Pediatric dentistry

2. NUTRITION AND HEALTH
Dr.Aminah
(post-graduate)

3.  Introduction
 Diet
 Types of diet
 Balanced diet
 Importance of balanced diet
 RDA of nutrients
 Good and harmful foods
 Superfoods
Contents

4. • Macronutrients:
– carbohydrates
– proteins
– fats
• Micronutrients:
– vitamins
– Minerals
– Trace elements
• Nutrition and dental health of children
 Conclusion
 References

5. Introduction
When man broke from the natural food chain, he developed
new energy resources and applied technologies to food
processing, since then our dietary habits have undergone
major changes. Both the qualitative nature of our diet and
pattern of eating has changed and are changing.

6. The science which deals with the study of nutrient and
foods and their effects on the nature & function of
organism under different condition of age, health & disease.
-NIZEL 1989
Nutrition
Nutrients are defined as the constituents of food, which
perform important functions in our body.

7. • Nizel (1989): Total oral intake of a substance that
provides nourishment & supply.
BALANCED DIET :
• One providing each nutrient in the (neither deficient nor excess)
needed to maintain optimum health.
- Stewart
Diet

56. Energy values of Foods and Nutrients :
• Energy from food is made available to the body in
four basic forms:
Chemical : for the synthesis of new compounds
Mechanical : for muscle contraction
Electrical : for brain and nerve activity
Thermal : for the regulation of body temperature
Human are inefficient energy users because they can convert only 25% of
chemical energy from the food they eat into mechanical energy (walking,
typing, and so forth). Most of the energy is dissipated as heat.

57. Energy needs of the body
Energy requirement = basal metabolism + physical activity + specific dynamic action
Minimum amount of energy
needed to regulate and
maintain the involuntary
essential life processes.

58. NUTRIENTS
• Organic and inorganic complexes contained in food are called
nutrients. They are broadly divided in to:
Macronutrients:
-Carbohydrates
-Proteins
-Fats/lipid
Micronutrients:
-Vitamins
-Minerals
Trace elements :
-Calcium, phosphorous, fluorides

61. • These are organic compounds of the elements
carbon, hydrogen and oxygen.
• As much as 80% of energy intake is derived from the carbohydrates.
CHEMISTRY & CLASSIFICATION
Monosaccharides
Pentoses
(ribose and
deoxyribose)
Hexoses
(glucose, fructose,
and galactose)
Oligosaccharides
Di, Tri
(sucrose, lactose,
maltose)
Raffinose
Polysaccharides
Starch, glycogen,
dextran, and
insulin
Cellulose, pectin,
agar,and carrageen.
mucopolysaccharides
Heparin, hyaluronic
acid, and chondroitin
sulfate

62. Digestion and absorption :

64. Utilization of carbohydrate

65. Functions

66. RDA of carbohydrate
• The Institute of Medicine report Dietary Reference Intakes for Energy has
established a Recommended Dietary Allowance (RDA) for carbohydrate
of 130 g per day for adults and children.

67. Food sources include

68. Systemic complications
• Diabetes mellitus
• Hypoglycemia
• Lactose intolerance

69. Diabetes mellitus (hyperglycemia)
• Complicated metabolic disorder in which the body cannot
control its level of sugar.
• Beta cells in the islets of langerhans in the pancreas are unable to produce
the hormone insulin in sufficient quantities to metabolize glucose.
• Consequently, glucose reaches a high level in blood and cells, causing tissue damage.

70. Oral manifestations
Other complications
 Coronary artery atherosclerosis
 Stroke
 Diabetic Neuropathy
 Diabetic nephropathy

71. Dietary management of Diabetes
OBESE DIABETIC
PATIENTS:
 Restricting calories
 Increasing exercise
 As long as the weight
is properly controlled,
the amounts of dietary
starch or the timing of
feeding periods for
this type of diabetes is
not critical.
LEAN DIABETIC :
 Calories should not
be restricted below
normal levels
 Coz they take insulin
they must eat 5 to 6
times a day to
correspond with the
time-action pattern
of the insulin so that
they do not develop
hypoglycemia.
 A typical diabetic diet contains the number of calories
necessary to achieve or adhere to the ideal weight.
 Refined sugars are either totally eliminated or sharply
limited.
 Natural sugars from fruits, vegetables and milk are
allowed at the 10% to 15% level
 Fat limited to 25 - 35%
 Protein 12 - 24%
 Remaining calories 30 - 40% derived from starch high in
fibres.

72. Hypoglycemia
• Excessive carbohydrate intake.
• Types: fasting & reactive(common)
• Low-carbohydrate, high-protein diet can afford variable relief
• Counseling for the emotional problem.
• Also, the possibility of an underlying chemical diabetes should
be investigated.

73. Lactose intolerance
• Digestive problem for some people.
• They may experience GI discomfort such as abdominal
cramps, flatulence, watery stools or all of these when they
drink milk or ingest milk products.
Management

75. PROTEINS
Word protein means “of prime importance”, because it mediates most of
the actions of life.
Essential for all body tissues: skin, tendons, bone matrix, cartilage, and
connective tissue.
The specific dynamic action (SDA) or the thermic effect of food (TEF) for
protein (29%) is much higher than that of carbohydrate and fat (5%).
Chemistry
Organic compounds containing alpha amino acids united by peptide linkages.
Composed of C, H, O and N2

76. Amino acids:
• Building blocks of proteins.
• 24 in number, 10 of them being essential amino acids
which cannot be synthesized by the human body.
• Among them, glutamine is termed as “anti-stress
nutrient”, and is present in largest amount in plasma.
• Tryptophan: also called “nature’s sleeping pill”:
precursor of serotonin “provitamin B3: precursor of
niacin (60mg tryptophan = 1mg niacin)

78. Digestion & absorption
pepsin
trypsin
erepsin

79. Metabolism

80. • As much as 300g of the 10kg of body
protein is replaced daily.
• Some 70g of endogenous protein is
secreted daily into the gut.
• 20g/day of plasma proteins is released
into circulation from the liver.

