Nutrition

And
Periodontium

Dr. Nikhat Fatima Dept of periodontics

LOGO
 Contents
 Introduction
 Malnutrition and generalized dietary
inadequacy in periodontal disease
 Host nutrition and plaque biofilm
 Interaction of immunity, infection, and
nutritional status
 Effects of nutrition on the immune response
 Protein deficiency and periodontal disease
 Vitamins and their systemic effects and
periodontium
 Trace elements
 Diet counseling
 Conclusion

LOGO
 Introduction

"Let your Foods be your

medicines, and your
medicines your food."
Hippocrates 460 - 377 BC
Father of Modern Medicine

LOGO
 Although dental plaque is the
major etiologic factor in
periodontal disease, inadequate
nutrition may alter the host
response to bacterial irritants
and render the host more
susceptible to establishment or
progression of periodontal
disease.
Nutritional disorders may arise due to :

 Inadequate dietary intake.

 Disturbances in the absorption of

nutrients.

 Economic and educational limitations.

 Self-imposed dietary restrictions.

 Geographic isolation from adequate

food supply.
Alfano (1976) suggested the following factors
affected in nutritional deficiencies:
 Protein and urea contents of both saliva and
crevicular fluid.
 Integrity of the dentogingival barrier and the
turnover of its constituent cells.
 Mobilization and activation of PMNs in the
early inflammatory response.
 Activation of lymphocytes and the production
of immunoglobulins in the immune response.
Malnutrition and generalized dietary
inadequacy in periodontal disease
 Today the world faces two kinds of
malnutrition, one associated with hunger
or nutritional deficiency and the other
with dietary excess. Urbanization and
economic development result in rapid
changes in diets and lifestyles.

 Several studies by Mehta et al (1959),

Sanjana et al (1958), Green (1960),
Ramfjord (1961) etc have reported a high
prevalence of periodontal disease in
rural populations in countries where
nutritionally inadequate diets are
common.
 Russell et al 1961, found no association
between periodontal disease and the
plasma levels of protein, ascorbic acid, vit.
A and carotene in Alaskan Eskimos and
also in Southern Vietnamese.

 Generally, elderly have a tendency to be

more prone for nutritional inadequacy. A
data collected by The Agriculture Human
Nutrition Research Center at Tufts
University (Massachusetts, USA) on elderly
people at least of 60 years age reveals
lower levels of vit. K and B12, riboflavin,
thiamine, folate and tocopherol with a high
degree of periodontal destruction and
recession.
 Host nutrition and plaque biofilm

 Nutrition has both direct and indirect effects

on the development and composition of
plaque biofilm.

 The primary mechanism by which nutrition

impacts the biofilm is through a direct supply
of specific nutrients (such as sucrose) as
substrates for energy, nitrogen, or carbon for
the bacteria. An example of this is the
introduction of excess glucose to a plaque
biofilm, which has been shown to result in an
increased rate of bacterial growth in the early
stages of biofilm development
 The second mechanism by which
nutrition has an (indirect) impact on
plaque biofilm is by having an effect
on the production of metabolic by-
products from one organism that
provide nutrients for other organisms.
These by-products include lactate and
formate from Streptococcus and
Actinomyces species, which are used
as nutrients by other bacteria.
 The third mechanism by which
nutrition impacts the biofilm is
through the production of specific
polymers used by other bacteria.
 An example of this is the use of sucrose to
produce the glucans used to facilitate the
adherence of bacteria such as
Streptococcus mutans and Streptococcus
sobrinus to the dental pellicle.

 Glucose and other carbohydrates are also

used to produce extracellular
polysaccharides and, therefore, diets
containing sucrose, glucose, and other
disaccharides can increase the plaque
mass and facilitate the retention and
colonization of the plaque biofilm.
 Finally, nutrition impacts the plaque
biofilm indirectly through byproducts of
bacterial metabolism of a nutrient to alter
the environment of the biofilm and
thereby influence the bacteria colonizing
the biofilm.

 As a by-product of the metabolism of

sucrose and glucose, bacteria produce
acids that lower the pH, resulting in a
more favorable environment for the
development of certain bacteria such as
S. mutans.
 Interaction of
immunity, infection,
and nutritional status
• Nutrition is a "critical determinant of
immune responses" due to the fact that
nutrients derived from food sources such
as proteins, carbohydrates, and fats as well
as micronutrients, vitamins, and minerals
interact with immune cells in the blood
stream, lymph nodes and specialized
immune system of the gastrointestinal tract.
The effects of these nutrients are
dependent on several factors:

(1) The concentration of a nutrient and its

interactions with other key nutrients.

