This document provides definitions and information about diet, nutrition, and their importance for oral health. It discusses the major components of a balanced diet including macro-nutrients like carbohydrates, proteins, and fats, as well as micro-nutrients like vitamins and minerals. Specific vitamins and minerals that are important for dental health such as vitamins A, D, and C are explained. The roles of important minerals like calcium, phosphorus and magnesium are also summarized. The document provides recommendations for nutritional assessment and counselling in children.

1. 1

2. Preventive Pedodontics
(Part 2)
Diet & Nutrition
Dr. Sucheta Prabhu
Second Year MDS
15/03/18
2

3. CONTENTS
• Definition
• Balanced diet
• Components of nutrition
• Macro-nutrients
• Vitamins
• Minerals and other micro-nutrients
• Assessment of nutritional status
• Diet counselling
• AAPD recommendations
• Nutrition affecting growth and development of infant to
Adolescent
• Nutrition considerations in children with special health Care
needs
• References
3

4. Questions asked previously
• Long essays
1. How is vitamin D formed & activated in the
body. How it regulates body calcium
pool.Add a note on hypo and
hypervitaminosis in growing child.
2. Discuss the role of nutrition in dental and
oral health of children.
3. Discuss the role of nutrition in a changing
society and their dental implications.
4

5. Short essays
1. Vitamin D & Calcium homeostasis
2. Relationship between diet, nutrition & dental caries.
3. Vitamin C
4. Trace elements in dental caries
5.Fat soluble vitamins
6.Dietary recommendations in children with caries risk
7. Balanced diet
8. Stepwise nutritional evaluation of a child
9.Diet diary
10. Diet counselling in rampant caries
5

6. definitions
6

7. DIET
It is referred to food
and drink regularly
consumed
Nizel 1989
Total oral intake of
substance that provide
nourishment and
energy.
7

8. NUTRITION
Who 1971
Science of food and
its relationship to
health.It is concerned
primarily with the part
played by the nutrients
in body
growth,development
and maintainence
The sum of processes
concerned in the
growth, maintenance
and repair of the living
body as a whole or of
its constituent parts.
8

9. FOOD
Any substance which
when taken into the
body of an organism
may be used either to
supply energy or to
build tissue.
Nizel 1989
Anything that is
eaten,drunk or
absorbed for
maintenance of
life,growth and
repair of the tissues
9

10. BMR
• Minimum energy required to carry out
essential life processes.

11. BALANCED DIET
• One which supplies all the nutrients in the
right quantity and proportion.
11

12. RDA
12
“levels of intake of
essential nutrients that
on a basis of
scientific knowledge are
adequate to meet the
known
nutrient needs of all
healthy persons.”
American food &
nutrition board
Assuming 2400 kcal as 1 unit of energy, RDA is
expressed as a proportion of this.(ICMR, Hyderabad)
Holliday and Segar formula
age of the child
Weech formula
For bedside approximation of expected weight and
height
Infant weight = (age in months)+9/2

13. Food group guide
13

14. Food guide pyramid
14

15. Food guide pyramid
15

16. FOOD PYRAMID
16

17. 17

18. COMPONENTS OF DIET
18
MAJOR NUTRIENTS
Carbohydrates: 65 to 80 per
cent
Proteins :7 to 15 per cent
Fats/lipids:10 to 30 per cent
TRACE NUTRIENTS
MICRO NUTRIENTS
RDA < 1mg/day
Vitamins
Minerals

19. Proteins
24 amino acids of which 9 are essential amino acids
and the remaining are non essential amino acids.
Functions
Body building
Tissue repair & maintenance
Synthesis of antibodies,plasma proteins,Hb,
Hormones,Enzymes
Deficiency:PEM
19

