Introduction Definitions Nutrition & Normal occlusion Calcium Phosphorous Vitamins D , A & C Nutritional deficiencies Nutrition & Dentofacial growth Role of Nutritional counseling Conclusion

1. Importance Of Nutrition
In
Orthodontic Treatment

2. Outline
Introduction
Definitions
Nutrition & Normal occlusion
Calcium
Phosphorous
Vitamins D , A & C

3. Nutritional deficiencies
Nutrition & Dentofacial growth
Role of Nutritional counseling
Conclusion

4. An old maxim of Medicine says
“Always remember you are treating a patient not
a disease “
Gulliford (1874) – dietary deficiencies as cause of malocclusion
Proper nutritional status
Proper response of bone to stimulation and reformation
Accomplishment of desired results

5. Definitions
 Nutrition – Nutrition is science of food, the nutrients &
other substance therein, there action and
interaction , & balance in relation to health &
disease, and the process by which the organism
ingests , digests ,absorbs , transports ,utilizes , and
excretes food substances.
Diet – Food & drink regularly consumed
Food –Any substance which when taken into body of an
organism may be used either to supply energy or build tissues

6. Nutrition ,Dentition & Normal Occlusion
Effect of Malnutrition
- Loss of teeth due to caries – local factor
-Severe caries in mixed dentition
Loss of arch length
-Periodontal disease- altered systemic
response to microbial plaque
e.g Scorbutic Gingivitis( Vit C deficiency)

7. Law of Minimum- Justus Von Liebig (1843)
…… among the substances nutritionaly essential for
growth, that one which is furnished to organism in minimum
amount will therby determine the rate of growth…..
Applicable to proteins but not to minerals
Children may grow to normal or average size inspite of
poor bone stucture.

8. Nutrient factors for Normal occlusal
Development
1. Carbohydrates – High intake interferes with appetite
-excludes other protective foods
2.Quality of Diet- Cariogenic foods- caries formation
Alkaline foods – high in vegetables & milk
reduce caries incidence
3.Minerals -Calcium- Phosphorous metabolism-vital for
bone & teeth

9. 4. Vitamins – Vit A & C for sound periodontal tissues,
Vit D – Normal bone physiology
5. Proteins – Sulfur containing amino acids
–collagen formation
6. Fats – Omega fatty acids – supportive role in calcium
metabolism

10. Calcium
Functions
1. Formation of bones and teeth
2. Maintainence of skeletal structure
3. Maintainence of normal memrane permeability
neuromuscular excitability, cardiac rhythum
4. Blood coagulation
5. Enzyme activation- succinic dehydrogenase ,
ATPase, proteolytic enzymes.
Sources
Milk, cheese, egg yolk, turnip green & cauliflower

11. Serum calcium levels- 9-11 mg /dl
Maintained by action of Parathyroids,Vit D
Requirements
National Research Council(US)
 New born infant - 360 mg
 Children & adults - 800mg
 Adolescents , Pregnancy & lactation – 1200mg
Minimum requirements – Not established

12. Factors affecting Plasma Calcium levels
1. Hormones
Parathyroid
Calcitonin
Thyroid
Vit D
Steroid hormones
2. Citrates, Phytates & Oxalates
3. Proteins
4. Lactose
5. Fatty acids

14. Calcium Deficiency
 Acute- Tetany – serum Ca levels < 6mg/dl
increased excitability of muscles- cramps
Chvostok’s sign, Carpopedal spasm
Chronic - Osteoporosis-weakening & fracture of long
bones

15. Calcium Supplements
Multivitamin tablets- Inadequate-RDA too high
Require adequate amount of Vit D, Fatty acids (omega 3
 better over 6)
Low fat milks- fortified with ergocalciferol
Calcium citrate &lactate – better over carbonates
& Gluconates
Best – Microcrystalline hydroxyapatite concentrate(MCHC)

16. Phosphorous
Functions
1. 80% - bones and teeth
2. Intermediate in fat & carbohydrate metabolism
“Phosphorylation”
3. Synthesis of phospholipids, nucleotides, energy
rich compounds
Serum levels – 2-4 mg /dl adults
3-5 mg / dl children
Regulation
PTH, alkaline phosphatase activity, Vit D

