Seminar on Significance of Vitamins in Conservative Dentistry $ Endodontics by DR RADHIKA YAGNIK , MDS ENDODONTICS AND CONSERVATIVE DENTISTRY

1. CLINICAL SIGNIFICANCE OF
VITAMINS
-DR RADHIKA YAGNIK

2. CONTENTS
Introduction
Functions of Vitamins
Classification of Vitamins
Fat soluble Vitamins
Water soluble Vitamins
Conclusion
References

3. INTRODUCTION
• The word "vitamin" comes from the Latin word “vita”, means "life".
• Vitamins may be defined as organic compounds occurring in small quantities in different natural foods and
necessary for growth and maintenance of good health in human beings and in experimental animals.
• Vitamins are essential food factors , which are required for the proper utilization of the proximate principles
of food like carbohydrate , lipids and proteins.

4. FUNCTIONS
Vitamins are helpful for the health and life of the body in the following respects:
(a) They build up the resistance of the body against diseases.
(b) Prevent and cure various diseases caused by deficiency.
(c) Help the digestion and utilization of mineral salts and Carbohydrates in the body.
(d) Stimulate and give strength to digestive and nervous system.
(e) Help in maintenance of proper health and normal growth.

5. CLASSIFICATION OF VITAMINS

6. VITAMIN A ( RETINOL )
• Vitamin A is fat soluble. The active form is present in animal tissues only.
• Three different compounds with vitamin A activity are –
1) Retinol
2) Retinal
3) Retinoic acid
Daily Requirement –
Children = 400 – 600 microgm / day
Men = 750 – 1000 microgm / day
Women = 750 microgm / day
Pregnancy = 1000 microgm / day

7. VITAMIN A DEFICIENCY
Deficiency Symptoms –
• Nyctalopia (night blindness)
• Xeropthalmia
• Bitot’s spots.
• Keratomalacia
• Follicular hyperkeratosis
and keratizing metaplasia

8. ORAL MANIFESTATION OF VITAMIN A DEFICIENCY

9. VITAMIN D ( CHOLECALCIFEROL)
• It is a steroid hormone. Biologically active form is Calcitriol
• It is derived either from 7 – dehydrocholesterol or ergosterol by the action of ultraviolet
radiations.
• Also called as “ Sun – shine vitamin “.
• Requirement of Vitamin D –
• Children = 10 microgram / day ( 400 IU / day )
• Adults = 5 – 10 microgram / day
• Pregnancy and lactation = 10 microgram / day
• Above the age of 60 = 600 IU / day

11. VITAMIN D DEFICIENCY
1) Effect of Vitamin D on Bone - –
• Active vitamin D has action on all three types of bone cells –
Osteoblasts , osteoclasts , osteocytes
It is responsible for increased production of bone matrix proteins such as collagen , osteocalcein and osteopontin.
Deficiency of Vit D leads to –
In children – Rickets
In adults - Osteomalacia

12. ORAL MANIFESTATIONS OF VITAMIN D DEFICIENCY

13. ENDODONTIC MANAGEMENT OF ENAMEL
HYPOMINERALIZATION
Deficiency of vitamin A and D results in hypomineralized enamel.
Management
It is believed that bonding composite resin by the acid etch technique to hypocalcified enamel is
more difficult than bonding to normal enamel .
The two-step self-etch adhesive (Clearfil SE Bond) and the two-step etch-and-rinse adhesive
(Scotchbond Universal) show the lower micro tensile bond strength value in hypomineralized enamel
than normal enamel .
Sodium hypochlorite (NaOCI) is known to an excellent protein denaturant that should be capable
of removing excess enamel protein.

14. • Pretreating hypocalcified enamel with sodium hypochlorite would make the enamel crystals
more accessible to the etching solution, resulting in a clinically more favorable etched surface.
• NaOCI pretreatment appeared to remove the amorphous surface material revealing a globular pattern.
These globular structures could represent blunted prism ends, ectopic surface mineralization, or
surface deposits of calculus. Given the morphologic variability of these surface features, they likely
represent several diverse structures. Acid etching that followed NaOCI pretreatment produced islands
of well-etched enamel apparently surrounded by shallow, depressed areas with feature less to slightly
etched bases . There appeared to bepreferential etching of the periphery of enamel prisms

15. • In most severe cases, porcelain veneers appear to be the best option.
• The porcelain veneers cavity preparation to hypoplastic teeth is similar to non-hypoplastic teeth but
usually crown lengthening by periodontal surgery is needed.