(2) The duration of the nutrient imbalance,

and

(3) The age of the host. Conversely, a

majority of nutrient deficiencies will
impair the immune response and
predispose the individual to infection.
In periodontal disease, the host immune
system responds to a bacterial challenge with
a well-regulated response consisting of:
(l) Innate factors that signal the endothelium
to initiate an inflammatory response.
(2) Neutrophils that attempt to protect the
periodontal tissues by controlling
pathogens in an acute inflammatory
response, and
(3) A chronic inflammatory response that
ensues in which the macrophages and
lymphocytes try to manage the local
infection to prevent it from becoming
systemic and life threatening.
 Effects of
nutrition on
the immune
response
Nutrient Function Deficiency impact on
immune response

Protein energy intake Energy metabolism ↓ salivary antimicrobial

properties
DNA/RNA synthesis
↓immunoglobulin
production
↓ lysozymes
↓ activation of
lymphocytes
↓ production of antibodies
↑ bacterial adhesion
Vitamin A Cellular differentiation and ↓ immune cell
proliferation differentiation
Integrity of the immune ↓ response to antigens
system ↓ antibody production
↓ production of
lymphocytes
↑ bacterial adhesion
Vitamin E Anti oxidant protecting ↓ antibody production
lipid membranes from ↓ response of
oxidation lymphocytes
↓ phagocytic function

Vitamin C Anti oxidant that reduces ↓ phagocytic function of

free radicals that cause neutrophils and
DNA damage to immune macrophages
cells ↓ antibody response
↓ cytotoxic T-cell activity
Riboflavin, Vitamin Coenzymes in ↓ antibody production
B6, and Pantothenic metabolic processes ↓ cytotoxic T-cell
acid activity
↓ lymphocyte response
Folic acid and Involved in DNA/RNA ↓ production of
synthesis lymphocytes
Vitamin B12
↓ cytotoxic T-cell activity
↓ phagocytic function of
neutrophils
 More than 100 ↓ antibody
Zinc enzymes response
associated with ↓ phagocytic
carbohydrate and function of
energy macrophages
metabolism ↓ B- cell and T- cell
Protein catabolism proliferation
and synthesis
Nucleic acid
synthesis
Involved in ↓ lymphocyte
Iron hemoglobin, proliferation
myoglobin and ↓ neutrophil
cytochrome cytotoxic activity
systems ↓ antibody
response
 Protein deficiency and periodontal disease

• Proteins are the constituents of organic

matrices of all the dental tissues including
alveolar bone and periodontal ligament.

• The integrity of the periodontal ligament, the

fibers of which are remodelled constantly is
dependent on a protein supply.
• Early research on experimental animals
revealed dystrophic changes in the
periodontal ligament, decreased cementum
formation, osteoporosis, resorption of the
alveolar bone and marked degeneration of
periodontal support in protein deprivation.

• Studies on the effects of protein

supplements on the periodontal structures
in humans by Ringsdorf and Cheraskin in
1960s revealed that a high – protein and low-
carbohydrate diet had a significant effect in
reducing mobility, sulcus depth and in
improving gingival health.
 The severity and the extent of immune
dysfunction in malnutrition are dependent
on several factors that include:

(1) The rate of cell proliferation

(2) The amount and rate of protein

synthesis, and

(3) The role of nutrients in the

various metabolic pathways.
Vitamins and systemic effects
NUTRIENT FUNCTION DEFICIENCY FOOD SOURCE
DISEASE

Vitamin A (retinol, •Fat soluble •Night blindness Egg yolk, liver, fish
provitamin A •Antioxidant •Xerophthalmia liver oils, fortified
carotene) •Bone and tooth •Poor growth milk, cream,
development cheeses; green
•Keratinization of leafy vegetables;
•Skin and mucous epithelium orange, red, yellow
membrane integrity •Dry, scaly skin pigmented fruits
•Cell differentiation; •Toxic in large and vegetables
essential for doses: double
reproduction vision, hair loss, dry
•Vision in dim light mucous
•Immune system membranes, joint
integrity pain, liver damage
Vitamin D •Fat soluble •Rickets in children Exposure to UV
(calciferol) •Aids in the absorption •Osteomalacia in sunlight, fortified milk,
of calcium and adults fish oils
phosphorus •Osteoporosis
•Mineralization of •Toxic in large doses:
bone calcification of soft
tissues, growth
retardation
Vitamin E •Fat soluble •Low incidence of Whole grains, wheat
(tocopherol) •Antioxidant deficiency germ, plant oils,
•Low toxicity margarines, legumes,
seeds, nuts, greens

Vitamin K (quinone) •Fat soluble •Prolonged clotting Synthesized by

•Synthesis of time intestinal bacterial
prothrombin in blood •Hemorrhage flora; dark green leafy
clotting and bone •Toxic in large doses vegetables, liver
proteins (patients on blood
thinners need to limit
use in diet)
Thiamin •Acts as coenzyme in •Beri-beri: weight loss, Enriched whole grains
carbohydrate and amino fatigue, edema, and cereals, pork, meats,
(vitamin B1) acid metabolism depression poultry, nuts, seeds,
•Essential for synthesis of Toxicity: not seen legumes
healthy nerves

•Coenzyme in energy •Ariboflavinosis Milk, cheese, enriched

Riboflavin metabolism of fat, •Angular cheilosis and whole grains and
(vitamin B2) carbohydrate, and protein •Growth failure cereals, rice, mushrooms,
liver
•Eye disorders
•Toxicity: not seen