81. Estimates of Amino acid Requirements at different
ages (mg per kg per day)
31
Food andAgriculture Organisation/World health
Organisation, 1983

82. Funtions

83. Food and Nutrition Board recommendations
0.8 g/kg of body weight

85. Problems associated with
protein in the diet

86. Effects of Protein Excess

88. KWASHIORKAR
• First recognized by Prof Cicely Williams in 1933 from Gold Coast.
• She observed that this was the disease of the first child when the second was on the
way displacing the first child from breast feeding.
• She named it Kwashiorkar, word taken from Ga language of Ghana, which means
the ‘red boy’ due to characteristic pigmentary changes.
• Later on, the term was interpreted as “deposed child”.
• Classic signs:
– Stunted growth
– Hepatomegaly
– Anaemia
– Oedema
• Grading
– Grade I- pedal oedema
– Grade II- I +facial oedema
– Grade III – II + paraspinal and chest oedema
– Grade IV- III + ascites

89. MARASMUS
• Word Marasmus is derived from Greek word
Marasmos, which means “wasting”.
• Affected children exhibit extreme wasting.
• Old man appearance to jaws and skin and bones.
Grading
– Grade I: wasting starting in axilla and groin.
– Grade II: I + wasting in thigh and buttock
region
– Grade III: II+ chest and abdomen
– Grade IV: buccal pad of fat
• Wasting of brown fat occurs first.
• Marasmic Kwashiorkar: when marasmic children
develop oedema.

90. Protein nutrition in oral health and disease
Effect of protein deficiency on the jaw and teeth
Adequate protein diet during pregnancy has been shown to benefit significantly the
bone and dental development of the child.
Protein nutrition is a basic consideration in the growth and development of the oral
cavity
If solid, protein-rich food intake is not adequate, jaw and tooth malformations are
possible.
Teeth of children who suffer from protein-calorie malnutrition tend to be crowded
and rotated, also delayed eruption and hypoplasia of their deciduous teeth may
result.
Literature shows that deficiencies of the amino acids lysine or tryptophan produced
an irregular predentin layer and a number of interglobular spaces in poorly
calcified dentinal matrix.
Protein compounds are known to have
significant anticariogenic effect (AA’s
such as glycine, lysine, casein)

91. Protein deficiency and the periodontal tissue

93. • It embraces,
True fats (e.g., butter, margarine, vegetable oils, and
body depot fat)
Substances whose molecular structure includes fatty
acids or fatty acid derivatives, such as cholesterol (a
sterol)
Compounds present in minor amounts associated with
lipids in nature , such as ergosterol (a fat-soluble
vitamin) or a steroid sex hormone
Visible type
Invisible type

94. TRUE FATS (Triacyl glycerols)
 They contain C, H and O2 as do
carbohydrates but lipids contain
greater proportions of C and H and
much less of O2.
 Complex lipids may contain
additionally Phosphorus and
Nitrogen
Chemistry Purefatiscomposedofmoleculesof
glyceroltowhich1,2or3fattyacidsare
linkedrespectivelytoform
Monoglycerides
Diglycerides
Triglycerides

95. Natural fats, as in meat, grain, and nuts
are made up mostly of triglycerides.
Animal fats consist primarily of triglycerides
but also contain cholesterol.
Processed fats, such as shortenings, contain up to 20%
mono- and diglycerides.

96. Fatty acids : Classes include
Fully saturated Monounsaturated Polyunsaturated
 Consist of C atoms connected
to H atom by a single bond.
 Cannot take up any more
hydrogen.
 They are stable compounds.
 They increase the serum
cholestrol level.
E.g,
 Stearic acid found in beef
and lard
 Palmitic acid in animal fat
and palm oil.
 Myristic acid and lauric acid
in milk and coconut oil
 Contain one reactive
unsaturated linkage or one
double bond and no
hydrogen atom.
 Palmitoleic acid and oleic
acid found in olive oil,
peanut oil, lamb and
poultry are the most
common ones found in
nature.
 These fatty acids have no
effect on serum cholestrol
 They are not saturated
with hydrogen atoms.
 They have two, three or
four double bonds per
molecule.
E.g,
 Linoleic acid, essential
fatty acid found in
soyabean, cotton,
cottonseed and other
vegetable oils.
 These FA’s lower the
cholestrol levels in the
serum.

97. Essential Fatty Acids (EFA)
Linoleic acid Arachidonic acid
Functions
 It has been shown that a diet high in EFA reduces
high levels of serum cholestrol.
 It is recommended that 1 to 2% of the total
calories consumed should be EFA

98. Food sources :Corn, Cottonseed,
Peanut, Soyabean & Safflower oil.

99. Functions
Deficiency

100. Trans fatty acids

102. Phospholipids

105. Sterols

106. Cholesterol

107. We absorb 50% of dietary cholesterol per day, so the
ideal intake should be in the range of 100 to 300mg
of dietary cholesterol.