16. VITAMIN E ( TOCHOPHEROL)
• The active form of vitamin E was isolated from wheat germ oil and named Tochopherol .
•
• Most powerful natural antioxidant.
• Protects RBC from hemolysis.
• Boosts immune response.
• Reduces the risk of atherosclerosis by reducing oxidation
Of LDL.

17. • Males = 10 mg / day
• Females = 8 mg / day
• Pregnancy = 10 mg / day
• Lactation = 12 mg / day
DAILY REQUIREMENT-

18. VITAMIN K
• Also known as Antihemorrhagic /coagulation vitamin or prothrombin factor.
• Three variants K1 , K2 and K3 are napthoquinone derivatives .
Biological Role of Vitamin K
• Necessary for coagulation. Factors dependent on
Vitamin K are Factor II ( prothrombin ) , Factor VII ,
Factor IX , Factor X.
Vitamin K is required for the Gamma carboxylation
Of these factors in liver.

19. DAILY REQUIREMENT -
• 500 – 1000 mg / day

20. Oral Manifestations of Vitamin E and Vitamin K

21. Endodontic Management of Patients with Vitamin K deficiency
Deficiency of vitamin K causes various bleeding disorders .
Endodontic therapy is preferred over extraction whenever possible in patients with bleeding disorders.
Endodontic therapy safe, less invasive and does not usually pose any signifcant risk of bleeding and can be
performed routinely .
Endodontic treatment considerations
1) Local anesthesia - The patients with bleeding disorders, the inferior alveolar nerve-block
anesthesia is contraindicated because of the risk of hematoma formation, which could be fatal if it
accumulates in the mediastinum and compromises the airway .

22. • Articaine is an amide local anesthetic with high lipid solubility due to the thiophene ring it also
contains an ester group which makes enable its hydrolyzation in plasma, it has high protein binding
capacity (94%) which helps in keeping the drug for longer period and increases its duration of action .
• Buccal infiltration to the mandibular first molars with 4% articaine hydrochloride (1:100,000
epinephrine) shows a more effective result than 2% lidocaine hydrochloride .
• Mental nerve block injection in the mandibular arch is considered safe and requires no hematologic
coverage prior to administration; therefore, it facilitates administration of local anesthesia in the
primary care setting .
• However, other local anesthetic techniques, such as intra-pulpal, intra-ligamentry, and buccal
infiltration, are safer. The alternative techniques, including sedation with diazepam or nitrous
oxide oxygen analgesia can be employed to reduce need of anesthesia

23. 2) Pain management -
• Dental pain can usually be controlled with a minor analgesic such as paracetamol (acetaminophen) in
the patients with bleeding disorders. The Aspirin should not be used due to its inhibitory effect
on platelet aggregation .
3) Endodontic procedure -
• Non-surgical endodontic treatment is generally low risk for patients with bleeding disorders. It can
be performed without any modifcation in anticoagulant therapy. It can be done routinely without
any risk of hemorrhage .
• The use of rubber dam is almost mandatory in modern endodontic practice to provide aseptic
operating field and to protect the patient against foreign body aspiration or ingestion and to prevent
laceration of soft tissues by the cutting instruments.

24. • Working length of the root canal should be calculated precisely to prevent over instrumentation.
Electronic apex locator is preferred over radiographic technique as it reduces the need of IOPA x-ray,
which can traumatize the soft tissue during placement and lead to prolonged bleeding .
• High-speed vacuum evacuators and saliva ejectors can cause trauma to the floor of mouth
thereby leading to haematoma formation. So they should be used very carefully in those patients. It
should be placed on a gauze swab in the floor of the mouth .
• Endodontic surgical procedures, which are more invasive that required the patient hematologist to adjust
patient INR or considered replacement therapy in case of factors or platelets deficiencies .