Coenzyme in energy •Pellagra: diarrhea, Enriched whole grains

Niacin metabolism of fat, dermatitis, dementia, and and cereals, rice, meat,
(vitamin B3) carbohydrate, and protein death poultry, fish, green leafy
vegetables
•Toxicity: not seen in food
sources
•Toxicity with large doses
of supplements for
treatment of hyper-
cholesterolemia (skin
redness and flushing,
gastric ulcers)
Pyridoxine •Coenzyme in •Dermatitis Widespread food
(vitamin B6) amino acid and lipid •Depression sources with the
metabolism •Convulsions exception of fat and
•Hemoglobin sugar
•Peripheral neuritis
synthesis
•Toxicity not seen in
•Homocysteine food sources
metabolism
•Toxicity from
supplements:
neuropathy,
irreversible nerve
damage

Cobalamin •Maturation of RBC •Pernicious anemia All animal foods,

(vitamin B12) •Requires intrinsic secondary to lack fortified cereals
factor from parietal of intrinsic factor
cells for absorption and total vegetarian
•Cofactor in folate diet
and homocysteine •Toxicity: not seen
metabolism
Folate (folic acid) •Maturation of RBC •Megaloblastic Green leafy
•DNA synthesis anemia, vegetables, fruits,
•Homocysteine •Neural tube legumes, fortified
metabolism defects: spina bifida grains
•Masks B12
deficiency
•Toxicity: not seen

Ascorbic Acid Antioxidant •Scurvy Citrus fruits,

(vitamin C) Collagen synthesis •Poor wound broccoli,
Wound healing healing strawberries,
•Petechial peppers, tomatoes,
Aids in absorption cantaloupe
of iron hemorrhages
•Increased
periodontal
symptoms
•Toxicity: potential
for rebound scurvy
• Vitamin C or ascorbic acid is essential
for the formation of collagen and
intercellular material, bone and teeth,
and for the healing of wounds.

• It helps maintain elasticity of the skin,

aids the absorption of iron, and
improves resistance to infection
(Mazzotta 1994).
• Humans are among the few mammals
unable to synthesize ascorbic acid in the
liver.

• Vitamin – C / L- ascorbic acid is the anti-

scorbutic vitamin.
• Present in a range of fresh fruits and
vegetables and human milk. Most
abundantly found in citrus fruits.
• The body is unable to produce
this vitamin endogenously and
is totally dependent on dietary
intake.
• A dietary deficiency of vit. C
produces scurvy which is a rare
entity in contemporary society, but
occasionally diagnosed in the
elderly, living alone at home,
alcoholics, dietary faddists, infants
who are fed exclusively on sterilized
milk and food.

• Recommended daily intake – 60

mg/day.
• Ascorbic acid contributes to
the formation of collagen, bone
matrix (glycosaminoglycans),
and the intercellular cement
substance of the endothelial
compartment in the vascular
tree.

• It helps in the hydroxylation of

lysine and proline which
occurs in the formation or
synthesis of collagen molecule.
• It is also associated with alkaline
phosphatase enzyme, the activity of
which is reduced in ascorbic acid-
deficiency.
• The concentration of ascorbic
acid in W B Cs is about
16mg/100ml of blood, which is
higher than that of plasma 0.5
– 1mg/100ml.

• The plasma level of the

vitamin fluctuates with a
fluctuation in the diet, nicotine
intake and the use of oral
contraceptives.
• The vitamin is important in
maintaining the function of
the WBCs.

• A deficiency of ascorbic acid

impairs the phagocytic
activity of the leucocytes,
thereby increasing the
vulnerability of dentogingival
junction.
• Ascorbic acid supplements
help in the stimulation of
Hexose monophosphate
shunt of neutrophils thus
increasing their
chemotactic ability.
Clinical features of scurvy

• Signs – Petechiae, ecchymoses

and spontaneous bruising of the
extremities.

• Haematuria, epistaxis, bleeding

into the tissues, joints and muscles
occur.
Scurvy – Clinical features
• Vascular congestion in the hair
follicles leads to enlargement,
keratosis and a localized reddening of
the skin.
• Hemorrhages in the sub
periosteal region of long bones
cause severe pain and
tenderness.

• Anemia may result from blood

loss.
• Generalized lethargy and increased
susceptibility to infections.

• Wound healing is delayed particularly

in deeper layers that rely on capillary
growth and the production of collagen
fibers for successful organization.
Periodontal features of scurvy
• Gingiva is often swollen, red and edematous.

• Inflammation often involves free gingiva,

attached gingiva and alveolar mucosa.
• Gingiva becomes brilliant red, tender and
grossly swollen.

• Spontaneous bleeding or bleeding on gentle

stimulation such that while chewing is
common.
• On long standing, the color may
change to dark blue or purple.

• Ulceration may occur leading to

secondary infections.