108. Lipoproteins
Specific protein which carry
cholesterol, triglycerides and
phospholipids in the plasma.
Chylomicrons
Pre-β cholesterol/VLDL
β cholesterol/LDL
α-cholesterol/HDL
ILDL
Obtained from
diet & cleared
rapidly
-Manufactured by
our body
- ↑,greater likelihood
of developing
atherosclerosis.
-Manufactured by
our body
-”Bad
cholesterol”
-Manufactured by our
body
-Higher the level lower
the risk of CVD.
-“Good cholesterol”
-Manufactured
by our body

109. Suggested normal limits of Plasma lipid
and Lipoprotein concentrations
From Fredrickson, D. S. Reprinted by permission of the
New England Journal of Medicine. (276; 151, 1967)

110. Hyperlipoproteinemia

111. Fat-soluble vitamins

112. Methods for Reducing Blood Lipids
It is advisable to reduce the total dietary fat to
about 33% of the total calories, to reduce the
saturated fats by 50%, and to double the
intake of PUFA.
This procedure could lower the blood
cholesterol by at least 15%.

113. Functions of LIPIDS
Cell
membrane
integrity
and
function
Phospholipids
Fats in meal
causes
satiety
Excellent
source of
energy
(9 calories)
True fats
Provide EFA’s
– linoleic for
humans
(normal
growth and
skin health)
Lipids are
carrier for
&
facilitates
absorption
Fat-soluble vitamins
Maintains
body
temperature
by insulating
against the
cold

114. Digestion and absorption

115. Metabolism and storage

116. Systemic effects
• Atherosclerosis
Definition
Progression
Literature
Degenerative disease
that produce a loss of
elasticity and a
hardening of the large
and medium arteries.
It is responsible for
ischemia(a lessened blood
supply). Also in coronary
arteries can cause MI
resulting in CHD, stroke in
brain, caudication and
gangrene in leg arteries,
hypertension in renal
arteries
In men, the risk
increases after age 45.
In women, the risk
increases after age 55.
It is suggested that
hyperlipidemia
contributes to this
disease process.
 “Lipid hypothesis” suggests that elevated blood
lipids, particularly cholesterol and LDL, can
cause coronary heart disease.
 Moreover, dietary fat, especially saturated fatty
acids and cholesterol, is suggested as the main
dietary factor influencing blood lipids.

117. Methods for Reducing risk of atherosclerosis
Children at high risk for
atherosclerosis such as those
with diabetes or familial
hypercholesterolemia, should
be advised to lower their fat
intake under close medical
supervision.
Since many factors
contribute to CHD, the
nutritional approach is only
one of several that must be
instituted to realize any
benefits.
Thus the risk of having
heart attack can be lessened
for the person whose diet
will not increase the serum
cholesterol levels, by
maintaining normal weight,
exercises regularly,
eliminates the stress of
emotional tension, doesn’t
smoke and obtains medical
treatment for high Bp or
diabetes.

118. Fats and Oral health
• There is indirect evidence that dietary fats may help prevent caries
in humans and the mechanism are probably as follows:
Coating of the
tooth surfaces with
an oily substance
would mean that
food particles will
not be so readily
retained.
A fatty protective
layer over plaque
would prevent
fermentable sugar
substrate from
being reduced to
acids.
High concentration
of fatty acids may
interfere with the
growth of
cariogenic bacteria.
Increased dietary
fat will decrease
the amount of
dietary fermentable
carbohydrate
necessary for
organic acid
formation.

119. Other effects,
PAROTID ENLARGEMENT
 Chronic swelling of the parotid
glands can be the result of the
distributed lipid metabolism that
accompanies alcoholism.
 Thus, the fatty deposits in the
parotid glands will result in
enlargement.

122. Water is a vital nutrient crucial to every
bodily function and second only to oxygen
in importance to the body.

123. Water requirement

124. Body fluids
• These fluids consist of water, protein, and solutions of electrolytes and
non electrolytes.
NON-ELECTROLYTES:
 Glucose
 Urea

125. In a healthy person, the volume and composition of body
fluids are carefully regulated and homeostasis is
maintained. However during illness or after trauma or
surgery, there is alteration of body fluid composition
Percentage of water is normally dependent on the amount of
fat in the body. The more fat, the less water. Obese person’s
body nearly has 50% of the total weight, whereas the lean
person’s body is about 70% of water.
The extracellular fluid (interstitial fluid and the blood
plasma) with sodium as major cation; chloride and
bicarbonate as principal anions constitutes 40% and
60% constituted by intracellular fluids.

126. Water balance

127. Sodium
• Considered as an essential nutrient.
Common table
salt and foods
of plant and
animal origin
such as bread,
sausages, fish,
cheese, butter
eggs, milk)
supply Na in
diet.
-Maintains
extracellular fluid
volume and
cellular osmotic
pressure.
-Transmission of
nerve impulses
-Permeability of
cell membrane.
-Muscular
contraction.
A minimum
dietary intake of
200mg/day
(0.5g NaCl, or
salt which is
39% sodium) is
necessary to
maintain
physiological
balance in
adults.
A decrease in both sodium intake and
excess body weight is probably
necessary for most hypertensive
patients to lower Blood pressure to
the normotensive range.