17.  Daily requirements
 Infants – 240 mg
 Adults – 800mg
 Pregnancy &lactation- 1200mg
 Deficiency - Rare
Along with Calcium, Vit D- Rickets & Osteomalacia

18. Vitamins
1.Vitamin D
-Prohormone
- Synthesized in skin by action of sunlight
- Antirachitic , Bone- builder vitamin
-Active form – 1,25 – dihydroxy cholecalciferol
Dietary sources-
Egg yolk , cod liver oil (richest),milk

19. Dietary ergosterol Endogenous 7- dehydrocholesterol
U.V. light U.V. light
Ergocalciferol (D2
) Cholecalciferal (D3
)
Hepatic 25 –hydroxylase
25 hydroxycholecalciferol
Renal 1 α - hydroxylase
1.25 dihydroxycholecalciferol
Increased intestinal Increased bone Ca
Increased renal Ca
Ca uptake mobilization reabsorption

20. Functions
Increases
 Ca & P absorption from intestine
 Calcification of bones
 Excretion of phosphate
 Citrate levels of blood, bone , kidney
 Activity of Phytase – hydrolyse phytic acid

21. Daily requirements
 400 IU
 Increased in pregnancy and lactation by 5mcg
Deficiency –
 Rickets – children
 Osteomalacia in adults

22. Rickets
Disorder of Vit D – Ca – P axis
Hypomineralized bone marix & failure of endochondral
ossification
Rats on rachitogenic diet
1.Cessation of calcification of epiphyseal disks
2.Increased width of disks
3.Continoued osteoid deposition
4.Bowing of legs

23. Effect on teeth – Mellanby
Wide Predentin zone and increased interglobular
dentin
Delayed eruption
Malalignment of teeth in Jaws
Increased caries index

24. HYPOPHOSPHATASIA
Deficiency of Alkaline Phosphatase
Diagnosis – Excretion of Phosphoethanolamine in urine
-Loosening and premature loss of primary incisors
HYPERVITAMINOSIS D
Decalcification of bones and poor calcification in developing
teeth

25. Vitamin A
aa:aa:
Antikeratinization Vitamin
Derived from naturally occurring carotenes
Sources
Carotenoids – leafy vegetables, carrots , turnip,
tomato
Animal sources- egg yolk, butter, fish oil, milk

26. Functions
1. Epithelial differentiation
deficiency- keratinising metaplasia
2. Normal formation of bones & teeth
3. Eyes- essential for dim light vision( rhodospin)
Daily Requirements
Infants –1500IU
Children-2000-3500IU
Adults – 500 IU
Pregnancy& lactation- 6000-8000IU

27. Dental changes in deficiency (Rats)
1. Failure of normal histodifferentiation and
morphodifferentiation of Odontogenic epithelium
2.Enamel hypoplasia
3. Interglobular dentin , pulpstones
4. Increased caries susceptibility
5. Retarded eruption
6 . Retarded development of alveolar process
7. Disturbances of Periodontal tissues

28. Vitamin C
Antiscorbutic vitamin
Sources – citrus fruits, guavas, berries , green vegetables
Functions
1. Redox reaction
2. Mobilization of iron from ferritin
3. Essential for activity of fibroblasts, osteoblasts
& odontoblasts
4. Role in collagen formation

29. Daily Requirements
Infants - 35mg
Adults - 60mg
Defeciency – Scurvy
Oral manifestations
1. Swollen , boggy gingiva
2. Spontaneous hemorrhages
3. Impaired wound healing
4. Severe case- Hemorrhages in
periodontal membrane, loss of alveolar bone.

30. Histologic features in mineralized tissues
“Scorbutic lattice”- inability to form osteoid
“ Trummer- field zone”
AO 1972
Co-relation of of dental & skelatal ages is
reduced during Vit C deficiency.
A0 1961
No difference in orthodontic tooth movement in
in scorbutic guinea pigs, although risk of tooth
mobility is increased.