• Alveolar bone resorption with

increased tooth mobility is seen.
Histopathological features
• Pathological changes are evident in both
epithelium and connective tissue.

• Epithelium
– Undergoes thinning and show spongiosis.
– Blood exudates through the breaks in the
epithelial layer in severe atrophy.

• Connective tissue – Structural

disorganization with poorly formed collagen
fibers and many thin walled and leaking
blood vessels.
Evidence for the role of ascorbic acid in
periodontal disease

• In most classical and widely quoted

study on the nutrition by Crandon et al
in 1940, Crandon himself consumed a
vitamin C – deficient diet for 6 months
and found a slightly boggy gingiva at
the end of 5th month.

• At this time, irregularities of lamina

dura occurred, although the oral
changes occurred almost 2 months
after the detection of skin lesions.
• Aurer – Kozelj (1982) et al found
marked changes in the gingival
epithelium and connective tissue
such as increase in length and
surface area of desmosomal
attachment, and increase in the
number of collagen-producing
fibroblasts on daily 70mg
supplementation of ascorbic acid
for 6 weeks.
• The use of vitamin C in the treatment
of ascorbutic patients with
periodontal disease is now outdated.
Local treatments like SRP are more
effective when combined with
dietary supplementation.

• The excessive intake of ascorbic

acid may however precipitate
problems such as renal calculi and
diarrhea and also can interfere with
the action of certain drugs like
aspirin and Warfarin. Hence their
use should be carefully monitored.
Vitamin B-complex
• The vitamin B-complex refers to all of the known
essential water-soluble vitamins except for
vitamin C. These include:

1. Thiamine (vitamin B1)

2. Riboflavin (vitamin B2)
3. Niacin (vitamin B3)
4. Pantothenic acid (vitamin B5)
5. Pyridoxine (vitamin B6)
6. Biotin
7. Folic acid and
8. The cobalamins (vitamin B12).
 Vitamin B1 (thiamin)
• A deficiency in thiamin intake leads to a
severely reduced capacity of cells to
generate energy.

• The earliest symptoms of thiamin

deficiency include constipation, appetite
suppression, and nausea, mental
depression, peripheral neuropathy, and
fatigue.
• Chronic thiamin deficiency leads to more severe
neurological symptoms and to cardiovascular and
musculature defects (Winston et al. 2000).

• Severe thiamin deficiency diseases include beriberi,

which results from a diet that is carbohydrate rich
and thiamin deficient, and Wernicke - Korsakoff
syndrome, most commonly found in patients with
chronic alcoholism due to their poor dietetic life
styles (Bohmer 2001).
 Vitamin B2 (riboflavin)
• Riboflavin deficiencies are rare in
developed countries due to the presence
of adequate amounts of the vitamin in
eggs, milk, meat, and cereals (Subar et al.
1995).

• Riboflavin deficiency is also often seen in

chronic alcoholics due to their poor
dietetic habits. Symptoms associated
with riboflavin deficiency include
glossitis, seborrhea, angular stomatitis,
cheilosis, and photophobia.
 Vitamin B3 (niacin)
• A diet deficient in niacin leads to glossitis,
dermatitis, weight loss, diarrhea, depression and
dementia.

• The severe symptoms of depression, dermatitis,

and diarrhea are associated with the condition
known as pellagra.
• Several physiological conditions (e.g.
Hartnup disease and malignant
carcinoid syndrome) as well as certain
drug therapies (e.g. isoniazid) can
lead to niacin deficiency (Carpenter
1983).
Pellagra

Ariboflavinosis
 Vitamin B5 (pantothenic acid)
• Deficiency of pantothenic acid is rare due to its
widespread distribution in whole-grain cereals,
legumes, and meat.

• Symptoms of pantothenic acid deficiency are

difficult to assess since they are subtle and
resemble those of other vitamin B deficiencies
(Schwabedal et al. 1985).
 Vitamin B6 (pyridoxine)

• The requirement for vitamin B6 in the diet is

proportional to the level of protein
consumption ranging from 1.4- 2 mg/day for
a normal adult.

• During pregnancy and lactation, the

requirement for vitamin B6 increases
approximately 0.6mg/day.
• Deficiencies of vitamin
B6 are rare and are
usually related to an
overall deficiency of all
the B-complex vitamins.
 VitaminB7 (biotin)

• Biotin is found in numerous foods and is also

synthesized by intestinal bacteria, making
deficiencies of the vitamin rare.

• Deficiencies are generally seen only after long

antibiotic therapies, which deplete the intestinal
flora.
 Vitamin B12 (cobalamin)
• Vitamin B12 is synthesized exclusively by
microorganisms and is found in the liver of
animals bound to protein as methycobalamin or
5'-deoxyadenosylcobalamin.

• The vitamin must be hydrolyzed from protein in

order to be active.
• Pernicious anemia is a
megaloblastic anemia
resulting from vitamin
B12 deficiency that
develops as a result of a
lack of intrinsic factor in
the stomach leading to
malabsorption of the
vitamin.
• The anemia results from impaired
DNA synthesis due to a block in
purine and thymidine biosynthesis.
(Andres et al. 2001, Antony 2001,
Peracchi et al. 2001).
Folic acid
• 50 – 90% of folate is destroyed in
cooking, canning and other processing.