20. PEM
• First indicator: Underweight child
• Clinical forms: MARASMUS KWASHIORKOR
20

21. Kwashiorkor
21
Prof Cicely Williams
‘red boy’ “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

22. MARASMUS
.
• Affected children exhibit extreme wasting.
• Old man appearance to jaws and skin and bones.
• Wasting of brown fat occurs first.
• Marasmic Kwashiorkar: when marasmic children
develop oedema.
22
Greek word
Marasmos
=Wasting
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

23. Proteins & Oral health
Atrophy of the gingiva
Degeneration of cementum and supporting periodontal
tissues
23
Malocclusion In A Pem Child Hypoplasia Of Pem Child
Tongue: Bright
red,loss of
papilla,edema
Dry mouth
Fissured lip
Loss of
circumoral
pigmentation
Reduced caries
activity(Lack of
substrate)
Delayed
eruption

24. VITAMINS
• Vitamins and Minerals form the protective
foods and are also called functional foods.
• Vitamins do not yield energy but enable the
body to use other nutrients
24
Fat soluble
Water
soluble

25. Vitamin A
25
Importance
Plays an
important
role in Walds
visual cycle
Deficiency
-Night blindness
Xeropthalmia
-Bitots spots
Keratomalacia
Oral Manifestations
1. Keratinising Metaplasia of
epithelium(increased keratin
formation)
2. Occlusion of salivary gland
ducts with keratin.
3. Enamel hypoplasia
4. Atypical dentin formation
5. Epithelial invasion of
connective tissues
6. Delayed eruption of teeth.
RDA:
1500 IU (500 μg)

26. Vitamin D (Anti Rachitic Vitamin)
26
1,25 –DHCC is active form.
Acts like a hormone.
Calcitriol increases the serum
calcium & phosphorus level by
increasing intestinal absorbtion
& reducing renal excretion

27. Vitamin D (Anti Rachitic Vitamin)
27
Deficiency
Rickets in children
Osteomalacia in adults
Pigeon chest is a feature
Renal rickets (CRF)
Plasma
calcitriol
Alkaline
phosphatase
Oral manifestations
1. Delayed eruption of
primary & permanent
teeth.
2. Developmental
anomalies of enamel
and dentin
3. Wide predentin zone
4. Increased
interglobular dentin
5. Elongated pulp horns

28. Vitamin E(Shady lady of nutrition)
• Antioxidant
• Protects liver from toxic
compounds
• Maintains germinal health of
gonads
• Protects RBC from hemolysis
• Prevents heart disease by
preventing oxidation of LDL
• Decreased male fertility
• Enacephalomalcia
• Nutritional muscular
dystrophy
Deficiency • Loss of pigmentation
• Atrophic degenerative
changes in enamel.
• Derangement of
ameloblasts.
Oral
manifestations
28

29. Vitamin K(Coagulation vitamin)
• Brings about post translational
modification of 2,7,9,10 protein c
protein s factors.
• Deficiency is uncommon may result in
prolonged CT
• Prothrombin levels below 35% results
in bleeding on brushing.
• Below 20% results in spontaneous
bleeding.
29

30. Vitamin B1(THIAMINE)
Plays important role in metabolism of
carbohydrates, alcohol and branched
chain amino acids.
30
Deficiency is seen in populations consuming polished rice.
Dry beri beri (peripheral neuritis)
Wet beri beri( Cardiac manifestations)
Cerebral or Wernickes encephalopathy with Kosakoff’s psychosis.
Oral manifestations
Burning tongue
Senstive OMM
Loss of taste

31. Vitamin B2 (Riboflavin)
• Has a vital role in cellular oxidation.
• It is a cofactor in number of enzymes involved with energy
metabolism.
• Deficiency manifests as angular stomatitis,
cheilosis, atrophic papillae on tongue
• In severe cases, tongue becomes glazed and
smooth due to complete atrophy of papillae.
• Lips: red and shiny because of epithelial
desquamation.
31

32. Niacin
• Nicotinic acid is essential for metabolism of
carbohydrate, proteins, and fat.
• It is also essential for normal functioning of skin,
intestinal and nervous system.
• Part of NADP co-enzymes.
• Deficiency state is termed PELLAGRA which
leads to dermatitis, diarrhoea and dementia.
• Casal’s necklace and glove and stocking type
dermatitis occurs in the exposed parts..
• Glossitis & Stomatitis
32