31. Causes of nutritional deficiency
Inadequate intake
Abnormalities of digestion and assimilization
Endocrinal disturbances
Hereditary idiosyncrasies
Infectious diseases

32. Nutritional deficiencies – Why we are
concerned ?
Prevalence higher in developing countries
Urban population – even subclinical- can retard
dentofacial growth
Important factor causing fetal malformations of
jaws during pregnancy
Long term care – proper nutritional counselling

33. Effect of Nutritional deficiencies
Growth of jaw bones
Retarded development , Poor calcification
Development & eruption of teeth
1. Systemic effect
2. Local effect
Soft tissues- Periodontium is most sensitive

34. Nutritional deficiency & Dentofacial growth
Short periods of malnutrition retards growth
As diet is adequately supplemented
Growth resumes
‘CATCH UP’ Growth
In general bone is more affected than teeth
Dentin –Calcium deficiency
Bone – Phosphorous deficiency

35. Nutrition – Dentofacial growth and
development
Prenatal Nutritional Deficiency
 Affects in later part of antenatal life
 Factors affecting DNA & RNA synthesis are major
culprits
 Animal experiments- Riboflavin deficiency
Shortening of mandible
Cleft palate
 Iodine deficiency- cretinism
Macroglossia
 Vitamin D – Fetal ricketts

36. Van Crevald – studied children with cleft palate,
micrognathia –extremely deficient maternal diet
during prenatal period
Nutritional demands are increased during prenatal
period
 -Supplementation over RDA must be provided
1. Iron
2. Folic acid
3. Riboflavin
4. Calcium
5. Vit D
Intake of too much Vit A , K & D can produce skeletal
malformations.

37. l
Adequate nutrition-essential for normal growth
-cannot stimulate growth
Active development of hard tissues of oral cavity
Increased demand of calcium, phosphorus, proteins
& Vit D
Diet – 2 types of effects
Systemic effects
- Calcification of teeth
-Eruption
-Growth of jaw bones

38. Local effects-
 Food composition
e.g sugars- caries
 Food consistency
Coarser diets
– increased jaw size
- increased arch length
- lesser crowding
-well developed masticatory
muscles

39. Softer diets
 Animal studies(AMJO I973)
 Comparison of rural and urban populations
 Secular trends

40. Animal studies
Morphologic effects
 Lower level of posterior eruption
 Narrow maxillary arches
 Shorter mandible , thinner condyles
 Decreased tone of temporal and massetor
 Shorter skull-linear dimension

41. Rural and urban population comparison
Study of Australian aborigines – Change to modern
diets Decreased arch length
Study of South American natives – Increased in occlusal
pathologic conditions
Secular trends
Change in skull proportions
Head and face – taller and narrower

43. NUTRITION AND MALOCCLUSION
Increased anterior open bites
Increased cleft lip & palates
Reduction in dental arch dimensions
Insufficient eruption
Shorter root length
Reduction in mesio –distal Diameter of third molars

44. Howe (1927) - Monkeys on Vit C & D deficient diets
Narrow arches , Proclined lower incisors
Levy (1951) –Pyridoxine deficiency in mice – abnormalities
in condyle
Parker et al (AO 1952)- Cephalometric studies in
malnourished
children
-Increase in N-A- P angle
-Increased difference in SNA & SNB angle
- Decreased effect with age

45. Nutritional Counseling
Balanced diet- all essential nutrients
 Proteins- essential amino acids
 Lipids - essential fatty acids, 30% energy
 Carbohydrates- 60% energy
 Minerals
 Vitamins
 Water
 Roughage

46.  Factors to be considered
1. Age
2. Sex
3. Body build
4. Occupation
5. Climatic conditions
6. Physiologic state
a. Pregnancy & lactation
b. Disease & pathologic conditions

47. Daily Food Guide
Basic Four food Groups
1. Meat, Poultry, Fish & Beans Group
- 2 basic servings(2-3 oz)
2.Milk & Cheese group
2-4 servings (8 oz)
3. Vegetable & fruit group
4 basic servings(1/2 cup)
4. Bread & Cereal group
4 servings (1 oz)

48. Dietary Guidelines
 Eat variety
Maintain ideal weight
Avoid too much saturated fat & cholesterol
Eat food with adequate starch and fibres
Avoid too much of sugar & sodium
If you take alcohol- do so in moderation

49. Summary and Conclusion
Nutrition - Important for overall growth & development
Influence of nutrition on dentofacial growth- starts from
Prenatal life
Special need of Ca, P Vit A,C &D for dentofacial development
Vit D- Special importance for children undergoing orthodontic
treatment
Effective dietary counseling during treatment ensures
favorable environment for dentofacial changes

50. THANK YOU