The predominant causes of folate

deficiency are:

• Impaired absorption or metabolism -

Certain drugs such as anticonvulsants
and oral contraceptives.

• Increased demand for the vitamin- Poor

dietary habits
• Daily folate requirement is
dependent on metabolic and
cell turnover rates.

• Stress, such as infections

increases metabolic rate and
therefore increases folate
requirements.
• Deficiency of folate leads to impaired
DNA production and asynchronism
between protein synthesis and cell
division which prevent cell maturation
from reaching completion, as a
consequence of which epithelial
barrier function is impaired.

• Folate deficiency has also been

related to a decrease in host
immunocompetence.
• Vogel and his colleagues postulated a
sub-optimal end-organ levels of folate in
gingival tissues compared to the serum
levels in folate deficiency, which can be
increased by the use of folate mouth
rinses.
• Changes in female sex hormone levels, as
seen during ovulation, menstruation and
pregnancy and in women taking oral
contraceptives are associated with a
decreased resistance of the periodontium to
local etiologic factors, thereby resulting in
increased gingival inflammation

• Vogel and his associates postulated that the

decreased resistance of the gingiva to
inflammatory changes associated with
pregnancy and the use of oral contraceptives
may be related in part to the suboptimal levels
of folic acid in the gingiva.
• The results of the Vogel study indicated
that the women on oral contraceptives
develop megaloblastic changes in the
sulcular epithelium, which are reversed on
folate supplementation for 60 days. This
reduction is attributable to a decrease in
permeability of the sulcular epithelium,
thereby decreasing gingival inflammation.
• Phenytoin is also reported to interfere
with the absorption and cellular
utilization of folic acid

• Vogel has hypothesized that the

pheyntoin – induced aberration of folate
metabolism could render the gingiva
more susceptible to irritation from local
etiologic factors, thereby enhancing
susceptibility to gingival overgrowth.
• Vogel reported a decreased incidence
and severity of phenytoin – induced
gingival overgrowth in cats receiving
both phenytoin and folic acid as
compared with controls.

• But no human controlled studies exist

regarding the effect of folic acid
supplementation on phenytoin – induced
gingival overgrowth
Water-soluble vitamins and immune
function

• Water-soluble vitamins are involved in RNA

and DNA synthesis and in cellular
metabolism, and hence deficiencies are likely
to impact proliferation of immune cells
deficiencies.

• Moderate deficiencies of vitamin C result in a

decrease in locomotion and a reduction in the
bactericidal capacity of neutrophils and
macrophages.
• In animals, folic acid riboflavin, and
panthothenic acid deficiencies cause
reductions in T-cell cytotoxicity, reduced
lymphocyte response to antigens, and a
decrease in antibody formation.

• Both folic acid and panthothenic acid had a

greater impairment of antibody response
than when either nutrient was deficient
alone. These changes are primarily due to
the function of these B vitamins as
coenzymes in many metabolic processes.
Fat-soluble vitamins
 Vitamin A

 Essential for normal function of the

retina, growth, differentiation and
maintenance of epithelial tissues and for
bone growth and embryonic
development.

 Vitamin A is present in dairy products,

fish –liver oils, and meats.

LOGO
  The storage of vitamin A in the
body is enhanced by vitamin E.

 Vitamin A deficiency causes

marked epithelial hyperplasia
and reduced cellular
differentiation in animals.

LOGO
 Vitamin A and periodontal disease

 Avitaminosis in the soft tissues

produces localized gingival recession,
epithelial hypertrophy and hyperplasia
in animals- (Glickman and Stoller 1948,
Miglani 1959.)

 It is unlikely that a deficiency of vitamin

alone will cause gingivitis and local
irritation is necessary before an
inflammatory response is observed.

LOGO
  In the vitamin A deficiency,
changes in the alveolar bone is
evident.

 The bony trabeculae are replaced

with fibrous connective tissue,
reduced bone formation and
increased thickness of bone and
greater deposition on the labial
aspect of the cortical plates due to
the inhibition of osteoclast
function.

LOGO
  Osteoblast function is also reduced
but the magnitude of osteoclast
functional reduction is more than
osteoblasts

 Cerna et al 1984 suggested that an

increase in serum vitamin A may be
responsible for improved periodontal
health seen in studies on vitamin E,
as that vitamin is known to inhibit the
oxidation of vitamin A.

LOGO
 Vitamin E

 Vitamin E ( - tocopherol) occurs in

wheat germ oil, animal fats and
grain.

 Its deficiency in animals causes

spontaneous abortions and impaired
spermatogenesis.

 It acts as a lipid antioxidant and it

has an important role in maintaining
the stability of cell membranes and
protecting RBCs against hemolysis.