128. Potassium (principal cation in intracellular fluid)
FUNCTIONS:
-control cardiac function
and muscle
-nerve irritability
-many cellular enzymatic
functions
-such as glycogen synthesis
-amino acid uptake
-glucose degradation
SOURCES :
Bread, chocolate, butter,
coffee, fish, fruits, milk
oatmeal, vegetables.
Min amt. needed is
300mEq / day.
Max amt. needed is
400mEq/ day.
Estimated safe range is
1875 to 5625mg.

129. Deficiency
Unlikely to occur, may occur from prolonged K-free diet/ excessive loss due to diarrhea;
diabetic acidosis; or use of drugs such as diuretics, steroids, and purgative.
Manifestations
Treatment
 Supplements to be
given
Excess
Consequences
Excess will result
from sudden
increase in intake of
about 18g of
potassium by an
adult

130. Chloride (predominent in extracellular fluid)
• Highest conc. are found in the secretions of the GI tract and in the CSF.
• Relatively low conc. in muscles and nerve tissues.
Functions
Food sources :
 Meat
 Diary products
 Common salt

131. Daily chloride intake is about 2 to 3 g.
Deficiency
Starvation, fever, diarrhea, excessive vomiting &
sweating can cause a decrease in plasma Cl.
Following its deficiency, there is an accompanying
increase of bicarbonate leading to alkalosis.
Supplementation is needed to correct deficiency.
Abnormalities of Cl metabolism are generally
accompanied by abnormalities in Na metabolism

133. Acid-Base balance
• Only when the blood is maintained within a narrow range of neutrality
between Ph 7.35 and 7.45 is health for the human possible.
• This precise equilibrium is maintained by the lungs and kidneys, to
prevent shifts in electrolyte patterns.
Like the other soft tissues, the
oral mucosa has 80% of water
content.
Pt who ingest high-salt diets & retain the Na
will accumulate body water. Conversely, pt
on low-carbohydrate, high-fat or protein
diet will lose large amt of water from the
excessive oxidation of body fat.
 Denture wearers :
Loss of water - xerostomia; denture
…loosening and discomforts
 Retained water – pressure induced sore
spots on the underlying swollen mucosa
 Increases plaque formation
 Burning sensation : roof of mouth,
tongue.
 Gingival irritation

138. In 1915, the vitamin B was thought to
be a single substance (Mc Collum and
Davis), later it was actually consisted
of a number of different chemical
substances with few similar properties. 11 different vitamins have been
discovered and categorized to the B
Complex group.
Vit B complex
Doz dat primarily
release energy from
carbohydrates & fat
Doz that catalyze
formation of red
blood cells
Vitamin important
in protein and
amino acid
metabolism
Vitamin-like
compounds
Based on function,
Thiamine
Niacin
Ribofllavin
Pantothenic acidBiotin Folic acid Vit B 12 Vit B 6

139. Energy-releasing B vitamins
Thiamine (Vit B1)

140. -Co-enzyme in the phospho-gluconate pathway
-Structural component of nervous system membranes.
-Co-enzyme in the production of ribose, the sugar needed
by cells for the formation of RNA and DNA.
-Thiamine is needed for the metabolism of Carbohydrates,
Proteins and Fats.
Functions :

141. Deficiency
• Severe thiamine deficiency is called Beri beri
Infantile Beri-Beri
First 6 months
Breast milk deficient in B-1
Mother w/o symptoms
Rapid onset
Cyanosis, tachycardia,
labored breathing
Heart failure and death
other types :
 Cerebral beri-beri
(wherein Wernicke korsakoff syndrome may
be associated)
 Shoshin beri beri

142. Oral manifestations of Vit B1 deficiency:
RDA
0.5 mg/1000 k cal
 Sensitivity of the oral mucosa
 Burning tongue
 Loss or diminution of taste
Therapy :
-a good diet & administration of 5
to 10 mg of thiamine hydrochloride
3 times a day will help the usual
cases of nutritional polyneuropathy.
-Vit B complex tablet supplements
in a therapeutic dose may help in
alcoholics and others with beri beri.

143. Niacin (Vit B 3)
• Biologically active form : Nicotinamide
Chemistry
Properties
 Slightly water-soluble
 Light and heat-stable
 Weak organic acid
 One of the most stable
vitamin but as it is water
soluble may be lost in
cooking water.
History
In 1938, Elvehjem and his
group demonstrated that
with nicotinic acid they
could cure black tongue
in dogs, a condition
similar to pellagra in
human. Shortly thereafter,
niacin was shown to be
effective in the prevention
and treatment of pellagra.

144. Niacin metabolism
Food sources
Critical for
genome
stability

145. Forms active portion
of coenzymes that
play an essential role
in supplying organ
tissues, marking its
presence necessary
for the health of all
cells.
Coenzymes : NAD
(nicotinamide adenine
dinucleotide) & NADP
(nicotinamide adenine
dinucleotide phosphate) act
as catalyst in cellular
respiration, Carbs
metabolism and fat
synthesis.
Normal function of the
Central Nervous
system
Maintaining the
integrity of the skin
and mucous
membrane.
Functions of Niacin

146. Clinical deficiency :
Pellagra
PRIMARY
(dietary inadequacy)
SECONDARY
(systemic factors such as
GI disease,
hyperthyroidism,
alcoholism)
 Casal’s necklace : pigmented and scaly rash forming a ring around sun exposed area of
neck.
 Tongue is sore, swollen, scarlet in color, and smooth.
 Secondary infection with fungi or bacteria characteristic of ANUG is common.
 Eating and swallowing are so painful that food is often refused.
 Diarrhea due to inflammation of the mucosal lining of the esophagus, stomach, and colon.
 Depression , confusion, hallucinations and delirium – degeneration of nerve and brain cells.
 Cheilosis and angular stomatitis can also be evidenced