33. Pyridoxine
33
•Plays an important role in the metabolism of
amino acids, fats, and carbohydrates
It keeps up the level of GABA, an
inhibitory neurotransmitter.
• Deficiency:
Peripheral Neuritis
Rashes
Convulsions
•Oral manifestations:
Cheilosis
Glossitis
Angular stomatitis

34. Folic acid
34
Folic acid plays an important role in the synthesis of
nucleic acids and development of Red blood cells in the
bone marrow.
Deficiency leads to megaloblastic anemia,
diarrhoea, and knuckle and periungual pigmentation.
Oral manifestations: Chelitis,glossitis
Preconceptional administration can prevent neural tube
defects in the baby.(RDA : 400mcg in pregnancy)

35. Vitamin B12(Cyanocobalamine)
35
Takes part in synthesis of fatty acids in myelin.
Essential in nucleic acid synthesis.
Deficiency leads to pernicious anemia,peripheral
neuritis,degeneration of spinal cord .
Oral Manifestations:
Sore painful tongue, glossitis and glossodynia
Beefy red tongue
Small shallow ulcers with atrophy of papillae with a
loss of normal muscle tone, called as Hunter’s
glossitis.

36. Vitamin C (Ascorbic Acid)
Functions
Converts proline to
hydroxyproline, which is a
constituent of collagen.
Involved in collagen synthesis
and teeth formation.
Increases iron absorption.
Acts as antioxidant due to its
reducing property.
Deficiency
Scurvy
Spongy ,sore gums,loose
teeth,anemia,swollen
joints,haemorrhage.
“Cork screw hair pattern”
“Woody legs”
Oral manifestations
Pathognomic signs swollen and
spongy papillae , particularly
interdental papillae producing
scurvy buds.
In severe cases haemorrhages
to periodontal membranes
followed by loose teeth.
36

37. Minerals
Major
Ca,P,Mg
Trace elements
with no known
function
Al,Hg,Pb
Trace elements
Fe,I,F,Mo,Se,Sn,
Ni,Si,Mo,Cr,Cu
37

38. Calcium
A major element of the body.
• Provides rigidity and strength to
bones and teeth.
• Calcium plays an important role
in blood coagulation, muscle
contraction, myocardial action,
and neuro muscular irritability
and is responsible for integrity
of various membranes.
38
Vitamin D
ParathhormoneCalcitonin
Deficiency
Osteomalacia, rickets, fracture
susceptible bones.
Impaired enamel apatite crystals
formation.
Low blood calcium causes TETANY.

39. Phosphorus
Second most abundant mineral.
Formation of bone and tooth.
Absorption and transport of nutrients.
Regulates acid – base balance.
energy released due to metabolism of carbohydrates, fats
and proteins is accomplished by phosphates (ADP).
Phosphates play an important role in cell protein
synthesis. It is a part of DNA and RNA.
39

40. Magnesium
Magnesium is essential for cellular respiration,
functioning chiefly as an activator for numerous
important coenzymes such as carboxylase and Co
enzyme A.
Plays an important role in synthesis of carbohydrates,
fats and proteins.
Helps in regulation of acid base balance of the
Magnesium is present in enamel and dentin but
more in dentin.
40
Magnesium
deficiency causes
chronic
malabsorption
syndrome, acute
diarrhea, renal
failure, weakness,
tremors,convulsions,
hyper excitability.

