliva is helpful in determining the nutritional status.and the saliva is helpful in determining the nutritional status.


ConclusionConclusion

--In the past ,the extent of a dentist `s nutritional counselling In the past ,the extent of a dentist `s nutritional counselling involved advising patients to reduce consumption of sweets involved advising patients to reduce consumption of sweets and frequency of snacks.However much more is required and frequency of snacks.However much more is required today.today.

-Dentists must be aware of how nutrition impacts general and -Dentists must be aware of how nutrition impacts general and oral health and how dental treatment affects the nutritional oral health and how dental treatment affects the nutritional status .Compared with other other health care workers the status .Compared with other other health care workers the dentists reach a large number of people per year and as the dentists reach a large number of people per year and as the dental visit is of longer duration than the medical visit ,better dental visit is of longer duration than the medical visit ,better opportunities for motivational interventions are present.opportunities for motivational interventions are present.


-Patients should be assessed for signs of nutrient imbalances and -Patients should be assessed for signs of nutrient imbalances and if they are suspected then appropriate referrals should be if they are suspected then appropriate referrals should be made.made.

--Incremental increases in height and weight as compared withIncremental increases in height and weight as compared with standardsstandards are one of the best measures of satisfied nutritional are one of the best measures of satisfied nutritional needs ,although they are not diagnostic for borderline needs ,although they are not diagnostic for borderline states.Thus the orthodontist who usually uses these data for states.Thus the orthodontist who usually uses these data for growth prediction is able to estimate past nutritional growth prediction is able to estimate past nutritional status .Additionally the presence of bands and brackets should status .Additionally the presence of bands and brackets should alert the orthodontist to the cariogenecity of the diet.Perhaps alert the orthodontist to the cariogenecity of the diet.Perhaps the best method for patient education is the diet history.the best method for patient education is the diet history.


While orthodontists will rarely see the frank manifestations of While orthodontists will rarely see the frank manifestations of nutritional deficiencies ,it should be recognized that nutritional deficiencies ,it should be recognized that suboptimal levels of certain nutrients are common and have an suboptimal levels of certain nutrients are common and have an effect on the biologic responses of the tissues influenced by effect on the biologic responses of the tissues influenced by orthodontic treatment.orthodontic treatment.

Additionally the age group typically involved in orthodontic Additionally the age group typically involved in orthodontic treatment has particularly high nutritional demands and treatment has particularly high nutritional demands and particularly poor dietary behaviour.particularly poor dietary behaviour.


ReferencesReferences

- Nutrition and oral health.Laura M Romite . Dent Clin N Am - Nutrition and oral health.Laura M Romite . Dent Clin N Am 47,2003, 187-207.47,2003, 187-207.

- Nutritional considerations in orthodontics.Wayne Hickory , - Nutritional considerations in orthodontics.Wayne Hickory , Ravindra Nanda .Dent Clin N Am 25 ,1981 ,195-201.Ravindra Nanda .Dent Clin N Am 25 ,1981 ,195-201.

- Principles of nutrition and diet therapy .Barbara Luke.- Principles of nutrition and diet therapy .Barbara Luke.- Nutrition in health and disease .Lenna Copper.- Nutrition in health and disease .Lenna Copper.- Textbook of oral pathology .Shafer.- Textbook of oral pathology .Shafer.- Severe oral manifestation in a case of Hand schuller christian - Severe oral manifestation in a case of Hand schuller christian

disease. F.Kokelj ,C.Plozzer.Acta dermatovenerologica,2001disease. F.Kokelj ,C.Plozzer.Acta dermatovenerologica,2001 vol no 3.vol no 3.


- Osteolytic lesions in the calvarium- an important manifestation- Osteolytic lesions in the calvarium- an important manifestation of Hand schuller christian disease. V K Sharma .of Hand schuller christian disease. V K Sharma . Ind J Radiol Imaging 2002 ,12:3:391 -392. Ind J Radiol Imaging 2002 ,12:3:391 -392. - Effect of aspargine on demineralized bone matrix implants.- Effect of aspargine on demineralized bone matrix implants. Hickory .J.D.R 58,139,1979;187.Hickory .J.D.R 58,139,1979;187.- Tissue tolerance to orthodontic banding.- Tissue tolerance to orthodontic banding. Dusterwinkle , J.Periodontology 37;132;1966Dusterwinkle , J.Periodontology 37;132;1966- Orthodontic tooth movement during an ascorbic acid - Orthodontic tooth movement during an ascorbic acid

deficiency.deficiency. Litton ,A J O 65.290;1974.Litton ,A J O 65.290;1974.


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