25. VITAMIN C ( ASCORBIC ACID )
• Daily Requirement of Vitamin C – 75 mg / day

26. VITAMIN C DEFICIENCY

27. ORAL MANIFESTATIONS OF VITAMIN C DEFICIENCY

28. Role of Vitamin C in Composite Restoration After Bleaching
Bleaching agents in varying concentration, namely carbamide peroxide (35% to 37%) or hydrogen peroxide
(30% to 40%) have been used to achieved rapid esthetic results.
Hydrogen peroxide undergoes ionic dissociation to give rise to the formation of free radicals such as nascent
oxygen,
hydroxyl radical, per-hydroxyl, and superoxide anions when they are applied to dental structure . These free
radicals are
highly reactive and hence reach out for electron-rich regions of pigment inside the dental structure, breaking
down the
large pigmented molecules with conjugated double bonds involving carbon, nitrogen, and oxygen atoms into
smaller, less
pigmented ones.

29. • Bleaching can cause complications that may vary from postoperative sensitivity to pulpal irritation, tooth
structure alterations or microleakage of existing restorations .
• Another important complication following bleaching procedure is decreased bond strength of composite
resin
to enamel when bonding is performed immediately after the bleaching process; this is attributed to the
presence
of residual peroxide that interferes with resin adhesion and inhibits resin polymerization.
Application of antioxidants (sodium ascorbate, alpha-tocopherol ) increase the shear bond strength of
composite resin to enamel following extra-coronal bleaching using 40% hydrogen peroxide.

30. • Ascorbic acid also shows high antioxidant activity. However, its pH is approximately 1.8, which makes it
inappropriate for clinical use. In contrast, sodium ascorbate has a pH of 7.4, but its antioxidant activity is
similar to that of ascorbic acid . The antioxidizing ability of sodium ascorbate aided to neutralize and
reverse the oxidizing effects of the bleaching agent
• Vitamin E functions as a chain-breaking antioxidant that prevents propagation of free radical reactions .
It has been
used on dentin and enamel with good bonding results and it also shows the antioxidant activity similar
to that of
ascorbic acid.

31. VITAMIN B1 ( THIAMINE )
Daily Requirement = 1 – 1.5 mg / day

33. VITAMIN B2 ( RIBOFLAVIN )
• Riboflavin was the first B – complex component to be isolated in a pure state.
• It exists in tissues tightly bound with enzymes. Enzyme containing riboflavin are called Flavoproteins.
• The two co – enzymes are FMN ( Flavin mono nucleotide ) and FAD ( Flavin adenine dinucleotide )
• RDA: 1.5-1.8 mg/day in adults

34. DEFICIENCY OF VITAMIN B2
• Cheilosis-fissuring at angle of the mouth
• Glossitis-tongue smooth and purplish
• Seborrhagic Dermatitis:scaly,greasy,desquamation
• Eyes: corneal vascularization
• Chronic alcoholics are susceptible to deficiencies
• Magenta colored tongue.

35. ORAL MANIFESTATIONS OF VITAMIN B2
DEFICIENCY

36. RIBOFLAVIN – A CROSS LINKING AGENT
• The durability of hybrid layer depends on the stability of its components such as collagen fibrils and
polymeric chains.
• These collagen fibrils are more susceptible to creep and degradation due to cyclic fatigue after long-
term function .
• Collagen cross-linkers can protect collagen fibrils from degradation and enhance their mechanical and
chemical properties. This is the main objective behind the use of collagen cross-linkers along with
adhesives in the bonding process. The advantages offered by collagen cross-linkers when used in
conjunction with bonding agents are mainly due to their ability to inhibit MMPs.
• Light activated riboflavin is capable of collagen cross linking. Other cross linking agents are-
glutaraldehyde and proanthocyanidin

37. VITAMIN B3 ( NIACIN )
• Niacin and Nicotinic acid are synonyms.
• Also called as Pallegra Preventing Factor by Goldberger.
• Niacin is converted to its co – enzyme forms
1) Nicotinamide Adenine Dinucleotide ( NAD+ )
2) Nicotinamide Adenine Dinucleotide Phosphate ( NADP+)
RDA: 17-21 mg/day in adults

38. VITAMIN B3 (NIACIN) DEFICIENCY

39. EPITHELIAL CHANGES IN VITAMIN B3 DEFICIENCY
EPITHELIAL CHANGES FOLLOWED BY THE CHARACTERISTIC
SKIN RASH PARTICULARLY IN THE AREAS EXPOSED TO
SUNLIGHT ESPECIALLY IN NECK REGION ARE CALLED
CASAL’S NECKLACE.
VAGINITIS AND ESOPHAGITIS MAY ALSO OCCUR.