41. Iron
Iron is necessary for formation of hemoglobin, brain development and
function.
Regulates body temperature and muscle activity.
Increases the production of T CELLS.
It helps in the production of antibodies.
Iron binds oxygen to blood cells, and helps in oxygen transport and cell
respiration.
41

42. Iron Deficiency
42
Stages
1. Decreased storage of iron
without any detectable
abnormalities.
2. Intermediate deficiency of iron
stores getting exhausted
but no evidence of anemia.
3. Overt iron deficiency with
decreased hemoglobin
concentration.
less than 12
g/dl for a child.
Iron-deficiency anaemia –
hypochromic
microcytic anemia
characterized by low
serum iron, increased serum
iron-binding
capacity, decreased serum
ferritin, and
decreased marrow iron
stores.

43. Clinical features of Anemia
• Weakness, fatigue, pallor, tingling of extremities, brittle nails.
• Spoon shaped nails (koilonychias), altered hair growth.
ORAL MANIFESTATIONS
•Inflammation of the tongue, atrophy of tongue.
•Smooth shiny red appearance of tongue.
•Dysphagia, grayish mucous membrane.
•Angular stomatitis.
•Combination of above all features is termed as
• PLUMMER VINSON SYNDROME.
43

44. Iodine
• Iodine is an integral part of the thyroid
hormones THYROXIN and tri IODO THYRONINE
whose function is to maintain the control of
energy metabolism of the body.
44

45. Deficiency of Iodine
• Hypothyroidism
• CRETINISM and MYXEDEMA
are pathological conditions
• Skin is dry and coarse
• Metabolism is slow.
• Macroglossia
• Stunted growth, delayed tooth
eruption
• Retarded mental activity
45

46. Hyperthyroidism
• The excessive activity of the
thyroid gland that is
brought on by a deficiency
of iodine characterized by
increased pulse
rate,temperature and blood
pressure with nervousness ,
irritability,sweating, weight
loss, dyspnea, and
tiredness. Patients may also
develop EXOPTHALMOUS.
46

47. TRACE ELEMENTS AND DENTAL CARIES
• Aside from fluorine certain trace elements in diet possess
increased resistance or susceptibility to caries.
• Molybdenum(Hungary)
• Vanadium(Tank &
Storvick)
• Strontium(works with F)
CARIOSTATIC
• Selenium(Oregon)
• Magnesium
• Cadmium
CARIOGENIC

48. 48

49. Assessment of Nutritional status
1. Clinical examination.
2. Anthropometry.
3. Biochemical evaluation
4. Functional assessment.
5. Assessment of dietary intake.
6. Vital and health statistics
7. Ecological studies.
49

50. Clinical
examination
50

51. ANTHROPOMETRICS
• STATURE:CDC guidelines define a height-for
age value less than 5th percentile as short
stature.
• CHEST CIRCUMFERENCE:Measured at the
nipple midway between inspiration and
expiration.
51
Rayner and Rudolf
low weight
for-age is a
marker of
Failure to
thrive
Head circumference
35cm at birth
50 cm by 3 yrs

52. Laboratory & Biochemical tests
52

53. Assesment of dietary intake
Weightment of raw foods
Weightment of cooked foods
Oral questionnaire method
53
Types of diet surveys
- 24 Hour Recall Diet Surveys
- Food Frequency Questionnaire
- Diet History
- Food Diary

54. 24 hour dietary recall
• Does not truly represent intake
54

55. Food Frequency Questionnaire
• List of around 100
items +servings,
• Daily ,monthly
• Errors in noting
serving size
• Long,tedious
55

56. Diet history
• Interview method
56
• Establish overall eating
pattern
• 24 hour recall
• Household measures of
servings
First
part
• Cross check
• Food preferences
established
Second
part

57. Food diary
• Amount , frequency,
type of food
consumed
• Period of collection
1-7 days
• Reliable,but difficult
to maintain
57

58. 58

59. • Diet counseling (Katz 1981)- it is the correction of
diet imbalance that could affect the patients general
health and sometimes is also reflected in his oral
health.
59

60. Five ‘W’ and one ‘H’ of diet consultation
• WHO may be benefited?
• WHAT are the objectives of diet and nutrition counseling?
• WHY is counseling beneficial?
• WHEN is counseling conducted?
• WHERE should the counseling occur?
• HOW to counsel?
60