147. Therapy
MILD DEFICIENCY
 Administration of 50mg of
nicotinamide orally three
times a day.
SEVERE DEFICIENCY
COMPLICATED BY OTHER B
COMPLEX VITAMINS
 Advisable to give an
additional multivitamin
capsule containing 5mg
thiamine, 5mg riboflavin,
5mg Vit B6, and 10 mg
pantothenic acid.
 Alternatively Brewer’s yeast
10 to 30 g/day can be given
Niacin in excess,  Liver toxicity
 Peptic ulcers
 Arrhythmias
 Transitory dilation of blood
vessels

148. Riboflavin B2
History : Kuhn and his co-
workers in 1935 reported on
the synthesis of riboflavin and
the relation of its activity to
green fluorescence.
BIOLOGICALLY ACTIVE FORMS
 Flavin mononucleotide (FMN)
 Flavin adenine dinucleotide (FAD)
METABOLISM & ABSORPTION
- It must be phosphorylated in the intestinal tract
before it can be absorbed.
- Absorption is best when eaten with meal.
- Very little is stored and hence need to be
supplied daily.
- Excess excreted in the urine.

149. Functions include,

150. RDA : 1.1-1.3 mg/day

151. Deficiency :
THERAPY
 A good diet of meat, eggs, liver, and
enriched cereal plus a special emphasis
on a quart of milk daily is
recommended.
 Also, mutivitamin capsule containing
atleast 5mg of riboflavin should be
taken two or three times a day.

152. Pantothenic acid (Vit B5)
HISTORY
The discovery of pantothenic acid
stemmed from investigation of yeast
growth factor and a live filtrate
factor. by R. J. Williams in 1938
PROPERTIES
 Easily destroyed by heat.
 The calcium pantothenate,
form in which it is
generally available
crystallizes readily.
 Soluble in water
RDA
Children : 3 to 4 mg
Adults : 4 to 7 mg daily.

153. Functions
Food sources

154. Deficiency
 Fatigue
 Sleep disturbances
 Headaches
 Malaise
 Nausea
 Abdominal stress
 Burning, paresthesia of the hands and feet
 Cramping of the leg muscles
 Impaired coordination
Therapy
 No definitive therapeutic regimen
 A balanced , adequate diet meets RDA
 Multivitamin B complex preparations may help.

155. Biotin (B7)
• BIOLOGICALLY ACTIVE FORM
 Binds to lysine residue of enzyme
• FUNCTION
 Cofactor in carboxylation reactions,
 Carrier of CO2 (acetyl-CoA to malonyl-CoA, synthesis of fatty acids)
 Regulation of gene expression
• SOURCES
 Almost all food, esp. milk, egg yolk, tomato, almond, peanuts, avocado,
mushroom.
 Also synthesized by intestinal bacteria
• RDA
(30 mg/day)

156. DEFICIENCY
Does not occur naturally unless
eat 20 raw egg whites per day. Characterized by,
 Inflammation of
skin and the
tongue(dermatitis
and glossitis)
 Loss of appetite
and sleep
 Nausea
 Muscular pains
increased skin
sensitivity
(hyperesthesia)
 Parasthesia
THERAPY
Inj of a concentrated
preparation (0.15 to
0.3mg) biotin daily

157. Vitamin B6
Not a single vitamin but rather a group of metabolically and functionally
interrelated pyridines.
pyridoxine pyridoxamine pyridoxal
occur in animal pdtsoccur in plant pdts occur in animal pdts
RDA
Infant upto 1 year : 0.3 to 0.6 mg
Children : 0.9 to 1.6 mg
Adolescent : 1.8 to 2.0 mg/day
Pregnancy and lactation : 2.5mg/day

158. Functions

159. Deficiency
Also,
Therapy :
 Primary deficiency, a daily dosage of 10 mg is
given.
 In iron-resistant hypochromic anemia, dose
upto 100 mg/day has to be given.
 Certain medications such as isoniazid and
penicillamine produce a need for a supplement
of Vit B6
 Toxicity has been
reported when used
in excess by the
alcoholics.
 Sensory nervous
system dysfunction
Toxicity

160. HEMATOPOIETIC B Vitamins
• Folacin (Folic acid)
BIOLOGICALLY ACTIVE FORM
Tetrahydrofolate (THF) RDA
400 mg/day, more during
pregnancy and lactation SOURCES
Green leafy veggies (“foliage”),
organ meats, legumes, okra,
whole grain cereals
Functions

161. Folic acid deficiency

162. Vit B 12 (cobalamine)
Chemistry

163. Functions of cobalamine

164. Deficiency
– Caused by pernicious anemia
– Methylmalonic acidemia (MMA)

165. Vitaminlike compounds
 Choline
 Myo-inositol
 Coenzyme Q (ubiquinone)
 Lipoic acid
 P-amino benzoic acid
 Bioflavonoids
These fail to meet one or more
criterias for a vitamin and presently
not considered as vitamin.