LOGO
Role of vitamin E in periodontal disease

 The possible role of vitamin E in the

management of periodontal disease is
based upon its ability to interfere with
prostaglandin synthesis, which
themselves are important in the
development of inflammation.

 Fiala and Coworkers 1969 have reported

less gingival bleeding in patients with
relatively high vitamin E blood levels.

LOGO
  A specific correlation between
vitamin E deficiency and periodontal
disease will be difficult if not
impossible to determine. This is due
to the wide distribution of the
vitamin in oils, fats and grains and
the relatively high prevalence of
periodontal disease.

LOGO
 Vitamin D, Calcium and phosphate

 Vitamin D (cholecalciferol) itself is

inactive but is converted to the active
form 1,25 dihydroxy cholecalciferol by
two hydroxylation reactions which occur
in the liver and kidney.

 The active form of vitamin D promotes

the retention of calcium and phosphate
in the body.

LOGO
  The principal actions of vitamin D are to
increase the absorption of calcium in
the small intestine and to mobilize
calcium from formed bone (in an
attempt to maintain plasma levels).

 With advancing age, the hormonal

metabolite of vitamin D can be reduced
in some individuals that may lead to a
reduced absorption of calcium,
resulting in secondary
hyperparathyroidism and bone
resorption – Bland 1984.

LOGO
  Oliver and his coworkers (1972)
worked on rats and proposed that a
deficiency of vit. D and calcium,
caused reduction of alveolar bone
mass and greater areas of
unmineralized osteoid and the number
and diameter of dentoalveolar fibers
of periodontal ligament were reduced.

LOGO
 Becks 1942 proposed periodontal effects or
overdosing with vitamin D in dogs which are:

 Increased osteoblastic activity,

 Pathologic calcification of the periodontal

membrane and gingiva,

 Osteosclerosis of the alveolar bone and

 Marked hypercementosis

LOGO
 Dietary calcium

 Of the body calcium, about 99% is in the

bones and teeth, where it plays a structural
role, while the remaining 1% is present in
body tissues and fluids, where it is essential
for cell metabolism, muscle contraction, and
nerve impulse transmission.

 A continuous exchange of calcium exists

between the skeleton, blood, and other parts
of the body, and is closely controlled by
specific hormones.

LOGO
  Calcium can also bind to a wide range of
proteins, altering their biological activity
that makes it important in nerve impulse
transmission and muscle contraction, and
is also involved in blood clotting due to its
activation of clotting factors.

LOGO
  A low level of calcium in the blood and
tissues can cause hypocalcemia.

 Excess calcium in the blood can cause

nausea, vomiting, and calcium
deposition in the heart and kidneys, as
a result of excessive doses of vitamin
D.

 Osteoporosis involves loss of calcium

from the bones and reduced bone
density, which causes bones to be
brittle and liable to fracture.
LOGO
  Osteoporosis involves loss of calcium from
the bones and reduced bone density, which
causes bones to be brittle and liable to
fracture.

 A low level of calcium in the blood and tissues

can cause hypocalcemia.

 Excess calcium in the blood can cause

nausea, vomiting, and calcium deposition in
the heart and kidneys, as a result of excessive
doses of vitamin D.

LOGO
Fat-soluble vitamins and immune function

Vitamin A deficiency:
 Decreased antigen-specific
responses and antibody production.
 Bacterial adherence to epithelial cells
is enhanced

 Vitamin A supplementation in deficiency

enhances antibody levels and
lymphocyte proliferation

LOGO
 Vitamin E deficiency

 Vitamin E is a lipid-soluble antioxidant

whose primary function is to reduce
damage to lipid membranes.

 In animal studies, vitamin E deficiency

impairs adaptive immunity and results in a
reduction in antibody synthesis.

 Vitamin E supplementation has been

reported to enhance both innate and
adaptive immunity

LOGO
LOGO
 Trace elements

 Copper
 Calcium
 Phosphorus
 Magnesium
 Fluoride
 Iron
 Zinc

LOGO
Alterations in serum levels of trace elements are more likely to be
a result of the periodontal disease process rather than a
consequence of variations in dietary intake.
Calcium • Muscle Osteoporosis Dairy products,
contraction Incomplete fortified
• Blood calcification of orange juice,
clotting hard tissues soy milk, green
•Nerve Toxicity: not leafy
impulse seen vegetables,
transmission canned salmon
• Calcification and sardine
of bone and bones
tooth structure
Phosphorus • Required for • Poor bone Dairy products,
bone and teeth maintenance meat, poultry,
strength • Incomplete processed
• Acid-base calcification of foods, soft
teeth drinks, nuts,
balance •
• Compromised legumes,
Muscle
alveolar integrity whole grain
contraction
• Toxicity: cereals
skeletal porosity
LOGO
Magnesium •Bone strength Alveolar bone Wheat bran,
and rigidity fragility whole grains,
•Hydroxyapatite Toxicity seen in green leafy
crystal formation medications vegetables,
•Nerve impulse containing legumes, nuts,
•Muscle magnesium chocolate
contraction Muscle
weakness
Fluoride Prevention of •Increased Fluoridated
caries incidence of caries water, tea,
•Toxicity: tooth seaweed,
mottling, enamel toothpaste
hypoplasia
Iron Component of Anemia:pallor of Meat, poultry,
hemoglobin face, conjunctiva, fish, whole
lips, mucosa, and grains, dried
Carries oxygen gingiva
to cells fruit, enriched
Shortness of
Immune grains
breath,fatigue.
function Decreased
Cognitive immunity
development Toxicity: Gl upset;
pigmentation; seen
in persons with
hemochromatosis