61. DENTAL HEALTH DIET SCORE
• Screening device
• Food score (adequate intake of foods from each of the food
groups) + Nutrient score(consuming foods from especially
recommended groups of ten nutrients) - Sweet score (frequent
ingestion of foods that are overtly sweet)
• 60-100- acceptable- dietary counselling not given unless
requested
• 56 or less indicated and recommended
61

62. Instruction for calculating a dental
health diet score
Record
(what,when,
how much)
Circled
Uncircled
Check
8 columns of
food
Check & add
nutrient
score(56)
62
Sweet
score
Put it all
together

63. Food group RDA NO.OF
SERVINGS
POINTS
MILK 3 X 8 HIGHEST
POSSIBLE
SCORE 24
MEAT 2 X 12 24
FRUITS AND
VEGETABLES
1 X 6 6
OTHERS 2 X 6 12
BREAD AND
CEREALS
4 X 6 24
FOOD GROUP SCORE 96 IS THE HIGHEST
63
FOOD GROUP EVALUATION CHART

64. Protein and Niacin
7
Vitamin A 7 Iron 7 Folic acid
Cheese
Dried beans
Dried peas
Eggs
Fish
Meat
Milk
Nuts
poultry
Apricot margarine
Broccoli milk
Butter peaches
Cantaloupe squashes
Carrots spinach
Eggs sweet
potato
Greens
Liver
Beef
Broccoli
Eggs
Green
leafy
vegetables
Liver
Oyster
Sardines
shrimp
Asparagus
Broccoli
Cereals
Kidney
Liver
Spinach yeasts
64
NUTRIENT EVALUATION CHART

65. Riboflavin 7 Ascorbic acid 7 Calcium and
phosphorus 7
Zinc 7
Broccoli
Chicken breasts
Eggs
Liver
Milk
Mushrooms
Pork
Okra
spinach
Broccoli
Grapefruit
Raspberries
Green peppers
Greens
Oranges
Strawberries
tomatoes
Broccoli
Cheese
Green leafy
vegetables
Milk
Oranges
String beans
Beef
Liver
Lobster
Oysters
shrimp
65

66. Step 4-Scoring the sweet
• Classify each sweet into liquid, solid and sticky or slowly dissolving
• For each time the sweet was eaten either at the end of a meal or
between meals(atleast 20 mins apart) place a check in the frequency
column
1. Add the checks
2. (Highest score-35)
66
FORM FREQUENCY POINTS
liquid 5
Solid and sticky 10
Slowly dissolving 15

67. Step 5
• Now put it all together
• Food group score
• 72-96-excellent
• 64-72-adequate
• 56-64-barely adequate nutrition counselling
• 56 or less-not adequate
67

68. • Sweet score
• 5 or less- excellent
• 10 -good
• 15 or more-watch out zone
• If your sweet score is in “watch out” zone your dentist will
talk about improvements
68

69. 69
Interviewing
• Separate room
• Indicates respect for
privacy
Physical Setting
• Eye contact
• Verbal,Non verbal
• Teaching,motivation
Effective
communication

70. Steps of decision making
Awareness
Interest
Involvement
Action
Habit
70

71. COUNSELLING APPROACHES
• Role of patient is passive
• Decision made by counselor
for patientDIRECTIVE
• Counselor’s role is merely to
aid the patient
• More recommendedNON-DIRECTIVE
71

72. NIZEL’S RULES
• 4 rules are
72
Maintain overall
nutrition
Vary slightly from the
normal diet pattern
Should meet body’s
requirements
Should take into
consideration
patient’s likes and
dislikes

73. Limit no. of eating to three meals per
day
Increase intake of protective food
Decrease carbohydrate
Wean from taste of sweet
Raw fruit and raw vegetable
Fluoridated water
73
For prevention of dental caries general principles
are as follows