40. ORAL MANIFESTATIONS OF VITAMIN B3 DEFICIENCY

41. VITAMIN B5 ( PANTOTHENIC ACID )
• The Greek word “ Pantos “ means everywhere. As the name suggests , it is widely distributed in nature.
• It contains bata – alanine and D – pantonic acid in amide linkage.
SOURCES
• Kidney
• Liver
• Egg yolk
• Yeast
• Cereals
• Legumes
• Sunflower oil

42. DEFICIENCY OF VITAMIN B5 (PANTOTHENIC ACID)
• Irritability.
• Inadequate growth.
• Fatty liver
• Burning foot syndrome- Pain and numbness in the toes

43. VITAMIN B6 ( PYRIDOXINE )
• Vitamin B6 is the term applied to a family of 3 related pyridine derivatives –
• 1) Pyridoxine
• 2) Pyridoxal
• 3) Pyridoxamine
• Active form of pyridoxine is Pyridoxal Phosphate
RDA: 2-2.2 mg/day

45. VITAMIN B7 ( BIOTIN )
• Egg yolk
• Liver
• Kidney RDA: 50-60 microgms/day
• Yeast
• Milk
• Tomato FUNCTION : IT ACTS AS CO – ENZYME
• FRUITS IN VARIOUS CARBOXYLATION REACTIONS
• VEGETABLES

46. DEFICIENCY OF BIOTIN -
1) Dermatitis of extremities 2) Anorexia & nausea
3) Pallor of skin & mucous membrane 4) Muscle pain and hyperesthesia
5) Depression, Lassitude and Somnolence 6) Hypercholesterolemia
A rare congenital disease of genetic deficiency to utilize Biotin is characterized by :
a) Dermatitis b) Grating of hairs
c) Loss of hair d) Incordinated movements
Leiner’s disease: In exclusive breast fed infants with persistant diarrhoea
•
• :

47. VITAMIN B9 ( FOLIC ACID )
• The name is derived from the Latin word Folium which means leaf of vegetable.
• Liver
• Yeast
• Kidney
• Green leafy vegetables
• Meat
• Fish
•

49. • RDA : 100 microgm/day
• DEFICIENCY:
• It is the most common vitamin deficiency observed primarily in pregnant women,
lactating mother , women on OCPs and alcoholics.
• In pregnancy decreased absorption and increased clearance is the cause.
• Anaemia: macrocytic type

50. VITAMIN B12 ( CYANOCOBALAMINE )
• Also known as Extrinsic Factor of Castle and Antipernicious Anemia Factor.
• RDA: 3 microgm/day.

52. ROLE OF VITAMIN IN COVID – 19 TREATMENT
• European Food Safety Authority (EFSA) evaluated and deems six vitamins (D, A, C, Folate, B6, B12) and
four minerals (zinc, iron, copper and selenium) to be essential for the normal functioning of the
immune system.
• Appropriate food choice, or even supplementation, to provide increased supply of certain micronutrients
(mainly
Zinc, Magnesium, Vitamin C, and B-group vitamins) is able to improve glycemic control and/or exert
antioxidant
activity

53. CONCLUSION
• Although vitamins are required in minute quantities , they are indispensable for maintain the integrity
and proper functioning of various body systems.
• Diet containing vitamins also play an important role in normal health of oral structures. As a dentist ,
we should have sound knowledge regarding functions of vitamins and oral manifestations of their
deficiencies.

54. REFERENCES
• Textbook of Biochemistry for Medical Students ; D M Vasudevan , 7th edition
• Shafer’s Textbook of Oral Pathology , 7th edition
• Textbook of Medical Physiology ; Guyton $ Hall , A South Asian Edition
• Essential Pathology for Dental Students ; Harsh Mohan , 4th edition
• Davidson’s Principles $ Practice of Medicine , 23rd edition

55. THANKYOU !