LOGO
Zinc •Required for Altered taste Seafood, meats,
>100 enzymes Growth whole grains,
•Normal growth retardation greens
and development Decreased
•Taste and smell wound healing
sensitivity Impaired
•Sexual immunity
development and Toxicity: rare
reproduction (stomach
•Immune irritation,
integrity cramps, diarrhea,
•Wound healing vomiting)
Copper •Aids in iron Anemia Whole grains,
metabolism Poor growth nuts, dried fruits,
•Collagen Low WBC legumes, shell
formation fish, organ meats
Bone
demineralization
Tissue fragility
Decreased
trabeculae of
alveolar bone
Toxicity:
vomiting,
diarrhea
LOGO
 Effects of nutritional supplements
on wound healing
 Several studies in the medical
literature have examined the
physiologic effects of specific
nutritional supplements on the healing
of surgical wounds.

 Alvarez & Gilbert (1982a, b) conducted

biochemical and mechanical
experiments to determine the effect of
dietary thiamine on collagen
maturation during wound repair in rats
and demonstrated a definite
involvement of thiamine in wound
repair and scar development.

LOGO
  Aprahamian et al. (1985) investigated the effect
of vitamin B5 supplementation and deficiency on
wound healing in rabbits and suggested that
vitamin B5 induces an accelerating effect of the
normal healing process. The mechanism
responsible for this improvement seems to be
an increase in cellular multiplication during the
first postoperative period.

LOGO
Effect of infection on nutritional status

Adverse effects through catabolic effects

A state of Loss of protein(0.6g/kg/day)

negative
nitrogen balance
Anorexia

Under nutrition

Malaise, fever, and infections

LOGO
 Infection

Gastrointestinal tract

Diarrhea Disturbed gastrointestinal mucosa

Nausea

Vomiting Malabsorption

10% to 30% reduced protein metabolism

LOGO
  Infections tend to induce a state of hyper
metabolism, causing an increase in
energy requirements

 It is extremely important during periods of

infection for individuals to have adequate
caloric intakes in order to spare amino
acids for maintenance and synthesis of
body proteins.

 If the individual does not obtain adequate

calories, then the body will break down
the amino acids and body protein stores
for energy.
LOGO
  During infections, it is not uncommon for
fevers to develop that also increase caloric
needs which adds another 9% beyond
normal calorie requirements for each 1°F
greater than 98.6.

 During periods of fever, basal metabolic

rate may increase by nearly one third.

LOGO
LOGO
 "To eat is a necessity, but to eat
intelligently is an art."

La Rochefoucauld

LOGO
 DIET COUNSELING

 It deals with providing guidance in the art

of food planning and food preparation
and food services.

 It assists a person to adjust food

consumption to his or her health needs.
(Nizel)

 It involves giving advice on food

selection based on the individual’s
reason for liking or not liking certain
foods.

LOGO
 Objectives of Counseling

 Correction of diet imbalance that could

affect the patient’s general health and
sometimes reflect on his oral health.

 Modification of dietary habits,

particularly the ingestion of sucrose
containing foods in forms, amount, and
circumstances that cause caries
formation.

LOGO
 Guidelines for Counseling
 Gather information

 Evaluation and interpretation

 Develop and implement plan of action

 Seek active participation of family

 Follow-up the progress and

assessment made

LOGO
Five ‘W’s and one ‘H’ of diet consultation.
WHO, WHAT, WHY,WHEN, WHERE AND HOW.

6 questions are to be made before making decision

about which patients will benefit from diet counseling
 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?

LOGO
Counseling should be done in a step by step
procedure starting with,

 Interviewing, where the diet diary is

introduced with a brief discussion of the
purpose of diet.

 24 hr diet record prepared to get an idea of

food, the patient is consuming.

 Seven-day diet diary advised to be prepared

by patient.

 Complete record of 7 day diet diary is

analyzed regarding the balanced and
unbalanced diet.

LOGO
  Isolate the sugar factor.

 Educating the patients in the role of

sugars in the process.

 Consumption of acceptable substitutes of

more cariogenic food.

 Recognition of practical limitation to

immediate success.

LOGO
Food Diary or Diet Diary
 It is the records of all the foods and beverages
consumed during 5 or 7 day period.

 It can be 24 hrs recall or 3, 5, 7 days record of

food intake.

 It helps to determine:
– Type, frequency, consistency of food
intake.
– Proper diet planning for oral health.