166. Vitamin C (Ascorbic acid)
The discovery of vitamin C
was the result of a search for
a cure for scurvy by Lind on
the ship Salisbury on 12
sailors who described their
signs and symptoms as
hemorrhagic spots, anemia,
bleeding gums and
weakness in the knees.
• Water soluble
• Strong reducing properties
• Humans, other primates,
guinea pigs cannot synthesis
ascorbic acid thus daily
dietary source is needed
History
Chemistry

167. Digestion, absorption and storage

168. Functions

169. Food sources

170. Deficiency
 In infants, often seen in those who are fed almost exclusively on heat-treated cow’s milk.
 In young children the symptoms include faiure to grow, weakness, restlessness, irritability and swollen joints.
 Small hemorrhages, bone changes, scurvy lines on tibia and femur. Gums of erupted teeth will be
swollen,tendon,hemorrhagic.

171. Oral signs of vitamin C deficiency
• Enlargement of the marginal gingivae.
• The gingivae are bluish red, soft and hemorrhagic spontaneously or with slight
provocation.
• Secondary infection resulting in Vincent’s infection.
( punched-out, membranous interdental papilla and fetid breath)
• Lack of periodontal support (falling out appearance)
• Interruption of lamina dura
• Sulcular epithelium becomes almost doubled.
Teeth :
 Odontoblast atrophy
 Either irregular dentin or no
dentin at all.
 Engorged pulp and dilated

172. Therapy
• Infantile scurvy, 50 to 100 mg of ascorbic acid four times daily
added to milk.
• Adult scurvy, 250mg four times daily for a week and then
decreased to 50mg to 100 mg four times until normal plasma
levels are attained.
• Pt with wound disruption should receive 250mg of ascorbic
acid four times daily until healing is complete.

174. Minerals

175. Calcium
Distribution:
 The adult human body contains approximately
1100g (27.5mol) of calcium.
 99% of the calcium is in bone.
 Blood calcium levels are normally 9-10.2mg/dL
 Of the total amount, 50% is free ionized calcium,
9% is combined with various anions (including
bicarbonate, citrate, phosphate, lactate and
sulphate) and the remaining 41% is bound to
serum proteins mainly albumin.
 Young bone contains primarily amorphous
tricalcium phosphate, whereas mature bone
contains primarily crystalline apatite.
 The calcium not in the bones and teeth is found
in the ECF and the soft tissue as a part of various
membrane structures.

176. Functions

177. Regulation of Ca balance

178. Absorption
• Two mechanisms have been proposed-
-Simple passive diffusion
-Active transport- involving energy and calcium pump.
• Vitamin D is important for the active process.
• Active calcium transport depends on the presence in the intestinal cell
of calbindin protein , the biosynthesis of which is totally dependent on
vitamin D. Intestinal absorption
 30-80% of ingested calcium is absorbed, primarily in
the upper small intestine.
 Absorption is related to calcium intake.
 If intake is low, active transcellular calcium transport
in the duodenum is increased and a larger proportion
of calcium is absorbed by the active process compared
with the passive paracellular process that occurs in
the jejunum and ileum.

179. • Passive absorption in the jejunum and ileum predominates when dietary calcium intake is
adequate or high.
• Calcium reaching the large intestine is absorbed by active and passive processes.
• Usually, not more than 10% of total absorption takes place in the large intestine, but this
….site becomes nutritionally important in conditions of significant small bowel resection.
• In a balanced diet, roughly 1000 mg of Ca is ingested each day and about another 200
mg/day is secreted into the GI tract in the bile and other GI secretions.
• Depending on the concentration of circulating vitamin D, particularly 1,25(OH)2D (1,25
Dihydroxycholecalciferol, Calcitriol, or active vitamin D, roughly 200 to 400 mg of Ca is
absorbed from the intestine each day.
• The remaining 800 to 1000 mg appears in the stool.
• Ca balance is maintained through renal Ca excretion averaging 200 mg/day.

181. Factors affecting absorption
• Factors favoring calcium absorption
 An acidic pH.
 Presence of sugar acids, organic acids and citric acid High protein diet-
Lysine and Arginine cause maximal absorption.
 Presence of vitamin D.
 Ca : P ratio- A ratio of dietary Ca: P not more than 2:1 is adequate for optimal
absorption, ratio of less than 1:2 reduces absorption.
 State of health and intact mucosa- A healthy adult absorbs about 40% of
dietary calcium.
 PTH (Parathormone) stimulates the activation of vitamin D, thus indirectly
increases absorption of vitamin D.

182. • Factors inhibiting absorption
– Alkaline pH
– High fat diet
– Fatty acids form calcium soaps that can not be absorbed
– Presence of Phytates and oxalates
– Insoluble calcium salts are formed
– Dietary fiber in excess inhibits absorption
– Excess phosphates, magnesium and iron decrease absorption
– Glucocorticoids reduce intestinal absorption of calcium
– Calcitonin reduces calcium absorption indirectly by inhibiting
the activation of vitamin D
– Advancing age and intestinal inflammatory disorders

183. Storage

184. Excretion
Dietary intake :
1000 mg of calcium
 700 -800mg is excreted in the feces which is mostly unabsorbed Ca from
food.
 When serum Ca level or dietary level is low, absorption is efficient and
thus less is excreted.
 During lactation mother loses between 150 to 300 mg of Ca daily in her
milk which is replenished from food or bone reserves.
 After the bone and soft tissues have taken up all the calcium they can hold,
excess is excreted in the urine.
 Also Ca is lost via bile and digestive secretions into digestive tract and
then excreted.