74. Breast-feeding of infants
with care to wiping or
brushing as the first
primary tooth begins to
erupt
Educating association
between frequent
consumption of
carbohydrates and caries.
Educating about health
risks associated with excess
consumption of simple
carbohydrates, fat, saturated
fat, and sodium.
The AAPD encourages
74
Pediatric dentists and other
health care providers who treat
children to provide dietary and
nutrition counseling

75. Food and beverage
manufacturers to make
nutritional content on
food labels more
prominent and
“consumer-friendly”.
Furthermore the AAPD encourages
75
School health
education programs and
food services to
promote nutrition
programs
Pediatric dentists and other
health care providers to
recommend or prescribe
sugar-free medications
whenever possible.

76. Nutritional considerations from
infancy to adolescence
• 0-1 year
76
Milk substitutes:
Regular unmodified cow’s milk is not
suitable:
Insufficient source of vitamin C and iron.
It may cause gastrointestinal bleeding.
Its solute load is too heavy for the infant’s
renal system to handle .
Low-fat milk: should not be used,
Insufficient energy provision.
Lack of essential fatty acids
On guard against dehydration

77. Infant -Toddler
2 years
• Reduction in apetite
• Dietary needs for
proteins and minerals
remain high.
• During first two
years of life: 40-50%
of energy should
come from fat.
• Consume 3 regular
meals per day
77
Older than 2 years:
Roughly 30% should come from fat, with no
more than 10% from either saturated
fats or polyunsaturated fats.
Carbohydrates: 55-60% of calorie
requirements with no more than 10% from
simple
sugars.

78. Preschooler
3-6 years
78
• Physical growth occurs in spurts.
• Fewer calories are required, but relatively
high protein and mineral needs remain.
• Child should be helped to lose ‘baby fat’ by
increasing physical activity rather than by
severely restricting calories.
• Wholesome, nutritious, low sugar snacks
can promote adequate intake of essential
nutrients without adding calories or
promoting dental caries.

79. School going child(6-12 year)
• Decline in food
requirements per unit
body weight( Because
of reduction in growth
rate.)
• Children should be
encouraged to have
breakfast.
• Thus, emphasis on high
nutrient density : High
ratio of nutrients to
calories
79

80. Adolescence
12-18 years
• Peer pressure & sociocultural influence.
• Weight control
• Development of eating disorders.
• Cigarette smoking to lose weight
• Nutritional requirements are influenced primarily by onset of
puberty and the final growth spurt of childhood.
• Increased needs for energy, protein, minerals and vitamins.
• “Female athlete triad” : American College of Sports Medicine
(ACMS) in 1992.
Seen among adolescent female athletes
• Disordered eating behaviours
• Amenorrhoea
• Osteoporosis
80

81. Special children considerations
81
Estimated 40%
Factors to be considered
Decreased apetite
Parental overindulgence
,overprotection
Poor oral hygiene & prevention
Long term use of cariogenic
medications
Xerostomia

82. Recommendations(AAPD)
Dental home by
age 1
Oral hygiene
management(2-2-2
rule)
Antimicrobial
products
Remineralising
agents
Management of
pain & discomfort,
xerostomia
82

83. 83

84. REFERENCES
1. Nutrition in preventive dentistry – Nizel and Papas.277-308
2. Finn SB. Clinical Pedodontics. 4th edn. WB Saunders company,
Philadelphia;2004.
3. Damle SG. Textbook of pediatric dentistry. 4th edn.Arya Medi
Publications, New Delhi.2014.
4. Marwah N. Textbook of pediatric dentistry.3rd edn.
5. Tandon S. Textbook of Pedodontics. 2nd edn. Paras medical
publishers.2009
6. Diet Counselling – A Primordial Level of Prevention of Dental Caries. Dr.
Girish V Chour, Dr. Rashmi G Chour. IOSR .2014;13:64-70.
8. American Association of Pedodontics and American Academy of Pediatric
dentistry . Policy on dietary recommendations for infants children and
adolescents. Reference Manual; 37:no. 6.15-16.
84