LOGO
 24 hr Recall
 This is used to determine the amount
of food and beverages consumed
during a previous 24 hrs.

 It’s a valuable tool for obtaining a

skeletal picture of patient’s food
intake.

 It is done to determine whether the 5

day or the 7 day food diary is
necessary for the diet modification
(diet counseling).

LOGO
  No comments or opinion should be
given at this time, allow the patient to
talk freely.

 This is the most rapid method (15-

20min) for recording current food
intake.

 Disadvantage: It can over or under

estimate food taken in a single day
and may not represent the usual diet.

LOGO
 5-7 Day Diet Diary

 It is a more accurate account of a patient’s

intake.
 The patient completes the food diary at
home, by writing it immediately after each
food consumption.
 Patient is instructed to be as accurate as
possible in determining quantities and to
include a weekend day as one of the
recorded day.
 Affords the patient a more active role in
the dietary assessment and a chance to
observe areas that require modifications.

LOGO
 Instructions for recording the dairy

 Record about everything you eat and

drink and the time of eating. eg:
between meals or during meals. Also
the activity involved in.

 Record about the candies, chewing

gums, cough syrups or other
medication taken.

LOGO
  The following should be included-
• Kind of food
• Amount in household measures.
• Order in which they are eaten.
• No. of teaspoons of sugar and sugar
products used.

 Do not choose days when dieting, fasting or

ill.

 Indicate the mood in which you are in,

reason why you are eating.

LOGO
 Name: Age/Sex: FIRST DAY

TIME FOOD AMOUNT WHERE WITH DOING FEELING

TAKEN WHOM WHAT WHILE
EATING
7:30 Idli 2 Kitchen Alone Thinking Relaxed

LOGO
LOGO
Food Group Guides/ Food guide pyramid

LOGO
LOGO
 Purpose
 To translate dietary standards into simple
and reliable devices for nutritional education
of lay person.
 It serves as a practical, workable plan for
helping the lay persons or home-maker to
select the kinds and amount of food that
needs to be included or excluded in order to
make each day’s meal a balanced diet.
 Divided into-
1. Bread-cereal group
2. Vegetable-fruit group
3. Milk-cheese group
4. Meat, poultry, fish, beans, nuts group
5. Fats, sweet, alcohols group
LOGO
 How to use the food guide pyramid

LOGO
 Limitations
 It has over-simplified and over generalized
the eating plans. For e.g. high amount of
iron is required by pregnant, lactating
women which cannot be met by the 5 food
groups.

 Ready to eat processed, formulated fruit

drinks cannot be classified into food groups
because they do not follow the nutrition
pattern of anyone food group.

 Combination of foods like casseroles, pizza,

makes groups difficult to classify.

LOGO
 Normal Diets

 A Normal Diet consists of any and all

foods eaten by you in health. It is
planned keeping the basic food
groups in mind so that optimum
amounts of all nutrients are
provided.

Foods allowed:
All foods that you eat in normal
health.

LOGO
 Foods partially restricted

 Fatty foods like rich cakes, pastries etc.

 Fried foods

 Strongly flavored vegetables like turnip,

capsicum, radish etc.

 Too many spices, relishes or pickles

LOGO
 Diet for periodontitis patients
 Specific instructions in diet selection

 For routine maintenance patients:

 Regular diet indicated to promote

healing
 Firm fibrous foods such as apples
or raw carrots to stimulate the
tissues and improve circulation.
 Firm foods increase salivary flow
which acts as buffer and aids in oral
clearance.

LOGO
 Surgical intervention patients

 May need to alter diet consistency

following treatment during the
healing period.

 Soft diet of high-quality protein is

indicated for adequate healing of
tissues.

 Scrambled eggs, milk shakes,

cottage cheese etc. have high-quality
protein to promote healing.

LOGO
 Conclusion
 The effects nutrition on periodontal
disease status and response to
treatment has been studied using
different methods and study models.

 Considering that nutrient

supplementation shows minimal or
no side effects, if future prospective,
controlled clinical trials are able to
demonstrate that it could be used to
enhance response to therapy, such
supplementation may prove valuable
in producing more predictable
treatment outcomes.

LOGO
 "If the doctors of today do not become the
nutritionists of tomorrow, then the nutritionists of
today will become the doctors of tomorrow."

Rockefeller Institute of Medicine research

LOGO
LOGO
 REFERENCES

1. Carranza’s clinical Periodontology – 9th Edition

2. Nutrition in clinical dentistry –Abraham E. Nizel,
Athena S. Papas – 3rd Edition
3. Nutrition in oral health and disease – Robert L.
Pollack, Edward Kravitz
4. Nutrition, diet and oral health – Andrew J.
Rugg-Gunn, June H. Nunn
5. Clinical practice of the dental hygienist – Esther
M. Wilkins – 9th Edition
6. Journal of clinical Periodontology 2003; 30:579-
589.
7. Nutrition, infection and periodontal disease –
DCNA 2003; 47(2):337-354

LOGO
LOGO
LOGO