185. Food sources
RDA

186. Calcium deficiency
Hypocalcemia is total
serum Ca concentration
< 8.8 mg/dL

187. Toxicity
• Hypercalcemia : excess Ca in blood
• Hypercalciuria : excess Ca in urine
• Hyperparathyroidism
• Kidney stones
High levels of Ca in the serum
and urine or calcification of
soft tissues.
Milk-alkali syndrome caused by prolonged
and excessive intake of milk and antacid
tablets, produces hypercalcemia.
total serum Ca concentration
> 10.4 mg/dl

188. Therapy
• Oral PO4 for serum Ca < 11.5 mg/dL with mild symptoms and no kidney
disease
• IV saline and diuretic (furosemide) for more rapid correction for serum Ca <
18 mg/dL
• Bisphosphonates or other Ca-lowering drugs for serum Ca < 18 mg/dL and >
11.5 mg/dL or moderate symptoms.
• Hemodialysis for serum Ca > 18 mg/dL
• Surgical removal for moderate, progressive primary hyperparathyroidism and
sometimes for mild disease
• PO4 restriction and binders and sometimes Calcitriol for secondary
hyperparathyroidism

189. Most essential elements of the body which is available in all food of plant and animal origin.

190. Absorption and metabolism

191. Food sources
RDA
800 to 1200mg of P daily

193. RicketsCause :
Defective mineralization or calcification of bones before epiphyseal closure in
children due to deficiency of Vit D, Ca and PO4.
Characterized by:
Delayed growth, bow legs, weakness and pain in the spine, pelvis and legs.
Laboratory findings:
Low levels of calcium and serum phosphorus
Serum alkaline phosphatase may be high.
Treatment:
Increasing dietary intake of calcium, phosphates and vitamin D.
Exposure to ultraviolet B light .
400 (IU) of vitamin D a day for infants and children.

194. Osteomalacia
Cause :
Deficiency of Vit D, Ca and PO4 in adults.
Clinical manifestations include:
General weakness
Aching
Laboratory findings:
Low serum Ca, PO4
Elevated alkaline phosphate
Treatment :
Dietary Ca and Vit D
Results in :
Excessive uncalcified osteoid
Abnormal bone mineral composition.

195. Phosphates and dental caries

196. Magnesium
• Major Cation in plant and animal tissues.
• Essential constituent of bone and soft tissues.
• Essential ion in fundamental enzymatic reactions and in protein synthesis.
Distribution:
 Adult human body contains 20 to 35 g of
magnesium, about 60% present as
phosphate and carbohydrates in bone.
 Remainder found in the cells and soft
tissue (muscles , body fluids as well)
 Mg third most abundant mineral in teeth.

197. Absorption and excretion
Significant amt. lost
during prolonged
vomiting or diarrhea.

198. Functions

199. Food sources
Normal adults :
350mg (males) and
300 mg (females)
RDA

200. Deficiency

201. Magnesium and Dental health
Mg is present in both Enamel and Dentine, but its conc. in dentine is
twice that in enamel.
Dietary deficiency produces degenerative changes in ameloblasts and
odontoblasts.
Also it can adversely affect the periodontal structures by producing a
lower rate of alveolar bone formation, widening of PDL and gingival
hyperplasia.

202. Trace elements/Micro-minerals
All these can be toxic at a small
increase over usual intakes
therefore supplements should be
used only at RDA levels.

203. Iron
Over 65% of body iron is found in hemoglobin, up to
about 10% is found as myoglobin.
Heme iron is derived mainly from hemoglobin and
myoglobin and thus is found in animal products especially
meat, fish, and poultry.
Nonheme iron is found primarily in plant foods (nuts,
fruits, vegetables, grains, tofu) and dairy products (milk,
cheese, eggs)
Sources
Metabolism
RDA
Adults :10 to 15 mg/day
Pregnant women : 18 mg/day

207. Zinc
Body contains 2 to
3 g of zinc
Concentrated in the
eyes, liver, bones,
prostatic secretions.
85% in RBC
WBC has about
25% more Zn than
each RBC

208. RDA :
Adult : 15mg
Pregnancy and lactation : 20-25mg/day
Infant under 6 months : oly 3 mg/day
6 months to 1 year : 5mg/day
1 to 10 years : 10mg/day
FOOD SOURCES

210. Supplementation :
Excessive amount of Zinc may increase the risk of CVD, bcoz
HDL which protects against heart disease is loweredand LDL
which can lead to cardiac problems increase.
Common level of Zinc in popular vitamin/mineral preparation
is 15 mg, safe.
Clinical significance:
Zinc sulfate : decrease wound healing time
significantly
Zinc peroxide powder : topically on acute
gingival lesion in ANUG

211. Copper
Deficiency symptoms
RDA
2 to 3 mg in adults.
Wilson’s disease,
neurological
degeneration,
cirrhotic liver
changes
Treatment
-chelating agents
(penicillamine, 300mg
thrice daily oral) to
mobilize copper from
tissue and promote
excretion.

212. Selenium
• At physiological levels, it performs an
antioxidant function.
• Essential component of the enzyme
that calatyzes oxidation of glutathione
which protects RBC.
• Selenium supplements are effective in
reducing Keshan disease
(abnormalities of heart muscles in
children)
• RDA ; 0.05 – 0.2mg (less for infants)
• Food sources : animal protein
• It has Cariogenic property

213. Chromium
Biologically active form : Trivalent Chromium
Functions :
- May act as cofactor in insulin
- Stimulates the synthesis of
fatty acids and cholesterol in
the liver.
Toxicity : not
known
(excesses are
rapidly excreted)
For adults the estimated
safe and adequate daily
dietary intake is 0.05 to
0.2mg.

214. Cobalt
• Considered as an essential trace element coz it is part of the
Vit B12 molecule.
Function :
 Involved in the metabolism of
sulfur-containing AA’s
Deficiency :
 Megaloblastic anemia
 Neurological disorders
 Infants can have developmental
delay and failure to thrive.
Toxicity : polycythemia
Increased hemoglobin levels.
No danger of dietary
shortage of this mineral as it
may appear in many foods
and the needed amt. is very
small

215. Manganese
• Essential nutrient
• Functions:
– Needed for normal bone structure
– for reproduction, and for the normal functioning of CNS
– Important catalyst
– Component of many enzymes in the body (pyruvate carboxylase,
superoxide dismutase)
• Sources :
– Nuts, seeds, whole grains, fruits and vegetables.
– Conc. In tea is exceptionally high
• RDA:
– 2.5-5mg
Deficiency :
-Skeletal abnormalities
-Cartilage defect
Excess :
-neurological disturbances similar to Parkinson’s
disease

216. Iodine
RDA
0.15mg daily

217. Effect of Iodine imbalance :
• Hypothyroidism
Pathological conditions : Cretinism and Myxedema
(Also, enlarged tongue, thick lips, arrested skeletal development, low BMR,
severe mental retardation)
Treatment : administration of thyroid hormone until a euthyroid state is
achieved.
• Hyperthyroidism
Increased pulse rate, temperature and Bp, with extreme nervousness,
irritability, sweating, weight loss and tiredness, exopthalmos.
Oral effects of imbalance :
 In hypothyroidism, the jaws are small and rate of tooth eruption is
retarded, predisposition to root resorption
 In hyperthyroid patients, caries occurance may be more as the
possible use of excessive sugars is increased.

218. Trace elements and dental caries

219. Nutrition and dental health in children
• Pregnancy and neonatal period
Neither malnutrition in mother during pregnancy nor in the child after
birth are likely to have any appreciable effect on the susceptibility to
decay. Only in severe calcium, protein or vitamin deficiency during tooth
development might significantly affect the incidence of decay in later life.
In areas with a high prevalence of malnutrition, enamel formed before
birth is adversely affected, with higher occurrence of hypoplasia which is
positively related to caries experience.
Vit D supplements remains desirable for all pregnant and lactating women.
(Dept of Health and Social Security.)
Excessive ingestion of F can result in “fluorosis” of enamel formed
prenatally.
Nutritional deficiencies or excess have not been associated with intra-oral
congenital abnormalities.

220. Infancy and weaning
• Diet and nutrition are relevant to dental health during 1st year of life in two ways
.
Pre-eruptive effect
Malnutrition (particularly Vit
D, protein deficiencies)
cause formation of hypoplastic
enamel and increase
susceptibility to DC.
Eruptive effect
The duration and frequency of
sugar exposure to newly
erupted teeth is very important
for caries formation.
Strong association seen with addition
of sucrose to milk in bottles, use of
reservoir feeders and comforters
containing sugary fruit flavour drink
and rampant caries upto 6 yrs.
Fluoride will help
forming teeth as well
as just erupted teeth
only if drinking water
conc is less.
Apple, carrot slices
and sugar-free rusks
are beneficial for
teething in infants.
During weaning, increasing
frequency of sugar consumption is
seen and the problem arises when
sugary foods are given inbetween
meals. Hence a healthy snaking
habit has to be advocated by
mothers to pacify the child.

221. Pre-school child
• Dept. of health and social security, reported that ‘added
sugars’provide one-fifth of the total energy in diet.
• Most of them have snacks at mid-morning, mid-afternoon with
sweet biscuits, fruit squash or milk.
• Snacking and drinks between meals are a regular part of
eating pattern among young children which significantly
promotes DC.
• Many permanent teeth are forming in this age group and F
(brushing with fluoride-containing tooth paste) and Vitamin
supplements can provide a useful pre-eruptive effects in these
teeth.

222. The schoolchild and adolescent
• Between 6 to 12 years: period of mixed dentition
• Local intra-oral effect of dietary sugars is of greatest importance in this age
group.
• Vit D supplements are found to be very beneficial.
• Fluorides continue to be important throughout the years of childhood and
adolescence. (either in drinking water, salt, milk or dietary supplements, or
topical F agents but in cautious quantity.)
• There are little data on diets of schoolchildren aged 5-10 years.
• Adolescence : time of rapid growth, independent food choices. A fairly
comprehensive account of the sugar (‘natural’ or ‘added sugars’) intake
have been documented.
• Principal targets at this age must be confectionery, soft drinks(erosion),
biscuits, cakes, sugar added to tea or coffee and the ‘Saturday sweets’.

223. Conclusion
Accurate, sound knowledge on nutritional information and
its association with benefits and risks of oral health among
us as pedodontist is very much needed to ensure uniformity
of advice and reassessment if necessary to the child as well
to their parents bcoz correct nutrition plays a key role in
ensuring good oral health maintenance for children.

224. References
 Textbook on Nutrition - Nizel and papa
 Nutrition and Dental health – Rugg Gunn
 Nutrition in Clinical Practice: A Comprehensive, Evidence-Based Manual for
the Practitioner, 2nd Edition by Dr. David L. Katz
 Therapeutic Pediatric Nutrition - 2011 by Sharma
 Krause’s Food & Nutrition therapy, 12th Edition, L.Kathleen Mahan Sylvia
Escott-Stump.
 Dentistry for the child and adolescent – Mc Donald, Avery, Dean